Amber Grove Place

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.

Type of visit: Required - 1 Year

On 10/24/2023, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Exclusive Director, Brenda Reitz, and explained the purpose of the visit. LPA conducted an inspection of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be clean, in good repair and odor-free. LPA observed bedrooms 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 115 degrees F. Each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids. LPA checked the kitchen area for the ability to prepare and store food. Facility 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. LPA observed the outdoor area and perimeter of the facility to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke detectors and carbon monoxide detector are operational. Fire extinguisher and first aid kit are maintained and ready for emergency use. LPA checked medication storage and found medication to be locked away and inaccessible to the residents. LPA reviewed (5) resident files and also reviewed six (6) staff files. As a result of this 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, Oct 24, 2023

Allegation investigated: Resident sustained injuries due to lack of supervision.

LPA Hiratsuka conducted this visit to deliver the results of the investigation above. LPA met with Brenda Reitz, Executive Director, and spoke to Tara Killinger, Vice President of Operations on the phone. During the course of the investigation the executive director, former staff, and current staff were interviewed. Medical records and facility records were reviewed. The resident in question had several falls during the duration of the time at the facility. Per the regulations the resident shall be accessed each time there a change in condition and written plans of care shall be adjusted accordingly. Record reviews show this did not happen. Interviews showed interventions were discussed but they were not implemented and there is no documentation stating why the interventions were not implemented. Substantiated Title 22 Regulations, Report Requirements state: 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. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. The facility produced documentation they spoke to the responsible party. There was another person related to the resident who requested the written report and wanted the same incident report that was submitted to Community Care Licensing Division. Title 22 Regulations state the information is to be released to the responsible party only and not a third party. There was no written consent produced from the responsible party to allow the third party to receive the information. Also, Title 22 Regulations does not state the incident report submitted to Community Care Licensing Division shall match the one released to the responsible party. LPA discussed with Executive Director Brenda Reitz, and Tara Killinger, Vice President of Operations about reporting requirements and what may or may not be released. Because LPA cannot prove or disprove what is required to be reported to responsible parties and what was discussed for this incident, the allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. An exit interview was conducted. A copy of the report was provided to facility executive director Brenda Reitz. The fall in question occurred in May 2023. The caregiver went to check on the resident in the morning and the resident did not want to get up. Per the facility report, about an hour later a housekeeper heard the resident yelling for help and that is the fall that resulted in the injury. The written care of plan did not indicate how frequently the resident needed to be checked on and there were no fall prevention interventions specific to the resident in question. As a result of this investigation, the Department finds the allegation above to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. At the time of the complaint visit, an immediate civil penalty of $500 shall be assessed for a violation of California Code of Regulations Section 87463(a). The licensee was informed that a civil penalty was under review and may be assessed at a future date according to Health and Safety Code 1569.49. Exit interview conducted. A copy of the report has been issued. Appeal Rights provided. Brenda Reitz signature on this report acknowledges receipt of the Appeal Rightsthe state’s words, verbatim · CDSS document, Oct 18, 2023 · control 59-AS-20230530143145

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a) · Plan of correction due date: Oct 19, 2023

Reappraisals. The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Based on observation and document review it was determined that the licensee failed to ensure the appraisal was updated and the written plan of care and after each fall. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 18, 2023

Plan of correction: By 10/19/2023, the licensee shall submit in writing a facility fall prevent plan that shall at minimum include documentation of meetings with responsible parties, documenting change of conditions, discussion of fall prevent measures with responsible party, and overall documentation of the resident. IMMEDIATE $500 CIVIL PENALTY ISSUED.