Amber Grove Place

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

Allegation investigated: Facility raised level of care rates without clear explanation

On XXX, 2026, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced for the purpose of delivering complaint findings. LPA was greeted by Administrator Stacy Baxter and explained the purpose of the visit. During the visit, there were 50 residents in the community and 10 care staff. During the course of the investigation, interviews were conducted, observations were made, and pertinent records were reviewed. Continued on LIC 9099-C Substantiated Allegation: Facility raised level of care rates without clear explanation It was alleged that facility representatives raised the monthly rates of Resident 1’s (R1) care without providing a clear written explanation for the change to R1’s responsible party (RP). On June 16, 2026, a care conference was held with facility staff and R1’s RP to discuss R1’s care needs and concerns. During this meeting, RP was initially provided a “Level 2” care plan describing the services and interventions that were to be provided to R1 as part of R1’s daily routine. During the meeting, a present staff member verbally changed the care plan to a “Level 3” citing the fact that R1 is now needing stand-by assistance with showering for their safety and to ensure cleanliness. R1’s RP requested a copy of a level 3 care plan which was unavailable for their review. LPA interviewed facility managerial staff who provided LPA with a Care Services and Fees document indicating the services provided for each level of care. At the bottom of this document, there was an asterisked statement claiming, “Level of care pricing subjected to change without notice.” LPA interviewed care staff at the facility who stated R1 was still primarily independent with the majority of their Activities of Daily Living (ADLs), but they had noticed a gradual decline in R1’s ability to cleanse themselves properly to ensure R1’s own health and hygienic safety. Additionally, staff reported R1 had begun to exhibit more confused behaviors and needed more reminders and stand-by assistance throughout the day, specifically with toileting and showering. However, LPA reviewed R1’s Admission Agreement and noted that on page 16 under the heading “Change of Level of Care, “the document states “if we (facility) determine that you need a level of care that is different from your current level, we will provide you and your RP with written notice of that change.” LPA reviewed an email dated July 8, 2026, to R1’s RP from facility administrator, Stacey Baxter, containing the level three (3) care plan that RP had requested over three (3) weeks prior. This was the first time the RP had been provided a level three (3) care plan for the resident when RP had already been directed to pay for level three (3) care for half of June 2026 and all of July 2026. Based on interviews conducted, observations, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Sep 16, 2026 · control 59-AS-20260706142739

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Oct 2, 2026

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments The requirement is not met as evidenced by: Based on interviews conducted, observations, and records reviewed, it was determined that staff did not adhere to the admission agreement provided to the resident in that the staff did not provide a written copy of the residents updated care plan indicating a change in the level of care for over three (3) weeks. This poses a potential health, safety, and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 16, 2026

Plan of correction: Administrator shall submit a statement of understanding of the allegation to LPA by end of business on September 25, 2026.

Allegation investigated: Staff did not follow resident's care plan Staff did not ensure resident's room was clean Staff did not ensure resident's wheelchair was clean

On September 9, 2026, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced for the purpose pf delivering complaint findings. LPA was greeted by Administrator, Stacey Baxter, and explained the purpose of the visit. During the visit, there were 50 residents and 10 staff providing direct care. During the course of the investigation, interviews were conducted, observations were made, and pertinent records were reviewed. Continued on LIC 9099-C Substantiated Allegation: Staff did not follow resident's care plan It was alleged that staff did not follow a resident’s (R1) care plan throughout their residency at the facility. Specifically, it was alleged that staff were not properly assisting the resident with bathing or daily grooming, not setting R1’s wheelchair up properly during meals resulting in food waste messes, and the facility donated a sit-to-stand device that the resident had a medical order to use. LPA reviewed all of R1’s care plans and confirmed these services/interventions were all documented as activities of daily living that staff were required to assist R1 with on a daily basis. LPA interviewed staff members during the course of the investigation. Staff #1 (S1) noted that the above allegation “may have been true in previous years” as S1 remembered R1’s family complaining about their level of care “many times.” S1 further stated that staff were directed to “shave R1 more often” indicating this task was not being completed daily. LPA reviewed R1’s initial care plan from their move which indicated “staff to provide daily shaving. Resident may refuse. Repeat attempts.” Additionally, LPA reviewed the R1’s shower logs and noted that no shower was given between July 22, 2025, and August 5, 2025, indicating 13 days passed without R1 receiving a shower. LPA reviewed R1’s progress notes for this period and found no documentation of R1’s refusal of shower during this period. All R1’s care plans created by facility staff throughout R1’s residency at the facility indicated R1 was to receive showers twice a week. LPA reviewed photographs documenting incidents when the resident’s wheelchair foot guard and seat area were covered in food waste, indicating the resident was not properly assisted during mealtime and his care plan order for a “plate guard” was not being followed. LPA interviewed staff regarding the previously mentioned use of the sit-to-stand “hoyer” device. Staff #2 (S2) stated the device was donated to the facility by a previous resident’s family. In order for R1 to use the device, it needed to be evaluated by a physical therapist and approved for R1s use. The evaluation was facilitated and it was determined that R1 was not compatible with the device due to R1’s lack of compliance with its utilization. It was determined in the evaluation and documented in R1’s care plan dated September 21, 2025, that “if the time comes where (R1) becomes unable to assist with transfers, the sit to stand will be re-introduced and another training will be held with the PT (physical therapist) for staff training.” S2 confirmed the device was subsequently donated to a local non-profit organization without notifying R1’s responsible party (RP). Based on interviews conducted, observations, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Allegation: Staff did not ensure resident's room was clean It was alleged that staff did not ensure that the resident’s room was kept clean and sanitary in that there were several instances where feces remnants were left on surfaces throughout the resident’s bathroom following showers and toileting assistance. Photographs dated August 5, 2025, were reviewed and showed feces on the resident’s shower floor and shower chair. LPA reviewed facility housekeeping logs, shower logs, and R1’s progress notes. Prior to August 5, 2025, the resident’s last recorded shower was provided on July 22, 2025, 13 days earlier, indicating that would have been the latest point in time when the soiling of the resident’s shower chair occurred. According to housekeeping logs, the resident’s room was serviced July 27, 2025. On a Housekeeping Report dated the same day, it was documented that housekeeping staff “changed bedding, cleaned the bedroom and bathroom,” however, the soilage remained until the photograph was taken on August 5, 2025. According to R1’s 2025 care plan, R1 was to be provided with a two-person assist with each shower, twice a week. Thus, indicating two staff members should have been present on July 27, 2025, for the resident’s last known shower. These two (2) staff members would have observed the soiling of the shower floor and shower chair and chose to neither clean the mess themselves, or alert housekeeping staff to the need for additional disinfecting of R1’s bathroom. Photographs dated August 25, 2025, were reviewed and showed feces remnants on R1’s bathroom floor, toilet seat, and inside the trashcan. Housekeeping reports indicated R1’s room was last serviced on August 19, 2025, where the notes indicate “cleaned room, bathroom”, thus indicating the soiling of the bathroom services occurred between August 19, 2025, and August 25, 2025. According to R1’s 2025 care plan, the resident required a two-person transfer for toileting indicating two staff would have present in the resident’s room multiple times within the above-mentioned time period and observed the mess without cleaning or alerting housekeeping. Continued on additional LIC 9099-C Finally, a photograph dated September 19, 2025, showed feces remnants on R1’s shower chair. It was alleged that the soiling was left there by staff for three days and the resident’s responsible party cleaned it themselves. Shower logs indicated R1 received a shower September 16, 2025, and September 19, 2025. Two staff should have been present for both showers and observed the soilage. LPA was provided housekeeping logs dated September 2, 2025, and September 30, 2025, indicating R1’s room was serviced. There was no documentation provided to the LPA indicating the resident’s room had been serviced between those dates. Based on interviews conducted, observations, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Allegation: Staff did not ensure resident's wheelchair was clean It was alleged that staff did not clean the resident’s wheelchair, particularly following meals. LPA observed photo documentation dated August 15, 2025, of food soilage covering the foot plate of the resident’s wheelchair. R1’s family reportedly cleaned the wheelchair. LPA reviewed the resident’s 2025 care plan which indicated the resident was to be provided a plate guard which would assist the resident in keeping food from falling to the resident’s feet. Due to the food soilage observed on the resident’s footplate, it is deducted that the care plan was not followed. Additionally, on August 13, 2025, a note was written in the care plan indicating that R1 would now require 1-on-1 assistance with feeding by a staff member. Specifically, the services/interventions column of the care plan indicates “Staff will provide set up, plating, and serving all meals/fluids.” If staff were providing the resident with the service documented in the care plan, staff would have observed the food mess created on the resident’s wheelchair and should have aided with cleaning in order to provide R1 with clean, healthful, accommodations. Based on interviews conducted, observations, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Exit interview conducted. A copy of this report and Appeal Rights were provided to Administrator, Stacey Baxter Allegation: Staff did not notify authorized representative of change of condition in resident It was alleged that R1 experienced a change in condition and the resident’s responsible party was not informed. Upon further investigation and interview, it was determined this allegation was a misunderstanding of the circumstances of the complaint and was ultimately determined to be a clerical error. This allegation is unfounded. A finding that the allegation is unfounded means the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. A copy of this report was provided to Administrator, Stacey Baxter.the state’s words, verbatim · CDSS document, Sep 16, 2026 · control 59-AS-20251124111505

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.2(c) · Plan of correction due date: Oct 2, 2026

Health and Safety Code section 1569.2(c) provides: (c) "Care and supervision" means the facility assumes responsibility for, or provides… ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement was not met as evidenced by: Based on interviews conducted and records reviewed, it was determined that staff did not ensure that R1’s care plan was being followed in that staff were not assisting the resident with regular grooming/bathing, staff were not providing the resident with his plate guard during meals, and staff donated a sit to stand device of which the resident had a medical order to utilize at a future date. This poses a potential health, safety, and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 16, 2026

Plan of correction: POC: Licensee/Administrator shall conduct a staff training regarding the above-mentioned regulation and the importance of following resident care plans. Administrator shall submit training outline/agenda and staff sign in sheet to LPA by end of business on October 3, 2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(A)(1) · Plan of correction due date: Oct 2, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. Based on interviews conducted, LPA observations, and records reviewed, it was determined that staff did not ensure that the facility was clean, safe, sanitary, and in good repair at all times, in that R1’s bathroom was found to have feces remnants on several occasions where staff did not take action or alert housekeeping to the need for extra services. This poses a potential health, safety, and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 16, 2026

Plan of correction: POC: Licensee/Administrator shall conduct a training, to include housekeeping staff, on ensuring resident’s rooms and personal areas are kept clean and sanitary at all times. Administrator shall submit training outline/agenda and staff sign in sheet to LPA by end of business on September 25, 2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a) · Plan of correction due date: Oct 2, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Based on interviews conducted, LPA observations, and records reviewed, it was determined that staff did not accord R1 with healthful and comfortable accommodations in that staff failed to clean food waste from R1s wheelchair footplate following meals. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 16, 2026

Plan of correction: POC: Licensee/Administrator shall conduct a training, to include housekeeping staff, on ensuring resident’s rooms and personal effects (i.e. wheelchairs, walkers, etc.) are kept clean and sanitary at all times. Administrator shall submit training outline/agenda and staff sign in sheet to LPA by end of business on October 3, 2026.

Allegation investigated: Staff does not ensure adequate supervision is being provided to residents in care Staff did not ensure resident was fully clothed while in care

On April 28, 2026, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced for the purpose pf delivering complaint findings. LPA was greeted by Human Resources and Talent Coordinator, Kristi Bracisco, and explained the purpose of the visit. During the visit, there were 53 residents and 7 staff providing direct care. During the course of the investigation, interviews were conducted, observations were made, and pertinent records were reviewed. Continued on LIC 9099-C Unsubstantiated Allegation: Staff does not ensure adequate supervision is being provided to residents in care It was alleged that staff were not providing adequate care and supervision to residents by not regularly checking on residents’ whereabouts in the facility. According to the complaint, a visitor arrived at the facility and staff were unable to locate the resident the visitor was there to meet with. The resident was later located in their room taking a nap. The visitor claimed staff were unable to provide any details regarding the residents’ previous whereabouts and actions. LPA conducted interviews separately with three (3) staff members who were present on the day of the above incident and all of whom stated the allegations were inaccurate. All staff stated that on the day of the incident described above, R1 had just finished their lunch and had indicated to staff that they would prefer to rest in the afternoon, rather than participate in activities as they usually did. A family member of R1 had arrived to the facility and was unable to locate the resident in the activities room or any other common areas. R1’s bedroom door was closed and locked as well to prevent other residents from potentially disturbing R1 during their nap. All staff interviewed noted the family member had arrived during the PM shift change at the facility, thus, when R1’s family member asked several staff where they could find R1, oncoming staff responded with “I don’t know.” S1, who had been at the facility prior to shift change and remained at the facility during the incident, explained to the family member that R1 was in their room and other staff were unaware of R1’s whereabouts as they had just arrived for their shifts. S1 allowed the family member into S1’s room where they were still napping. Although the allegation may have happened, the preponderance of evidence has not been met. Therefore, the allegation is UNSUBSTANTIATED. Continued on LIC 9099-C Allegation: Staff did not ensure resident was fully clothed while in care It was further alleged that staff were not properly assisting R1 with dressing for the day, as indicated in R1’s care plan. LPA conducted interviews separately with three (3) staff members who were present on the day of the above incident and all of whom stated the allegations were inaccurate. Staff were in agreeance that R1 had requested to go to their room to rest following lunch. All staff reported that staff had provided R1 with a shower prior to having R1 lay down in their bed. S1 further reported that R1 had requested to lay down without pants on for comfort and R1’s clothing was placed next to their bed so R1 could be assisted with re-dressing once they had woken up. LPA reviewed facility shower logs and confirmed R1 was provided a shower from an AM shift (6:00 am – 3:00 pm) staff person on the same day as the allegation. Further, facility progress notes indicated that the resident did in fact have a visitor that afternoon, left the facility accompanied by family, and returned to the facility around dinner time where they then returned to their room to rest and watch television. Although the allegation may have happened, the preponderance of evidence has not been met. Therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted. A copy of this report was provided to Executive Director, Stacey Baxter, via email.the state’s words, verbatim · CDSS document, Apr 28, 2026 · control 59-AS-20250626121539

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on November 18, 2025 to conduct an annual continuation visit utilizing the inspection tool following the Required-1 Year Inspection conducted on November 6, 2025. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed eight (8) resident apartments and three (3) common area bathrooms. LPA observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 118 degrees F. LPA observed the perimeter of the care home to be free of clutter and debris. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. Smoke detectors and carbon monoxide detectors are hard wired in the care home. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA reviewed two (2) residents' medications and observed medication storage to be locked away and inaccessible to the residents. As a result of today's visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report given at the conclusion of this visit.the state’s words, verbatim · CDSS document, Nov 18, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on November 6, 2025 to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA reviewed five (5) resident files and five (5) staff files. LPA conducted interviews during inspection. Facility has a current copy of certificate of liability insurance and LPA requested a copy. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. LPA will return at a later time to conduct a tour of the premises and complete annual inspection. Exit interview conducted and copy of report given at the conclusion of this visit.the state’s words, verbatim · CDSS document, Nov 6, 2025

Type of visit: Case Management - Incident

On 04/11/2025, Licensing Program Analyst (LPA) Sarah Benson arrived at the facility to conduct an unannounced case management visit in response to an incident report submitted to licensing on 4-4-25 and explained the purpose of the visit. LPA Benson met with Lori Whitburn Clinical Services Director Kristi Bracisco Resident Care Coordinator. LPA Benson reviewed the resident file, medications records and documentation from hospital pertaining to R1’s incident. LPA interviewed staff and the resident. LPA determined that facility took appropriate action in responding to incident on 4-3-25. No deficiencies cited. Exit interview done and copy of report left with the facility. Exit interview conducted.the state’s words, verbatim · CDSS document, Apr 11, 2025

Type of visit: Required - 1 Year

On 09/19/2024, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Brenda Reitz and explained the purpose of the visit. LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, courtyard, kitchen and common restrooms. LPA observed each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids and 20-second hand-washing poster. LPA observed the resident bedrooms to have all the required furnishings, working lights/fan and windows with screens. LPA observed medications, chemicals and knives locked inaccessible to residents. LPA observed the water temperature to be within the required range. Facility has a 2-day perishable and a 7-day non-perishable amount of food. LPA observed fire extinguishers, fire detectors, and carbon monoxide detectors. LPA observed a complete emergency first aid kit ready for emergency use. LPA observed a completed emergency disaster plan and emergency disaster drills conducted as required. LPA observed the facility to be clean, in good repair and odor-free. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA reviewed a total of six (6) residents' files and six (6) staff files which contained all of the required documentation. Several topics were discussed. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Sep 19, 2024

Allegation investigated: Staff does not monitor resident's change of health. Staff does not ensure resident is adequate fed resulting in resident losing weight. Staff do not ensure resident's grooming needs are being met. Staff do not provide adequate supervision to resident in care.

On 04/23/2024 Licensing Program Analyst Jaynae Boyles made an unannounced visit to the facility and met with Clinical Services Director. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation the administrator, resident, four witnesses and three staff were interviewed. LPA reviewed the following documents: Resident file, visitation log and the staff schedule for the facility. This agency has investigated the complaint alleging Staff does not monitor resident's change of health, Staff does not ensure resident is adequate fed resulting in resident losing weight, Staff do not ensure resident's grooming needs are being met, Staff do not provide adequate supervision to resident in care. We have found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted. A copy of the report was provided to staff. Unfounded LPA investigated, “Staff does not monitor resident's change of health”. All witnesses and staff have stated that there has been no change of condition for the resident since the onset of placement within the facility. LPA investigated, “Staff does not ensure resident is adequate fed resulting in resident losing weight”. All witnesses and staff reported that the resident has not lost any weight since placement within the facility. LPA investigated, “Staff do not ensure resident's grooming needs are being met”. All witness and staff have reported that the residents grooming needs are met by the resident or the facility staff. Family reported that at the onset of placement in the facility the resident was having difficulty saving and the family purchased an electronic shaver for the resident. LPA investigated, “Staff do not provide adequate supervision to resident in care”. All witness report that the resident is receiving adequate supervision at the facility. The staff report that the resident receives assistance when requested.the state’s words, verbatim · CDSS document, Apr 23, 2024 · control 59-AS-20240229113634

Allegation investigated: Facility failed to follow care plan leading to a resident developing pressure injuries. Facility is retaining residents beyond their level of care. Facility staff are not supervising residents.

On 03/19/24, Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 05/01/23. LPA Gurriere met with Brenda Reitz, Administrator, and explained the purpose of the visit. Facility failed to follow care plan leading to a resident developing pressure injuries. During the interview process, numerous documents were obtained. Documents included the Physician’s Report, Medication Administrative Records (MARs), Home Health records, Hospice records, Resident Care Plan, and Physicians Orders. continued Substantiated continued During the investigation process, management, numerous staff persons, a physician and a nurse were interviewed regarding the resident’s condition. The resident (Resident 1) was not interviewed, as she has since passed away. It was reported that the resident developed several pressure injuries while in care. The following information was provided regarding the resident: On 07/11/22 the resident was seen by her physician, and it was noted that the resident had a skin breakdown in her groin area and topical cream was prescribed. On 07/14/22 the first notation of a breakdown was on the resident’s “bottom.” It was stated in the care notes that the “resident has a sore on her bottom that is getting bad, we are going to rotate her while in bed and please apply cream after toileting.” On 07/17/22 it was documented that the resident had an “open” wound on her coccyx and blisters on her heel. The resident was not seen by the physician until 07/29/22 and at that time, the physician opened the resident to Home Health for wound care. The resident did not get professional medical care from the physician or a home health nurse for numerous days for several pressure injuries. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed. Facility is retaining residents beyond their level of care. During the interview process, numerous documents were obtained. Documents included the Physician’s Report, Medication Administrative Records (MARs), Home Health records, Hospice records, Resident Care Plan, and Physicians Orders. During the investigation process, management, numerous staff persons, a physician and a nurse were interviewed regarding the resident’s condition. The resident (Resident 1) was not interviewed, as she has since passed away. It was reported that the resident developed several pressure injuries while in care as noted in the above-mentioned report. It was indicated that for numerous days, the resident had several pressure injuries that were not staged by a physician or an appropriately skilled professional, as required. If the licensee chooses to retain a resident with pressure injuries, the licensee shall have the pressure injuries staged and shall ask the licensing agency for an exception to retain the resident if the pressure injuries are a Stage 3 or 4. It is noted that at the time, when the resident had pressure injuries, initially the resident was not receiving home health care or hospice services for several days. It was determined that the facility failed to obtain an exception for the resident when it was determined that the resident had pressure injuries (unstaged), which is a prohibited and/or restricted health condition. According to the Mayo Clinic a pressure ulcer is, “A localized injury to the skin and /or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear”. The National Pressure Ulcer Advisory Panel (NPUAP) advises that “Unstageable wounds are either Stage 3 or 4 ulcers that cannot definitively be placed in either of these stages due to eschar (dry scab or mass of dead tissue covering a wound) that obstructs clear observation of the wound. Therefore, by general medical consensus, a wound diagnosed as an unstageable wound is either a Stage 3 or 4 wound and, as such, is to be treated as a prohibited health condition.” Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed. Facility staff are not supervising residents. During the interview process, numerous documents were obtained. Documents included the Physician’s Report, Medication Administrative Records (MARs), Resident Care Plan, and Physicians Orders. During the investigation process, management, and numerous staff persons, were interviewed. The resident (Resident 2) was not interviewed, as he has since passed away. It was reported that the resident was a fall risk. Physical therapy was brought in for the resident between November-December 2022 and documented that the resident improved in his ability to ambulate with a walker but was noted “as ambulating with a standby assist.” Prior to the resident’s fall on 06/12/22, the resident had five falls documented between 01/22-05/23/22. The resident was sent to the hospital for the fall on 05/23/22 with a hematoma to his forehead. The charting notes state that the resident was very unsteady, was wandering (as usual) and needed repeat reminders to use his walker. On 06/12/22 the resident was sent to the hospital after sustaining an unwitnessed fall in the hallway of the facility. The resident was diagnosed with and underwent surgery to repair a left femoral neck fracture. Some staff reported that the resident had a shuffled step, was unsteady with his walker or would walk very rapidly with his walker and needed an escort or additional supervision. However, other staff reported that the resident only needed reminders to use his walker but was otherwise able to ambulate without assistance. It was reported that the facility was unable to provide a fall risk care plan that was updated prior to 06/12/22. When a resident is at fall risk, the facility shall complete a fall risk care plan for the resident. There was no written fall risk care plan addressing the resident’s falls. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed. An immediate civil penalty in the amount of $500.00 assessed for R2 sustaining a serious bodily injury while in care at this facility. During the investigation process, management, numerous staff persons, a physician and others were interviewed. It was reported that the resident (Resident 1) had severe dementia, anxiety issues and quit wanting to eat. The resident had pneumonia right before she had pressure wounds. The resident’s physician reported that once a resident contracts an infection like pneumonia, it can be very hard to come back from. The resident’s death certificate stated the cause of death as Cardiopulmonary Arrest with Nutritional Deficiency, Anorexia and Dementia as underlying causes. It was stated that there was not a preponderance of evidence found to substantiate that the resident’s death was a result of the pressure injury or neglect. It was reported that the resident (Resident 2) had an unwitnessed fall at the facility and suffered a left femoral neck fracture. After surgery, the resident was transferred to a Post-Acute Skilled Nursing facility for rehabilitation and while there, suffered another fall. The resident was transferred to the hospital with confusion, lethargy, and laceration. In addition, scans showed another fracture and concern for a possible subarachnoid hemorrhage. It cannot be substantiated that the resident’s death was a result of neglect or lack of care and supervision on the part of the facility. A facility staff was working while intoxicated. During the investigation process, management, and numerous staff persons, were interviewed. The residents were not interviewed due to their dementia status. It was reported that there could have been a person that came to the facility to work and was allegedly intoxicated. Another staff person contacted management to advise of the allegation. The manager arrived at the facility and as a precaution, requested that the staff person in question be sent home. It was stated that after the incident, the staff person was terminated from her position. It was reported that there was not an issue with resident care during the time of the incident. The facility is unsanitary. During the investigation process, management, and numerous staff persons, were interviewed. The residents were not interviewed due to their dementia status. The allegation was stated to report that soiled adult briefs are left unattended in resident rooms and that sheets are not changed when soiled. Overall, staff reported that the staff bag up the soiled adult briefs and dispose of them in designated trash cans. In addition, it was reported that sheets are changed as needed and when soiled. Facility staff are not meeting residents’ hygiene needs. During the investigation process, management, and numerous staff persons, were interviewed. The residents were not interviewed due to their dementia status. It was reported by nearly all staff persons that they are meeting the residents’ hygiene needs, as they follow a showering schedule. Staff reported that if a resident refuses to shower, they will try again later. It was stated that some of the residents will refuse their shower day, which is the resident’s right to do so. Facility runs out of supplies. During the investigation process, management, and numerous staff persons, were interviewed. The residents were not interviewed due to their dementia status. The allegation indicated that the facility does not have enough disposable wet wipes available when changing the adult briefs of residents. An inventory list was obtained and reviewed, and the list indicated that the facility is ordering wet wipes to use on the residents. Overall, staff confirmed that wet wipes are available when changing a resident and providing care and supervision. Although the above allegations mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and all of the above findings are Unsubstantiated.the state’s words, verbatim · CDSS document, Mar 19, 2024 · control 59-AS-20230501133628

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(d) · Plan of correction due date: Mar 20, 2024

Basic Services - A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement was not met as evidenced by: Based on interviews by numerous persons, and records reviewed, the licensee did not ensure that the resident received care in a timely manner for her pressure injuries. This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Mar 19, 2024

Plan of correction: The administrator agrees to submit to the licensing agency how this type of deficiency will be avoided in the future.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87616(a) · Plan of correction due date: Mar 20, 2024

Exceptions for Health Conditions As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means. This requirement was not met as evidenced by: Based on interviews by numerous persons, and records reviewed, the licensee did not ensure that an exception was in place for a resident that had pressure injuries. This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Mar 19, 2024

Plan of correction: The administrator agrees to submit to the licensing agency a statement that she understands the requirement to request an exception when a resident is staged with a pressure wound, Stage 3 or 4.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Mar 20, 2024

Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by interviews and documentation review. The licensee failed to comply with the regulation cited above. A fall risk care plan was not in place. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 19, 2024

Plan of correction: The administrator agrees to assess all residents that are a fall risk. Training shall be provided to care providers regarding prevention practices of residents that are a fall risk. The administrator agrees to submit to the licensing agency the materials used to train the care providers and a sign in sheet of those that were trained. An immediate civil penalty in the amount of $500.00 assessed for R2 sustaining a serious bodily injury while in care at this facility.