342700077-3-1-2023-25-AS-MSEY-CPKMNU-20230303084604

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700077
Report Date: 03/01/2023
Date Signed: 03/01/2023 03:01:05 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/17/2023 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20230217141618

FACILITY NAME:	COURTE AT CITRUS HEIGHTS, THE		FACILITY NUMBER:	342700077
ADMINISTRATOR:	ARMSTRONG, ANDREA		FACILITY TYPE:	740
ADDRESS:	6825 SUNRISE BLVD		TELEPHONE:	(916) 721-0644
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	48	CENSUS: 20	DATE:	03/01/2023
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Andrea Armstrong, Administrator and Kylie Whitaker, Health Services Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff leave residents in soiled diapers for extended periods of time which resulted in diaper rashes
Staff failed to re-position resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude a complaint investigation and deliver findings to a complaint received on 2/17/23. LPA met with Kylie Whitaker, Health Services Director (HSD) and Andrea Armstrong, Administrator, and explained purpose of inspection. LPA completed required COVID-19 department protocols, conducted a daily self-screening for symptoms of COVID-19 infection and was wearing an N95 mask.

During the investigation, LPA interviewed the facility Administrator, Health and Services Director (HSD, (3) caregiver or Med-Tech staff, (1) nurse, (2) residents and (1) family member of resident (R1). LPA also reviewed pertinent documentation including R1's physician report, physician's orders, Interim Service plans and other documentation. LPA toured the facility (2) times during the investigation and observed resident (R1), who is the subject of the investigation.

The results of the investigation are as follows:
cont on 9099C(1)..

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023

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 3

Control Number 25-AS-20230217141618

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: COURTE AT CITRUS HEIGHTS, THE	FACILITY NUMBER: 342700077
	VISIT DATE: 03/01/2023

NARRATIVE

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9099C (1).. Allegation: Staff leave residents in soiled diapers for extended periods of time which resulted in diaper rashes.
Complaint alleges that staff (S1) doesn’t change the residents in a timely manner, including resident (R1) and leaves them in soiled diapers for extended periods of time, causing residents to sustain diaper rashes.

All staff interviews indicated that all residents are checked regularly, every (2) hours as part of incontinent checks and staff is not aware of any residents being left in soiled diapers for extended periods of time. One staff stated "there are a few fighters when we try to provide incontinent care so we will try a different approach."

One caregiver staff stated R1 is a "heavy whetter" and gets changed constantly" with a staff nurse stating that staff will check R1 every 2 hours at least, and during meals and snacks also. Staff (S1) stated she has never witnessed any resident to be soiled on her shift due to neglect- and at 2 pm, "pm" staff will communicate with "am" staff during the "shift exchange" and staff check on residents every 2 hours and we "take action if we know they need to be changed". S1 confirmed that she and another staff assist in changing R1 and R1 "urinates a lot and tends to go all at once".

R1's care plan indicates that R1 is checked for incontinent care every two hours. QMAR documentation was reviewed from 1/22/23 through 2/21/23, for all shifts, showing that the caregiver assigned on each day signed off that the required care was provided per the care plan.

LPA observed (2) caregivers to be assisting R1 on 3/1/23 at approximately 1:45 pm. LPA observed R1 during an inspection on 2/21/23 and did not observe any odors to be present in the room, at (2) different times.

R1'a family member stated he has "been very happy with the level of care" R1's family member stated he has never noticed R1 to be laying in soiled diaper when he visits her. The same family member stated he is not there all of the time but every time he does visit, R1 appears as well taken care of.

Based on information obtained, LPA finds the allegation to be UNFOUNDED-- a finding meaning that the allegation was false, could not have happened and/or is without a reasonable basis
cont on 9099C(2)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20230217141618

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: COURTE AT CITRUS HEIGHTS, THE	FACILITY NUMBER: 342700077
	VISIT DATE: 03/01/2023

NARRATIVE

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9099C-2... Allegation: Staff failed to re-position resident.
Complaint alleges that resident (R1) is bedridden and is being neglected by staff (S1), who does not re-position and change R1 in a timely manner, causing diaper rashes.

R1's physician's report, dated 2/20/23, notes that R1 has a history of stage 2 on the cocyx.

Staff interviews indicated R1 does not currently have open sores, but "just redness" and R1 is being re-positioned every 2 hours as needed to prevent pressure sores. One staff stated "we do reposition her every 2 hours but she still has redness". When asked if R1 had/has any pressure sores, a facility staff nurse stated "maybe- I would say yes- it was very tiny but it healed very quickly - Hospice would have taken care of it". R1's family member confirmed that R1 does not have any pressure sores now but did before when on hospice.

S1 stated that she and another staff change R1 and "at that time, we rotate her to other side". S1 confirmed that staff do document this care in the QMAR. S1 stated R1 does not have any pressures sores but the nurse would put barrier creme on R1 to prevent redness. Physician's Orders show R1 has an as needed order for Calmoseptine, effective 2/28/22, for redness or excoriation.

LPA observed an Interim Service Plan, dated 1/18/23 where R1 had a small pressure sore on the intergluteal, left side and a second service plan, dated 10/20/22, where R1 had a Stage 1 sore on the Left buttocks and a Stage 2 on the cocyx. Hospice records show R1 was on hospice at the time of both sores and was discharged on 1/31/23. Both care plans show multiple staff signed and were aware of R1's pressure sore(s).

LPA observed R1 at (2) different times during the inspection on 2/21/23 and HSD showed LPA that the pillow had been rotated from one side to the other to prevent pressure sores.

Based on information obtained, LPA finds the allegation to be UNFOUNDED-- a finding meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview. Copy of report provided to facility.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023

LIC9099 (FAS) - (06/04)

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