Amber Grove Place

Exceptions for Health ConditionsAs 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.

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.

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.

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.

87470(a)(4)(a)(1) Infection Control Requirements – (a) A licensee shall ensure that infection control practices are maintained as follows: (4) All facility staff and volunteers shall use gloves as a protective barrier to prevent the spread of potential infection as specified below. (A) Gloves shall always be worn when: (1) Coming into contact with blood or body fluids such as saliva, stool, vomit, or urine. This requirement is not met as evidenced by: Based on observation and document review it was determined that the licensee failed to ensure that staff were wearing gloves when handling potentially infectious materials. This poses a potential health and safety risk to residents in care.

Personal Rights of Residents in All Facilities. Residents …shall have all of the following personal rights: (2) To be free from … humiliation, … This requirement was not met based on statements and photo/video evidence that staff S1-S10 took photos and videos of residents that were shared on a staff group SnapChat site. In several of the videos staff could be heard laughing at residents who demonstrated deficits or behaviors due to their dementia disabilities. This posed an immediate risk to resident personal rights.

Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1,…residents…have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations... This requirement was not met based on statements and photo/video evidence that staff S1-S10 took photos and videos of residents that were shared on a staff group SnapChat site. This posed an immediate risk to resident personal rights.

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: (11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not met in the case of R1. This posed a potential risk to their personal rights