347001498-7-20-2023-59-AS-MSEY-CTXPPJ-20230721112937

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001498
Report Date: 07/20/2023
Date Signed: 07/20/2023 05:25:54 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
04/12/2023 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20230412085616

FACILITY NAME:	CITRUS HEIGHTS TERRACE		FACILITY NUMBER:	347001498
ADMINISTRATOR:	TINA PREWITT		FACILITY TYPE:	740
ADDRESS:	7952 OLD AUBURN ROAD		TELEPHONE:	(916) 727-4400
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	45	CENSUS: 45	DATE:	07/20/2023
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Editha Mc Cullough, Interim Administrator		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Resident sustained pressure injuries while in care
Facility staff are not meeting residents' hygiene needs.
Facility staff are not providing residents assistance with toileting.
Facility staff left residents in urine soaked bedding.
Facility staff does not ensure that residents have clean bed linens.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on 4/12/23. The allegation: Resident sustained pressure injuries while in care was investigated by the Department and LPA investigated the remaining (4) allegations. LPA met with Editha McCullough, Interim Administrator, and explained purpose of inspection. T

During the investigation, the Department conducted interviews and reviewed documentation, including medical records. The results of the investigation are as follows:

Resident (R1) was admitted to the facility on 10/6/2021 from a skilled nursing after being hospitalized. Resident had been receiving home health services for an extended period of time before being hospitalized. A wound was noted on 10/5/21 on resident's right foot; a second wound was not noted until January 2022. In June 2022, resident had an annual assessment and Physical Therapy was recommended. Resident was admitted to the SNF in early June 2022 and was not discharged until late August 2022.

cont on 9099C-1..

Unsubstantiated

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: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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-20230412085616

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: CITRUS HEIGHTS TERRACE	FACILITY NUMBER: 347001498
	VISIT DATE: 07/20/2023

NARRATIVE

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9099C-1...On 9/2/22, the facility staff called home health staff and reported a wound on resident's buttocks.

Charting notes from Sept 2022, note that resident had a rash on his body and was receiving care from home health nurses. Notes from October 2022 indicate that resident still complained of pain on his legs, feet and bottom and home health nurses were aware. Notes entered on 3/23/23 document resident was "100% bed bound" and refuses to get out of bed.

Resident's Service Plan dated 8/22/22 notes that resident needs maximum assistance with bathing, dressing, grooming, dental, toileting, transfer/mobility, special care needs, cognitive, disposition and behaviors, sleep, communication, psycho-social engagement and medication management.

Resident sustained only pressure injuries of stage 1 and 2 while living at the facility. Home health records obtained through 2/24/23, indicate,there were no stageable pressure injuries. Home health records did not reflect any concerns or neglect with facility care being provided, including with wound care. Residents family member stated during the investigation that resident does not currently have any pressure sores.

Home health nurse was not interviewed due to no concerns noted in the home health records.

Based on information obtained, the Department finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Facility staff are not meeting residents' hygiene needs.

LPA reviewed the Shower Schedule binder for July 2023 and observed residents are scheduled for a shower at least twice weekly. The Administrator and a caregivers stated that staff is supposed to initial on the individual resident’s calendar page, at the end of the work shift, when a shower is given, but sometimes it is not done. LPA observed that almost all residents have multiple days that have not been initialed. If a resident is on hospice, the hospice staff will give the shower.

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: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 59-AS-20230412085616

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: CITRUS HEIGHTS TERRACE	FACILITY NUMBER: 347001498
	VISIT DATE: 07/20/2023

NARRATIVE

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9099C-2... On/around April 2023, LPA was provided with names of (2) residents (R2 and R3) who are not receiving regular showers. Multiple staff interviews confirmed that R2 will regularly refuse a shower and it can take 2-3 staff to be able to get R2 in the shower. Additionally, R2’s family member is not able to get her to cooperate in taking a shower. R2 stated to LPA on 7/20/23 that she regularly takes a shower. LPA observed that R2 refused only (1) shower and has received (5) showers in July and R3 received (2) showers and refused (4) showers. R3 declined to talk to LPA. Staff stated they will try the next day or shift if a resident refuses a shower. Another resident, R4, who can be combative and refuse showers, received (4) showers this month and missed (2). The Administrator stated that once a resident refuses, staff cannot force a shower.

Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED-meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Facility staff are not providing residents assistance with toileting.

LPA toured the facility multiple times in April 2023 and in July 2023 and did not observe any incontinent odors in the hallways or resident rooms. Interim Administrator stated she does rounds every morning around 7:30-8:00 and has implemented stand-up meetings, since July, where any issues are immediately brought to staff’s attention. Staff interviewed indicated there have no significant delays in providing incontinent care to residents. Administrator stated (3) care staff and (1) Med-Tech is usually sufficient during the morning and afternoon/early evening hours and (2) care staff, which includes a Med-Tech, work during the overnight shift. Staffing schedules reviewed show that there are at least 4 staff scheduled during the day time hours and 2 scheduled during the overnight hours. A staff who works during the overnight shift stated that residents are checked every (2) hours and provided incontinent care when needed, as well as during the day time hours, and incontinent care provided at night has improved in the last few months.

Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED-meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred

cont on 9099C-3..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 59-AS-20230412085616

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: CITRUS HEIGHTS TERRACE	FACILITY NUMBER: 347001498
	VISIT DATE: 07/20/2023

NARRATIVE

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9099C-3... Allegation: Facility staff left residents in urine-soaked bedding.

LPA toured the facility multiple times in April 2023 and in July 2023 and did not observe any incontinent odors in the hallways or resident rooms. LPA and the Administrator observed specific resident rooms on 4/24/23 and noted each resident to have clean linen and the room to be odor free. One staff who works on the NOC shift stated that residents are checked every (2) hours and provided incontinent care when needed and it’s possible that soiled linens could be changed after the resident is changed, but the resident would not be left to lay in soiled linens for an extended period of time. A resident interviewed today said there have been no issues with caregiving or housekeeping staff not providing clean linens and towels and other staff interviewed said there have been no issues with residents being left in soiled bedding.

Based on information obtained, the Department finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Facility staff does not ensure that residents have clean bed linens.

LPA and Administrator toured on 4/24/23 and observed several resident rooms. LPA observed the bed to be made and the sheets and pad on top to be dry and odor free in all rooms checked.

Interview with a housekeeper indicated that caregivers will change sheets and there have been no issues with caregivers not changing soiled sheets. Housekeeper stated she cleans the rooms and empties trash as often as daily. LPA observed linens to not be soiled or any incontinent odors on 7/20/23 when touring. A resident interviewed today said there have been no issues with caregiving or housekeeping staff not providing clean linens and towels. Staff who works at night, stated staff check residents every (2) hours during the overnight hours and provide incontinent care, when needed, including placing an absorbency pad on the linens. Residents were able to be interviewed indicated staff will change the linens timely.

Exit interview. Copy of report provided to the Interim Administrator.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC9099 (FAS) - (06/04)

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