317005531-8-18-2020-27-AS-CYAG-BSLP49-20200818105843

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 317005531
Report Date: 07/24/2020
Date Signed: 08/18/2020 10:59:40 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	SIERRA RIDGE SENIOR LIVING		FACILITY NUMBER:	317005531
ADMINISTRATOR:	PERKINS, JOYCE		FACILITY TYPE:	740
ADDRESS:	3265 BLUE OAKS DR		TELEPHONE:	(530) 887-8600
CITY:	AUBURN	STATE: CA	ZIP CODE:	95602
CAPACITY:	65	CENSUS:	DATE:	07/24/2020
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:			TIME COMPLETED:	05:00 PM

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	On 07/24/2020, Licensing Program Analyst (LPA) Charlie Yang met with Joyce Perkins, Sierra Ridge Senior Living Executive Director, for a case management visit to follow up on a substantiated allegation that the facility failed to seek timely medical care for a resident (R1) after a fall. On October 11, 2016, the Department concluded a complaint investigation which alleged the facility failed to seek timely medical care for R1. R1 sustained a fall on May 18, 2016 and was not sent to the hospital until May 19, 2016. The allegation was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87466 Observation of the Resident: for failure to ensure that the resident was “regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.” The licensee failed to seek timely medical care for R1 who fell on May 18, 2016 at approximately 7:30 p.m. R1 was not sent to the hospital until May 19, 2016. R1 returned to the facility the same day with no documented injuries and an order for new pain medication (Tramadol). Over the course of the next four days, the facility documented that R1 complained of pain. R1 was taken to Sutter Auburn Faith Hospital on May 23, 2016 by R1’s daughter, R1 was diagnosed with two pelvic fractures. According to the Mayo Clinic, a pelvic or “hip fracture is a serious injury, with complications that can be life-threatening.” On May 18, 2016, facility documentation revealed that R1 fell at 7:30 p.m. in the common area of the facility. Interviews with multiple facility staff indicated that R1 was in the common area awaiting evening activities and fell near the nurse’s station while attempting to stand from R1’s wheelchair. The fall was witnessed by facility Medication Technician (Med-Tech) (S1). S1 stated during an interview that on May 18, 2016, R1 was in the dining room following dinner waiting for activities to start.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2020

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SIERRA RIDGE SENIOR LIVING	FACILITY NUMBER: 317005531
	VISIT DATE: 07/24/2020

NARRATIVE

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S1 stated that R1 did not complain of pain immediately following the fall. S1 did note that later in the evening of May 18, 2016, R1 complained of pain. S1 stated that R1’s son instructed the facility to wait to send R1 to the hospital. Facility staff interviewed indicated that R1 complained of pain through the night and was not sent to the hospital until May 19, 2016, the following day. R1 returned to the facility on May 19, 2016 with Emergency Department (ED) notes from the hospital indicating no injuries, but was given a prescription for Tramadol, a narcotic pain medication. According to the Mayo Clinic, “Tramadol is used to relieve moderate to moderately severe pain, including pain after surgery.”

During the course of the Department’s investigation, the Department discovered that on March 28, 2016, R1 sustained a fall at the facility. On that same day, R1 was taken to the Emergency Department (ED) for medical evaluation. R1 returned to the facility without further medical findings. On March 29, 2016, R1 was taken to the hospital based on recommendation of R1’s primary care physician to R1’s family members. R1 was then diagnosed with a fractured left hip and underwent a partial hip replacement.

On April 1, 2016, R1 was discharged from the hospital following a successful hip replacement surgery. R1 then went to a skilled nursing facility (SNF) and resided there until May 3, 2016. The Department’s review of the facility’s “Milestone Assessment”, dated April 28, 2016, indicated that R1 was a fall risk. This assessment was completed when R1 was accepted back to Sierra Ridge Senior Living from the SNF. The facility failed to implement a fall awareness plan despite documentation that R1 was a fall risk.

The Department reviewed Care Progress notes (alert charting, heightened frequency care notes) which indicates R1 complaining of pain on May 20, 2016, May 21, 2016, May 22, 2016, and May 23, 2016. These notes were documented by various facility staff members. The facility failed to contact the doctor for four (4) days. R1’s daughter visited R1 on May 23, 2016 and took R1 to Sutter Auburn Faith Hospital emergency department because she observed R1 screaming in pain when staff transferred R1 from R1’s wheelchair to a recliner. R1 was diagnosed with two hairline fractures of the pelvis. Based on a review of hospice care notes, R1 was placed on hospice on or around May 28, 2016. R1 expired on June 17, 2016 due to end stage dementia as documented on R1’s Death Certificate.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2020

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SIERRA RIDGE SENIOR LIVING	FACILITY NUMBER: 317005531
	VISIT DATE: 07/24/2020

NARRATIVE

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Based on The Department’s document review and interviews, it has been determined that R1 had significant change in condition including multiple reports of pain which was documented over a period of four (4) days. The facility failed to bring these changes in R1’s medical condition to the attention of R1’s physician. The facility failed to get timely medical attention after R1 fell and continued to experience pain for four (4) days causing him to suffer extreme pain due to the undiagnosed pelvic fracture.

At the time of the complaint visit, the issuance of a civil penalty was still being determined and the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for the serious bodily injury that R1 sustained. The Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to hospitalization, surgery, or physical rehabilitation.” R1 suffered extreme pain for four (4) days following a witnessed fall and injury on May 18, 2016. The facility failed to seek timely medical care for R1 following R1’s return from the hospital on May 19, 2016.

Today, 07/24/2020, the Department is issuing a civil penalty per Health and Safety Code § 1569.49 in the amount of $10,000 for a violation that the Department constitutes as a serious bodily injury. A copy of the LIC 421D was given to Joyce Perkins.

Original signatures were not able to be obtained at this time. The facility designated Administrator, Joyce Perkins, stated that prior to signing these documents they will have to be reviewed by the corporate office.

Appeal rights provided.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2020

LIC809 (FAS) - (06/04)

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