045002503-8-1-2023-59-AS-KHOS-CV6PW3-20230829114001

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002503
Report Date: 08/01/2023
Date Signed: 08/01/2023 01:51:16 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/07/2023 and conducted by Evaluator Rebecca Knight

COMPLAINT CONTROL NUMBER: 59-AS-20230307154007

FACILITY NAME:	ALMOND BLOSSOM SENIOR CARE-BIDWELL HEIGHTS		FACILITY NUMBER:	045002503
ADMINISTRATOR:	CARTWRIGHT, KATHERINE		FACILITY TYPE:	740
ADDRESS:	1 BUDLEE COURT		TELEPHONE:	(530) 809-2408
CITY:	CHICO	STATE: CA	ZIP CODE:	95928
CAPACITY:	6	CENSUS:	DATE:	08/01/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Katherin Cartwright 0 Executuive Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained severe pressure injuries due to staff neglect. - UNSUBSTANTIATED
Staff left resident in soiled diaper for an extended period of time. - UNSUBSTANTIATED
Staff did not assist resident with eating. - UNSUBSTANTIATED

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

08/01/2023 1:30 PM Licensing Program Analyst (LPA’s) Rebecca Knight and Jayna Boyles made an unannounced visit to the facility and met with Executive Director Katherine Cartwright. The purpose of this visit was to deliver the results of a complaint investigation.
During the course of the investigation the Executive Director, staff, and residents were interviewed. In addition, 2 physicians, 1 home health RN, and 1 wound specialist RN were interviewed.

The following documents were received and reviewed: Related incident reports, Pre-admission plan, Physicians report, ADL Care Charting notes, medical records, staff roster, resident roster.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 59-AS-20230307154007

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ALMOND BLOSSOM SENIOR CARE-BIDWELL HEIGHTS	FACILITY NUMBER: 045002503
	VISIT DATE: 08/01/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Page 2
Resident sustained severe pressure injuries due to staff neglect. - UNSUBSTANTIATED

It was alleged that Resident 1 (R1) sustained an unstageable pressure injury while in care, due to staff neglect and lack of care and supervision.

R1 was admitted to the hospital on 12/23/2022 with an unstageable pressure injury to their buttock area and a deep tissue injury (DTI) on their right heel. Medical records also showed a diagnosis of sepsis and inhalation pneumonia. R1 subsequently passed away in the hospital on 01/08/2023. Medical records obtained provided that, “in spite of appropriate resuscitative efforts and antimicrobial therapy,” R1 continued to decline. The family ultimately elected for comfort care. R1’s causes of death were listed as: 1. Septic shock, 2. Aspiration pneumonia, 3. Advanced Parkinson’s disease. R1’s attending physician was interviewed and stated R1 was at a high risk of aspiration and could have aspirated on food, liquid, saliva or acid reflux. R1’s attending physician stated they had not been concerned that timely medical attention had not been sought or that R1’s care was being neglected.

Although, some witnesses interviewed expressed concern regarding the level of care able to be provided by a solo staffed facility and that there may have been times that R1’s brief was not changed in a timely manner, all current staff interviewed stated they were not aware of any pressure injury on R1’s buttocks or heel and were not treating any skin redness or breakdown. There were no skin breakdown issues noted in ADL charting in the days and weeks leading up to R1’s admission, nor any indication that barrier cream was being used per R1’s medication administration record (MAR).

R1 received home health visits through 11/23/2022 and there were no indications of skin breakdown noted. The home health nurse was interviewed and stated she had not seen anything concerning regarding the care R1 was receiving from staff.

Continued on LIC9099-C

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 59-AS-20230307154007

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ALMOND BLOSSOM SENIOR CARE-BIDWELL HEIGHTS	FACILITY NUMBER: 045002503
	VISIT DATE: 08/01/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Page 3
A wound care specialist was interviewed and stated that R1’s wounds were plausible to be the “evolution and manifestation” of sepsis and “not necessarily due to lack of movement.” The specialist stated, “These are not the kinds of wounds that look to me like the patient was not getting appropriate care.” It is possible that the wounds and discoloration on R1’s heel and buttocks could have developed quickly within a few hours or overnight. The specialist stated, based on the medical records indicating that R1 had had increased weakness and had seemed to be declining over a period of time, she felt “they must have been doing something right, otherwise we would have seen large, deep wounds.”

Although medical records confirm that R1 did sustain an unstageable pressure injury and DTI prior to being admitted to the hospital, based on statements by the wound care specialist, there is not a preponderance of evidence to show that these wounds were the result of staff neglect or lack of care and supervision. This allegation is unsubstantiated.

Staff left resident in soiled diaper for an extended period of time. - UNSUBSTANTIATED

During the investigation, concerns were raised by some former staff and residents that resident’s needs are not being met in a timely manner due to lack of staffing. The home health nurse was interviewed and stated they had not seen anything concerning regarding the care R1 was receiving from staff. This allegation is unsubstantiated.

Continued on LIC9099-C

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 59-AS-20230307154007

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ALMOND BLOSSOM SENIOR CARE-BIDWELL HEIGHTS	FACILITY NUMBER: 045002503
	VISIT DATE: 08/01/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Page 4
Staff did not assist resident with eating. - UNSUBSTANTIATED

Regarding allegations that R1 was not being assisted or supervised when eating, and that R1’s recommended mechanical soft and thickened liquid diet was not being followed, there were multiple staff who stated R1 either did not require assistance in eating or was unsupervised when eating. Multiple staff and the home health nurse stated that R1’s family would bring in food that was not in line with R1’s recommended diet. However, one staff admitted that they purchased and provided chips to R1 that were not in accordance with a mechanical soft diet. However, other staff stated R1 would ask for the food R1 wanted and staff were following R1’s right to choose.

It was determined that even though it was recommended that R1 follow a mechanical soft and thickened liquid diet, R1 chose to eat foods that are not suitable for that diet. Furthermore, R1’s family brought foods into the facility to give to R1 that are not suitable for a mechanical soft diet. Facility staff did provide R1 with chips at R1’s request. This 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 Executive Director Katherine Cartwright.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4