Granite Bay Countryhouse

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: -Staff mismanaged resident's medications.

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Acting Executive Director (ED), Kelly Blackwood, to open and deliver complaint investigation findings regarding the above stated allegation. During today's visit, LPA conducted a medication count, reviewed/obtained documentation pertinent to the investigation, and conducted an interview. LPA attempted to conduct a medication count for resident (R1) comparing the Centrally Stored Medication Log with the Medication Release form. However, a count could not be conducted as the Centrally Stored Medication Log was missing start dates. LPA conducted a medication count for residents (R2 & R3), comparing the residents' medication lists on file with the medication centrally stored for the residents. ********************************************Continued on LIC9099-C************************************************** Substantiated LPA observed one (1) medication for R2 to be over the documented amount and one (1) medication to be under the documented amount. R3 had three (3) medications that were under the documented amount. On March 19, 2026, the department received an Unusual Incident/Injury Report LIC624 indicating that on March 4, 2026 the facility was notified that R1's medications were not being given as prescribed. The facility had nurses from an outside vendor conduct audits on all medications, which was concluded on March 18, 2026. The investigation/audit found that R1 was being given an incorrect dosage of medications. The facility indicated that they notified R1's primary care physician. The audit also found that start dates were not being consistently documented for several residents, some medications were expired, and some medications were not being stored as ordered. Due to investigation/audit findings, the facility initiated a staff training for all Med Techs covering the job description, medication assistance procedures, and medication basics. The Acting ED indicated that all Med Techs were shadowed on the medication carts as well. The facility provided LPA with the sign off sheets for all staff that participated in the training as well as their final exams following the training. The facility took corrective action against staff involved in mismanaging residents' medications. The facility also terminated one staff after making an error following the retraining. Based on a medication count, records reviewed and interview conducted, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Apr 29, 2026 · control 59-AS-20260423145444

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 30, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication count and records reviewed, the facility did not ensure that residents (R1, R2, and R3) were receiving medications as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 29, 2026

Plan of correction: Facility agrees to conduct bi-weekly audits of all medications for the next two months and submit audits to LPA. The facility will split the audits up by wing in the facility. The last week of audits will be conducted the week of 6/28/26. The facility has already provided LPA with copies of Med Tech training conducted the week of 3/23/26 as well as the medication audits concluded on 3/18/26.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Acting Executive Director (ED), Kelly Blackwood, to conduct a case management visit in relation to a separate inspection conducted on today’s date, April 29, 2026. On March 19, 2026, the department received an Unusual Incident/Injury Report LIC624 indicating that on March 4, 2026 the facility was notified that resident (R1) was not being given their medications as prescribed. The facility conducted an investigation/audit that concluded on March 18, 2026. The audit found that R1 was being given an incorrect dosage of medications. The facility was informed of R1's medication issues on March 4, 2026 and they notified licensing on March 19, 2026, which is not within the seven day reporting requirement that the facility shall report in writing to the department. As a result of today's inspection, deficiencies are being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies are listed on 809-D pages. Exit interview was conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 29, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: May 13, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on records reviewed, the facility did not ensure they notified CCLD of the mismangement of R1's medications within seven days, which poses a potential health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Apr 29, 2026

Plan of correction: Acting Executive Director indicated that they will ensure all reporting requirements are being followed. Facility will submit a statement of understanding by the POC due date of 5/13/26.

Allegation investigated: -Facility is not providing incontinence care -Facility is not providing adequate food services -Facility is not providing care and supervision to residents -Facility is not providing supplies for personal care -Facility staff did not follow reporting requirements -Facility is in disrepair -Facility staff did not seek medical attention for residents

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Acting Administrator, Kelly Blackwood, to deliver complaint investigation findings regarding the above stated allegations. During the course of the investigation, LPA conducted interviews, made observations, and obtained documentation pertinent to the investigation. *********************************************Continued on LIC9099-C*************************************************** Unsubstantiated Allegation: Facility is not providing incontinence care Interview with hospice services indicated that they have no concerns regarding the facility providing resident (R1) incontinence care. Interview with staff (S1) indicated that R1 receives incontinent care every two (2) hours. Interview with staff (S2) indicated that they have never witnessed staff not providing incontinent care to residents that require assistance. Interview with staff (S3) indicated that all residents that require incontinent care are receiving assistance from staff. Interview with the Health and Wellness Director, Maria Pena, indicated that R1 requires incontinence checks every two (2) hours. The Health and Wellness Director indicated that resident (R2) will inform staff when they need to use the restroom. Also, staff cue resident to use the restroom. On November 7, 2025, LPA observed R1 and R2 to be clean as well as each resident having plenty of incontinent care supplies on hand for staff to provide care. Allegation: Facility is not providing adequate food services On November 7, 2025, LPA toured the kitchen area for the ability to prepare and store food. The kitchen appeared to be in good repair, and the care home had the required 2-day perishable and 7-day nonperishable food supply on hand. The meal menu for the month of November indicated a variety of food offered to the residents in care. LPA observed that the staff supply the bistro areas in the facility with snacks for the residents. LPA observed several residents eating in the dining room. LPA also observed S1 providing mealtime assistance to R1. Interview with hospice care services indicated that they have no concerns regarding R1’s eating habits. Interview with S2 indicated that residents are provided with adequate food services and have plenty of food options. Interviews with S3 indicated that they have never witnessed residents not receiving enough food and that residents are also offered snacks twice during a shift. Interview with resident (R3) indicated that the food services are good and the type of cooking is good. Interview with resident (R4) indicated that the food is good and that they are getting enough food. Allegation: Facility is not providing care and supervision to residents On November 7, 2025, LPA toured the facility and observed several residents eating in the dining room, watching television, and interacting with care staff. Residents appeared clean and LPA observed staff providing care to residents. R1 was receiving mealtime assistance from S1. R2 was interacting with staff in the dining room. Interview with S2 indicated that they have never witnessed staff not providing care and supervision. Interview with hospice services indicated that they have no concerns regarding staff providing care and supervision and that R1 always appeared clean. Interview with S2 and the Health and Wellness **********************************************Continued on LIC9099-C***************************************************** Director, Maria Pena, indicated that laundry is constantly going and that showers are done on the residents scheduled shower days. S3 indicated that they have never witnessed residents wearing dirty clothing. S2, S3, the Health and Wellness Director indicated that soiled laundry gets done immediately. On January 29, 2026, LPA observed residents in the common areas to appear clean. LPA observed care staff interacting with residents. R3 and R4 appeared to be clean and wearing laundered clothing. Interview with R4 indicated that staff are conscious of their responsibilities to the residents and that they all seem to be doing the right thing. R4 indicated that they feel all of their care needs are being met. Interview with R3 indicated that staff provide good care. Allegation: Facility is not providing supplies for personal care On November 7, 2025, LPA observed the supply closet to be fully stocked with gloves, briefs, wet wipes, and bed pads. LPA also observed personal care supplies that the facility keeps on hand if a resident does not have their own such as, body soap, toothpaste, toothbrushes, shampoo, conditioner, and cotton balls. Interview with Executive Director, Kimberly Springer, indicated that the residents’ responsible parties typically provide hygiene supplies to residents. However, the facility has supplies on hand if a resident doesn’t have needed personal care products. LPA observed R1 and R2’s rooms to have locked cabinets that included all the residents’ personal care supplies. Interviews with S2 and S3 indicated that there are plenty of personal care supplies for the residents at the care home. Interview with R3 indicated that the facility will provide hygiene products. Interview with R4 indicated that, if they ask for supplies or the facility staff thinks that a resident needs them, the facility will provide personal care supplies to them. Allegation: Facility staff did not follow reporting requirements Interviews with S2 and S3 indicated that, when there is an incident with a resident, they inform a med tech on duty who will generate an incident report. S2 indicated that the caregivers will provide the information and record any observations of residents in the facility’s internal system. S3 indicated that, if a resident is receiving hospice care services, they will contact hospice. S3 also indicated that, if there is an incident, care staff assess the situation and will call paramedics or 911, if needed. S3 indicated that they will also inform the resident’s responsible party as well as the Wellness Director and/or the Executive Director. No specific incident was provided in the complaint. LPA has observed the facility to provide incident reports to the department. *******************************************Continued on LIC9099-C*************************************************** Allegation: Facility is in disrepair On November 7, 2025, LPA toured the facility which appeared to be clean and in good repair. LPA observed all the laundry rooms to be in good repair. There was one (1) stacked washer and dryer on the second floor and five (5) stacked washers and dryers on the first floor. Interview with the Maintenance Director indicated that there have always been enough washers and dryers to get the laundry done in the care home. They indicated that the caregivers do laundry daily and that there are assignments to do laundry for specific residents each day. Interview with S2 indicated that there are six (6) washers and dryers, so there are plenty to get the laundry done even if one (1) went out. S3 indicated that there are six (6) functioning washer and dryers in the care home. Allegation: Facility staff did not seek medical attention for residents Interview with S2 indicated that they have never witnessed staff not providing timely medical attention for the residents in care. S2 stated that staff ensure residents are seen timely by a physician or are sent to the hospital, if needed. S3 indicated that, in an emergency, care staff will call 911 to ensure timely medical attention. S2 indicated that, if a resident receives hospice care services, staff will contact hospice. S2 indicated that, if there is an incident, care staff will assess the situation and act accordingly. If needed, staff will contact paramedics. Interview with hospice services indicated that they have no concerns regarding communication with the facility regarding residents that need medical attention. No specific incident was provided in the complaint. Based on interviews conducted, observations made, and documentation obtained, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 29, 2026 · control 59-AS-20251029114604

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melissa Parks arrived on Tuesday October 21, 2025, to conduct the unannounced annual inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (7) and staff (7) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training. LPA and Administrator Kim toured the facility together to ensure the health and safety of residents in care. The areas toured included the following areas in resident apartments (7), resident bathrooms, common areas, kitchen, laundry room, medication room, and courtyard. Facility had current inspection tags on fire extinguishers. Facility was current on fire drills. Water temperatures were within the required range. Facility had fully stocked first aid kits. All required postings were observed. Facility was clean and well organized. In the areas toured, there were no health or safety violations observed. LPA obtained a copy of the current liability insurance, LIC500 and LIC610E for facility file. Exit interview conducted. A copy of this report was emailed to the Administrator.the state’s words, verbatim · CDSS document, Oct 21, 2025

Allegation investigated: Facility staff are not properly administering medication to residents as prescribed

Licensing Program Analyst (LPA) Graham Gunby arrived unannounced on 06/17/2025 to complete and deliver findings to a complaint received on 01/13/2024. LPAs met with Office Manager, Lorraine Stafford and explained the purpose of the visit. Throughout the course of the investigation, the department conducted interviews and record reviews. Please continue to LIC9099C.. Unsubstantiated Based on interviews and documents obtained, staff confirmed that hand-over-hand and live pouring the medications is the preferred process. Staff are also providing residents with a water cup and water dispenser while administering medications. During the visit on 04/18/2025 LPA observed med tech (S5) administer mediation to several residents using the live pour method. The facility also uses a 3rd party business to discard expired and unusable medication. The facility provided a copy of their bill which included the charge for discarding medication on 11/07/2024 and 03/07/2025. Through interviews with staff, all confirmed that if the resident is on hospice, that agency will dispose of their medications. If the resident is not on hospice, they will need multiple eyewitnesses and to sign off on the disposal. Based on interviews and records reviewed there is insufficient evidence to prove that facility staff is not properly administering medication to residents as prescribed causing residents to go to the ER due to lack of care. Based on information obtained during the investigation, LPA finds the allegations to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Based on interviews and obtained documents, the previous administrator (S1) left abruptly just before 12/25/2024. During this time the facility facilitated a replacement administrator and begun the onboarding process. On their first day, the new administrator (S2) did not show up and the facility looked to hire an internal employee. The announcement for the new administrator (S3) was sent to residents and families and set for 02/27/2025. During this time, period the facility did have an active administrator (S4) with an approved Administrator Certificate. Records reviewed show the Administrator is at the facility an adequate number of hours. Additionally, the administrator stated that they devote additional hours to the facility to fulfill their responsibilities when the need for such additional hours is needed. This department has investigated the complaint alleging the administrator is not present at the facility to meet facility’s operational needs and found out that the allegation was UNFOUNDED. Based on records reviewed, the above allegations are found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis.the state’s words, verbatim · CDSS document, Jun 17, 2025 · control 59-AS-20250113151326

Allegation investigated: Staff did not properly assist resident with wound care. Staff did not seek medical attention to resident as needed. Staff did not provide a comfortable temperature to resident. Staff did not communicate with resident's authorized representative in a timely manner.

Licensing Program Analyst (LPA) Melissa Parks arrived unannounced on Tuesday October 1, 2024, to complete and deliver findings to a complaint received on 12/21/2023. LPA met with Goshong and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator, staff, and hospice staff. LPA reviewed R1’s physicians report, death report, care plan, assessment, nursing notes, and outside agency notes. The result of the investigation is as follows: Allegations: Staff did not properly assist resident with wound care. Staff did not seek medical attention to resident as needed. LPA reviewed R1’s hospice notes. These were well documented nurse visits each time a hospice nurse visited R1 at the facility. Hospice notes always included any indication of pain and wound presence. LPA learned the following: R1 received weekly hospice visits which began around 10/12/2023 and ended when R1 passed in December. LPA reviewed nurse documentation on 11/13, 11/16, 11/22, 11/28, Unsubstantiated 11/30, 12/4, and 12/8. All these documented dates stated that R1 had no verbal signs of pain such as grimacing or frowning. Additionally, R1 had a documented stage 1 wound on their coccyx which was identified and staged on 10/12/2023. Each subsequent visit described the wound and treatment. This wound was always described as a stage 1 with instructions to use barrier cream and cover with a bandage. There were no documented notes of this wound progressing or worsening. On 11/16/2023, R1 had a new skin tear to the right linear arm, close to the elbow. Treatment was stated for staff to cleanse with wound cleanser and pat dry. On 11/30/2023, R1’s right heal was noted to be red. Hospice provided foot protectors for staff to use to keep pressure off the heal. All staff interviews stated that R1 never had an open pressure ulcer. Staff described redness and were instructed to frequently reposition R1 in bed to alleviate pressure. LPA interviewed R1’s primary hospice nurse who stated that R1 never had an open pressure ulcer. This hospice nurse stated that, to their recollection, there was no odor. Additionally, the hospice nurse stated that if R1 had a stage 3 or stage 4 wound, nurse visits would have occurred several times per week for treatment. LPA did not identify a medical emergency for R1. R1 had a gradual decline. Notes show that hospice staff and facility staff communicated throughout R1’s decline. Allegation: Staff did not provide a comfortable temperature to resident. LPA learned that each room could control their own thermostat. Staff interviews did not reveal that R1’s room was kept unusually hot or cold. LPA interviewed R1’s hospice nurse who did not recall R1’s room being kept at an uncomfortable temperature. Allegation: Staff did not communicate with resident's authorized representative in a timely manner. LPA learned that there were several managers who were assisting the facility while they were seeking a Director of Nursing and Executive Director. Leticia Higares, a Regional Director with the company, was assisting the facility while R1 was actively transitioning. Leticia stated that she spoke with R1’s POA after learning that they had called the facility. Observation notes detail when med techs called R1’s POA. Per staff interviews and observation notes, R1 had a gradual decline. Observation notes also detail frequent communication between the facility and R1’s hospice company. Based on information obtained, LPA finds the allegations to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted. A copy of this report was left with the facility.the state’s words, verbatim · CDSS document, Oct 1, 2024 · control 59-AS-20231221093928

Allegation investigated: Facility is malodorous Staff did not meet residents' needs

LPA Parks and LPA Mikkelson arrived on Thursday September 12, 2024, to conclude a complaint investigation regarding the above allegations. LPA met with Administrator James Hall and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator, Director of Nursing, and staff. LPA and Administrator toured resident apartments and common areas. The result of the investigation is as follows: Allegation: Facility is malodorous On the initial complaint facility visit, on July 26, 2024, LPA Parks and Administrator Hall toured the facility together. LPA inspected 5 apartments whose occupants incontinence needs were provided by staff. LPA did not observe any odor in the resident apartments. Furthermore, LPA Parks and Administrator Hall toured the common areas of the facility, and no odor was detected. Unfounded Allegation: Staff did not meet residents’ needs LPA Parks interviewed staff who stated there have always been 2 staff members to provide care and supervision for the overnight shift. LPA Parks reviewed staffing schedules which corroborate that there are at least 2 staff on the NOC shift. No staff interviews acknowledged that there have been any shifts were a sole staff member is at the facility to provide care and supervision for all staff. Based on the evidence provided, the preponderance of evidence standards was not met, therefore, the above allegations are found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted. A copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Sep 12, 2024 · control 59-AS-20240723114956

Allegation investigated: Staff do not ensure the facility is free from pests. Staff do not ensure the facility is clean. Staff do not ensure laundry equipment is in good repair.

LPA Parks and LPA Mikkelson arrived on Thursday September 12, 2024, to conclude a complaint investigation regarding the above allegations. LPAs met with Administrator James Hall and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator, Director of Nursing, and staff. LPA toured the facility with Administrator Hall. LPA reviewed pest control documentation. The result of the investigation is as follows: Allegation: Staff do not ensure the facility is free from pests. LPA interviewed staff who stated that they observed ants in R1’s room. Staff interviews also acknowledged that management has followed up with pest control and taken action in order to mitigate the issue. The facility supplied pest control invoices which show that the facility has routine pest control visits. Unsubstantiated Allegation: Staff do not ensure the facility is clean. LPA Parks and Administrator Hall toured the facility together. LPA did not observe any common area furniture which had been soiled by residents. LPA observed that the facility was relatively clean and organized. LPA toured resident rooms which also appeared to be clean and orderly. LPA learned that the facility’s full time housekeeping staff had recently quit without notice. In the interim of hiring a new housekeeper, the care staff are assigned to complete housekeeping tasks. Allegation: Staff do not ensure laundry equipment is in good repair. LPA toured the facility’s laundry room with Administrator Hall. Per interviews, 2 washers were in the process of being repaired or replaced. Facility has 3 laundry rooms throughout the facility which are accessible to staff. Staff interviews stated that there is sufficient washers and dryers to timely clean and return resident laundry. Based on information obtained during the investigation, LPA finds the allegations to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, Exit interview conducted. A copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Sep 12, 2024 · control 59-AS-20240715152518

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Melissa Parks and Cassandra Mikkelson arrived on Thursday September 12, 2024 to conduct the unannounced annual inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPAs reviewed resident (6) and staff (6) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training. LPAs and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included apartments, common areas, kitchen, and dining room. LPAs observed all required postings. LPA observed emergency evacuation chairs in each stairwell. First aid kit was fully stocked. Fire Extinguishers had current inspection tags. Facility was clean and well organized. Residents were engaged in activities during LPAs visit. Water temperatures were within the required range. In the areas toured, there were no health or safety violations observed. LPAs requested the following: a copy of the facility's current liability insurance, updated LIC500 and LIC610E by the end of the month. No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.the state’s words, verbatim · CDSS document, Sep 12, 2024

Allegation investigated: Staff did not assist resident with protective boot Staff did not ensure that facility is free of pests

LPA Parks arrived on Friday May 3, 2024, to conclude a complaint investigation regarding the above allegations. LPA met with HR Assistant Goshong Vang and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the Administrator, Director of Nursing, and staff. LPA reviewed observation notes for R1-R4. LPA reviewed pest control documentation. Additionally, LPA observed the apartments of R5 and R6 and the kitchen. The result of the investigation is as follows: Allegation: Staff did not assist resident with protective boot LPA reviewed R4’s hospice orders which stated that resident is to wear protective boots. LPA interviewed staff who stated that they always put the boots on R4. One interview acknowledged that agency staff have previously forgotten to put on the boots, but when observed by facility staff, this is corrected immediately. Unsubstantiated Allegation: Staff did not ensure that facility is free of pests LPA interviewed the facility Administrator who stated that there were ants observed by the beverage machine. The Administrator stated that this machine was then moved inside the kitchen, to prevent spills from residents. LPA reviewed pest control documents which stated that there was no evidence of pests in the facility. Facility staff interviews stated that they have not observed ants in the facility in a long time. Based on information obtained during the investigation, LPA finds the allegations to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, Exit interview conducted. A copy of this report was provided to the facility. Allegation: Staff did not provide adequate supervision, resulting in residents sustaining falls After reviewing resident documentation, LPA did not find any evidence of falls due to lack of adequate staffing. Staff interviews discussed facility protocol if a residents falls are witnessed and unwitnessed. Interviews stated that the facility is utilizing agency staff in order for each shift to be fully staff. Additionally, interviews acknowledged that management will also assist on the floor when needed. Allegation: Staff did not evaluate residents after sustaining falls LPA reviewed observation notes for R1-R4. LPA reviewed detailed documentation by the Director of Nursing for a fall sustained by R1 on 3/8/2024. R1 was sent to the hospital for evaluation. Documentation detailed conversation with R1’s POA. Staff documentation noted that R1’s primary physician was notified. LPA did not find any documentation of falls for R2-R4. Additionally, staff interviews did not acknowledge any recent falls (within the last few months) for R2-R4. Allegation: Staff did not provide residents with a healthful living environment LPA observed R5 and R6’s apartments. Both apartments were tidy and well-maintained. LPA did not observe any feces in the bathroom or on personal items. LPA interviewed staff who stated that they have never observed feces in R5 and R6’s apartments. Additionally, staff stated that should a resident have an incontinence episode after housekeeping has left for the day, they have access to cleaning products. Allegation: Staff neglected to care for resident’s injury LPA reviewed R1’s documentation. No documentation revealed that R1 had an injury to the back of their head. Additionally, no staff interviews acknowledged that R1 had a head injury. Allegation: Staff did not ensure residents were provided adequate food services LPA interviewed staff who stated that there is a meal roster utilized for each meal. If residents are not at meals, staff then check on them. If residents do not want to eat in the dining room, there is a meal tray provided for them. All staff interviews stated that residents are, at a minimum, offered each meal. Residents can decline to eat. Additionally, interviews stated that R3 never missed three consecutive meals. Allegation: Staff did not ensure furniture was clean and sanitized LPA toured the facility’s common areas and did not observe any stains or odors on the furniture. Staff interviews stated that if a resident soils a chair/cushion, that it is removed and sanitized. Interviews acknowledged that staff clean the soiled furniture, timely. LPA interviewed the Maintenance Director and Housekeeping which both stated that they routinely clean furniture and as needed. Based on the evidence provided, the preponderance of evidence standards was not met, therefore, the above allegations are found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted. A copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, May 3, 2024 · control 59-AS-20240412103029

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday March 28, 2024 to conduct a case management visit about an incident which occurred on March 15, 2024 and reported to the Department on March 22, 2024. LPA interviewed the Administrator regarding the behaviors of R1 and R2. LPA obtained additional information about the altercation between R1 and R2. LPA determined that the facility followed proper procedures regarding the incident. No deficiencies cited. Exit interview conducted. A copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Mar 28, 2024

Allegation investigated: Staff neglect resulted in a resident to be hospitalized.

On 2/15/2024, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final finding Community Care Licensing (CCL) received on 10/16/2023. LPA met with Executive Director, Leticia Higares, and explained the purpose of the visit. During the course of the investigation, the Department conducted interviews with facility staff, residents in care, relevant parties, and obtained pertinent documents relevant to the complaint investigation such as resident (R1) physician’s report, plan of care, assessments, and medical records. Continue on page LIC 9099-C. Substantiated According to interviews conducted, in August of 2022 R1 had a wound on their right foot due to bunions. Medical records indicated the wound was completely healed by the end of January 2023. R1 was admitted to Granite Bay CountryHouse on 2/1/2023, after recovering from bunion surgery. Granite Bay CountryHouse staff were aware of R1’s foot condition. Based on records review, R1’s podiatrist indicated staff were to monitor R1’s feet for any changes or worsening condition. The Department subpoenaed R1’s medical records for review. According to medical records, R1 was transferred to local Emergency Department (ED) by ambulance on 10/09/2023. It was discovered that R1 had sustained two open wounds on the bottom of the right foot that measured two centimeters by three centimeters each. The wounds were malodorous and expressed salmon colored purulence when touched. On 10/10/2023, hospital staff admitted R1 to the Intensive Care Unit (ICU) due to the following: septic shock, altered mental status, acute respiratory failure with hypoxia, elevated troponin, acute kidney injury, and cellulitis of right leg. On 10/11/2023, R1 was seen and evaluated by hospital medical professionals. Medical records indicated medical staff determined R1 required a right Trans-metatarsal amputation (TMA) to prevent spread of infection and systemic illness. On 10/13/2023, due to septic shock, R1 underwent a right lower extremity angioplasty and a right TMA. The Department requested for the facility to submit R1’s physician’s report, pre-placement appraisal, assessments, and plan of care for review. According to R1’s physician’s report dated 11/20/2022, R1’s primary diagnosis is Dementia without behavioral disturbance. The secondary diagnosis is right foot ulcer with wound care being ordered twice weekly. Preplacement appraisal notes R1 has a stint in the right leg and is non-ambulatory. R1’s initial assessment was conducted by the facility on 01/26/2023. According to the assessment conducted, nail care is to be provided by a Podiatrist every month as needed. Instructions included for staff to monitor for signs and symptoms (i.e., reddened areas on the toes, dark areas on toes, non-healing open areas, resident reports discomfort), any observations will be reported to the nurse. R1 is a stand-by assist during bathing, assist in/out of bath/shower, assist with washing back and assist with drying weekly. According to interview with R1’s Podiatrist (W1), R1 was seen on three (3) separate occasions while residing at the facility. On 3/18/2023, W1 indicated R1 had red, swollen feet, and complained of pain in toes. W1 prescribed a change of shoe for R1 at that time. On 6/8/2023, R1 was seen again by W1, during this appointment R1’s foot was doing better. At the time of the appointment, it was noted there were no signs of redness, swelling, open wounds, and no complaint of pain. On 8/28/2023, W1 had final visit with R1 and noted there was no sign of any redness, swelling, open wounds, and there was no complaint of pain. W1 indicated that during R1’s appointment on 8/28/2023, R1’s foot was in good condition. During the interview with W1, it was mentioned R1’s 10/09/2023 hospital visit W1 expressed surprise as they stated the facility never contacted them regarding R1’s feet deterioration. W1 further stated, “For an infection to get that bad there would be a lot of early warning signs such as pain, swelling, and discoloration. An infection would take time to become that severe and it should have been noticed by staff well before reaching that level”. The Department conducted interviews and received statements from a total of seven (7) facility staff and five (5) residents in care. Interview statement received from staff (S1) indicated, R1 was admitted into the facility in February 2023. S1 stated, R1 had a “stand-by” assist for showers. During a stand-by assist, caregivers are supposed to help undress the resident, help the resident enter the shower, and help them dry off. During this time the staff are supposed to be looking for any concerns or issues while they are assisting the residents. Interview statement received from S2 indicated, S2 worked at the facility from July 2023 to November 2023. S2 stated staff (S3) was the staff who worked with R1 and was responsible for bathing needs. S2 observed there were very few observation notes in R1’s ECP (computer program log). When S2 asked S3 about the lack of notes, S3 told S2 that R1 refused to be bathed every single time. The refusals were never logged in ECP which S3 never told anyone about R1 refusing care or never mentioned R1 having any other signs or symptoms of any kind. S2 stated did not have any knowledge of R1’s foot condition until after R1 was sent to the hospital. S2 was unfamiliar with R1’s medical history. S2 stated information regarding R1’s pre-existing foot issue was not available when S2 took over. Interview statement received from former staff (S3) indicated, S3 worked at the facility from March 2023 through November 2023 as a caregiver and Med Tech. S3 stated information was passed down via word of mouth at shift change and via computer system used to enter notes (ECP). S3 notified management about the issues with ECP but the system was never fixed. S3 worked with R1 frequently and assisted R1 with showers. S3 stated R1 would often refused showers. S3 stated never saw any redness, swelling, or open wounds on R1’s body. S3 stated had knowledge of R1’s foot condition when S3 began working at the facility in March 2023. During S3’s interview, they admitted to not checking the condition of R1’s feet. Based on interview statements and records review, staff did not observe and monitor R1 for signs and symptoms (i.e., reddened areas on the toes, dark areas on toes, non-healing open areas, resident reports discomfort) which resulted in R1 being admitted to the hospital for septic shock where R1 sustained a right lower extremity angioplasty and right Trans-metatarsal amputation. The Department finds the allegation to be SUBSTANTIATED. A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. California Code of Regulations, Title 22, is cited on the attached LIC 9099-D. The facility is being advised that under H&S Code §1568 the issuance of a Civil Penalty is currently under review and may be assessed later, due to a resident sustaining serious bodily injury while in care of the facility. Appeal rights provided. Exit interview conducted. A copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 15, 2024 · control 59-AS-20231016155615

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Feb 16, 2024

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided... the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on records review and interviews, facility staff did not monitor R1's feet which resulted in R1 being admitted to the hospital for septic shock and had a right lower extremity angioplasty and a right trans metatarsal amputation. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 15, 2024

Plan of correction: Licensee agrees to conduct training with staff on ensuring staff are aware of each resident’s care needs in accordance with each individual care plans. Additionally, training shall include how staff document and communicate any changes in resident needs. Training shall be completed within 30 days of POC date. Licensee shall submit training dates and topics by POC and submit training completion ducmentation once training is completed.

Allegation investigated: Facility disclosed resident confidential information to the wrong people. Staff did not provide resident's authorized representative with records in a timely manner Staff did not properly dispose of trash Staff are not following medication orders. Staff are not meeting residents' needs Staff did not notify resident’s authorized representatives of incidents

LPA Parks arrived on Thursday December 14, 2023, to conclude a complaint investigation regarding the above allegations. LPA met with Interim Executive Director Jackie Hernandez and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the previous Administrator, previous Director of Nursing, Med techs, caregivers, dietary staff, and R1’s hospice nurse. LPA reviewed R1’s facility file including medication lists, MARs, and controlled substance count sheets. The result of the investigation is as follows: Allegations: Facility disclosed resident confidential information to the wrong people and Staff did not provide resident's authorized representative with records in a timely manner LPA reviewed emails between R1’s POA and the facility. The POA began requesting R1’s facility records on August 20, 2023. The POA sent a follow-up email on September 1, 2023, again requesting R1’s records. The facility emailed the POA some of R1’s file to the POA on September 5, 2023. The POA Substantiated followed-up on September 19, 2023 requesting R1’s full file including MARs, incident reports, etc. The POA received an email from the Director of Nursing on September 27, 2023, stating that they were working on compiling the file. According to the previous Administrator Jessica Sanders, all records requests are processed through the corporate office. The previous Administrator acknowledged that another resident’s information was accidentally provided to the POA of R1. Additionally, according to the timeline of emails and the interview with the previous Administrator, the facility provided R1’s requested facility records approximately 4 weeks after the initial request. Furthermore, once the requested documents were provided, there were documents for 5 other residents documents (R2-6) provided to the POA. Allegation: Staff did not properly dispose of trash The previous Administrator Jessica Sanders stated that R1’s POA was upset that once there was an instance of used incontinence products left in R1’s bathroom. Staff interviewed stated that R1’s room was normally kept tidy and clean. Interviews stated that the facility has dedicated housekeeping which deep cleans each room once per week. Care staff are responsible for cleaning accidents which may occur during the week. LPA also interviewed R1’s hospice nurse who stated that they would visit the facility twice per week. Per this hospice nurse, there were often where used incontinence products were discarded in the room or bathroom, rather than being taken to the trash. LPA was provided photos which show used incontinence products in R1’s room, outside of the trash can on several occasions. Allegation: Staff are not following medication orders. According to the reporting party, R1 was prescribed Lorazepam 1 mg every four hours as needed. The reporting party was told by a med tech that they were giving R1 this medication every four hours routinely. LPA reviewed R1’s scheduled and routine medications. According to the controlled substance count sheet, R1 began taking this medication in October of 2022 as PRN. LPA reviewed PRN MARs from May – September 2023. LPA also reviewed the facility’s controlled substance count sheet for this medication. According to the controlled substance count sheet, this medication was given as needed until 8/24/2023. On 8/24/2023 until 8/28/2023, R1 was given this medication at 7am each morning. According to R1’s hospice nurse, they spoke with staff and instructed them to give this medication as needed, and not routinely. LPA also identified that the MAR and controlled substance count sheet did not match. Staff were not correctly signing the MAR as this medication was given. Allegation: Staff are not meeting residents' needs According to the interview with R1’s POA, R1’s incontinence needs were not met. The POA provided documentation which showed that several times they found R1’s bed soaked with linen. Additionally, interviews with staff stated they did the best they could, but R1’s incontinence needs were not always met timely. Additionally, staff interviews acknowledged that R1 would often have dirty clothes as they would spill food on themselves during mealtimes. Allegation: Staff did not notify resident’s authorized representatives of incidents During R1’s stay at the facility, they had had approximately six witnessed falls and 12 unwitnessed falls documented in observation notes. According to both the POA and hospice nurse, POA was not notified of every fall. Observation notes state that on 8/7/2023, R1 was found on the floor by care staff. Hospice was notified. POA arrived at the building after hospice notified them of the incident. Additionally, LPA’s interview with R1’s hospice nurse revealed that R1 had a fall on 9/1/2023. Again, R1’s POA was not notified of this fall until they received a call from the hospice nurse. Based on the information detailed above, LPA finds the allegations to be substantiated. A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on 9099-D. Appeal rights were printed and given. Exit interview conducted. A copy of this report was left at the facility. and dinner meal was served with a vegetable. Care and kitchen staff stated that fresh fruit and vegetables are served daily. Furthermore, staff stated that there is always extra food available should a resident want additional servings. Allegation: Staff are not meeting resident's laundry needs LPA interviewed care staff on all shifts in regards to R1 and their laundry needs. Staff interviewed stated that R1 required frequent clothing changes after meals. Additionally, R1 required incontinent care which sometimes led to a change of clothes. Staff stated that R1 always had dirty clothes to be laundered by the facility. However, staff interviewed also stated that R1 was never without clean clothes. Based on information obtained during the investigation, LPA finds the allegations to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, Exit interview. A copy of this report was emailed to the Administrator.the state’s words, verbatim · CDSS document, Dec 14, 2023 · control 59-AS-20231003164146

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Dec 15, 2023

87465 Incidental Medical and Dental Care (c)If the resident's physician . . . nonprescription PRN medication but can communicate his/her symptoms clearly, (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by R1's PRN medication begin given routinely at 7am 8/24 - 8/28/2023. This poses a direct threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Dec 14, 2023

Plan of correction: Facility to submit plan in regards to training staff for PRN medication regulations. Additionally, Facility will add auditing measures to ensure staff are following procedures.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(b)(3) · Plan of correction due date: Dec 15, 2023

Managed Incontinence (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by R1's incontinence needs not being met as evidenced by soiled bedding and clothings. This poses a direct threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Dec 14, 2023

Plan of correction: Facility to submit date/time for training all staff in regards to incontinence needs being met.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(2) · Plan of correction due date: Dec 28, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (2) To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement was not met as evidenced by R1's POA receiving paperwork for other residents (5). This poses an indirect threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Dec 14, 2023

Plan of correction: Facility to submit a statement of understanding in regards to keeping residents information confidential.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Dec 28, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities 19) To have prompt access to review all of their records and to purchase photocopies of their records. . . . (2) business days and at a cost that does not exceed the community standard for photocopies. This requirement was not met as evidenced by R1's repeated attempts to obtain R1's file while took approximately 4 weeks. This poses an indirect threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Dec 14, 2023

Plan of correction: Facility to submit a statement of understanding regarding the timeline for residents to receive their documents.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 28, 2023

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. . This requirement was not met as evidenced by R1's soiled incontinence products being left throughout the room. This poses an indirect threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Dec 14, 2023

Plan of correction: Facility to submit training records for staff regarding taking used incontinence products out of residents rooms, overall cleanliness etc.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Dec 28, 2023

87468.1 Personal Rights of Residents in All Facilities (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met as evidenced by R1's POA not being notified of 2 falls. This poses an indirect threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Dec 14, 2023

Plan of correction: Facility to submit training records for med techs and Department heads are calling POAs in regards to falls and change of conditions.

Allegation investigated: Staffing shortage Lack of supervision

LPA Parks arrived on Thursday December 14, 2023, to conclude a complaint investigation regarding the above allegations. LPA met with Interim Executive Director Jackie Hernandez and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed the previous Administrator, previous Wellness Director, Med techs, caregivers, and dietary staff. Additionally, LPA interviewed R1’s hospice nurse and Administrator of current facility. LPA reviewed R1’s facility file in addition staffing schedules and employee timecards. The result of the investigation is as follows: LPA reviewed documentation which showed R1 had a weight loss of 21.6 pounds from May 4, 2023 through August 1, 2023. According to staff interviews, R1 required assistance with eating. This assistance varied from helping R1 get started with their meal to assisting with the entire meal. Staff acknowledged that R1 had a good appetite and usually ate most of their food. LPA interviewed a family friend of R1 who visited towards the end of R1’s stay at this facility. This family friend reported that no one was assisting R1 with their meal. Substantiated As they began to assist R1, they drank 3 glasses of liquid and ate all of their food. This complaint does not have specific allegations about the food or service provided by the dietary department, rather that there were not sufficient staff to assist R1 with their meals resulting in weight loss. R1 later moved to a 6-bed facility. LPA interviewed R1’s hospice nurse who stated that R1 has had a documented weight gain since being at this new facility. LPA interviewed staff who acknowledged that there are typically 3 caregivers in the morning and evening shifts along with a med tech scheduled. NOC shift typically has 2 caregivers and one med tech scheduled. LPA reviewed the facility’s census for the months of July, August, and September 2023. LPA reviewed staffing schedules vs. timecards for July 27, 2023 where the complainant alleged that there was insufficient staffing. LPA found that there were 2 caregivers and one med tech for the morning shift. The census this date was 37 residents. Upon review of timecards, LPA found that there is a pattern of less than stated staffing during weekends. According to staff interviewed, management often found it difficult to find replacements when staff were unable to work their scheduled shift. Additionally, staff stated that management would rarely help staff with residents when they were short staffed. Based on the information detailed above, LPA finds the allegations to be substantiated. A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. LPA previously cited the facility for insufficient supervision and lack of staffing on 12/6/2023 for complaint control # 59-AS-20231003164146. Due to the timeline of when this complaint was received and completed, although the allegations are substantiated, there will not be any citations given. Appeal rights were printed and given. Exit interview conducted. A copy of this report was left at the facility. and dinner meal was served with a vegetable. Care and kitchen staff stated that fresh fruit and vegetables are served daily. Furthermore, staff stated that there is always extra food available should a resident want additional servings. Based on information obtained during the investigation, LPA finds the allegations to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, Exit interview. A copy of this report was emailed to the Administrator.the state’s words, verbatim · CDSS document, Dec 14, 2023 · control 59-AS-20230802143046

Allegation investigated: Staff not supervising residents Resident sustained multiple fractures due to staff neglect

LPA Parks arrived on December 6, 2023, to deliver findings to two allegations from a complaint received on October 3, 2023. LPA met with Interim Executive DIrector Jackie Hernandez and explained the purpose of the visit. Throughout the course of the investigation, current and previous staff were interviewed. LPA reviewed R1’s facility file including medication lists, incident reports, observation logs, MARs, care plans, and controlled substance count sheets. The result of the investigation is as follows: R1 sustained two falls on 8/27/2022 and 5/29/2023 that resulted in serious injuries. The 8/27/2022 fall was a witnessed fall and R1 sustained a fractured left fibula and was placed in a split. Per the observation notes, R1 was attempting to walk on their own and collapsed on the floor. The 5/29/2023 fall was an unwitnessed fall and R1 sustained a “nondisplaced hairline fracture of radial head.” Per R1’s observation notes and Incident Report, R1 was found outside in the pond by their spouse. Staff were unable to provide a time frame as to how long R1 was outside for and staff did not know how R1 got outside. Substantiated Per the South Placer Fire District Prehospital (SPFD) Care Report, it was noted that staff reported R1 may have fallen into the water about an hour prior to SPFD being dispatched to Granite Bay CountryHouse LLC. After reviewing observation notes, it was determined R1 had approximately six witnessed falls and 12 unwitnessed falls, between 4/10/2022 to 8/30/2023. With the number of falls R1 had, staff were asked what they were doing to prevent R1 from falling. Staff indicated they were just “keeping an eye” on R1. R1’s care plans dated 2/25/2022 and 10/5/2023 noted that R1 requires two safety checks during the nighttime. However, the care plans did not indicate any special checks throughout the day or indicate that R1 was considered a fall risk. Per the Hospice “IDT” notes dated 11/17/2022, R1 was noted to become more dependent on care and can no longer walk due to wheelchair bound restriction. Additionally, it was noted on 11/4/2022, that R1 was a fall risk due to their fractured left foot. Staff reported that there are no specific procedures if a resident is considered a fall risk. Based on the information detailed above, LPA finds the allegations to be substantiated. A finding that the allegations are Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted. Deficiencies cited on 9099-D. Appeal rights were printed and given. Exit interview conducted. A copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Dec 6, 2023 · control 59-AS-20231003164146

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(4) · Plan of correction due date: Dec 7, 2023

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her. . current appraisal. This requirement was not met as evidenced by R1's safety needs not being met which allowed them to sustain an unwitnessed falls with fractures. This poses an immediate threat to the health and safety to residents in care.the state’s words, verbatim · CDSS document, Dec 6, 2023

Plan of correction: Facility to submit detailed plan of measures put into place of staff identifying unmet needs and how the facility will address it. Additonally, plan will detail meeting needs of wander risks.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Dec 7, 2023

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. . . . This requirement was not met as evidenced by the facility not providing R1 with appropriate safety measures as a fall risk. This poses an immediate threat to the health and safety to residents in care.the state’s words, verbatim · CDSS document, Dec 6, 2023

Plan of correction: Facility will submit detailed plan on proactive measures once a fall risk is indentified.