347005332-3-10-2023-25-AS-MSEY-CPWNFA-20230314102513

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005332
Report Date: 03/10/2023
Date Signed: 03/10/2023 04:59:17 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, 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
07/07/2022 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 25-AS-20220707132241

FACILITY NAME:	CHRISMAN COMMUNITY		FACILITY NUMBER:	347005332
ADMINISTRATOR:	CLAUDIA MIHAI		FACILITY TYPE:	740
ADDRESS:	4230 PARADISE DRIVE		TELEPHONE:	(916) 515-8590
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	0	CENSUS: 0	DATE:	03/10/2023
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Claudia Hahai		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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All aspects of care performed by the medical professional and facility staff for resident's healing wound were not documented in the resident's file.
Facility staff did not properly rotate resident.
Facility staff did not properly care for the resident's wound.
Facility staff did not ensure resident's total daily diet met the needs of the resident.

INVESTIGATION FINDINGS:

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On 3/10/23, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Claudia Mahai . Prior to initiating the complaint visit, LPA completed the department's COVID-19 precautions. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened at the facility.

The department received this complaint on 7/7/22.
LPA Mknelly conducted records review and LPAs conducted interviews.
The Department is unable to find and or meet the preponderance, per policy.

R1 was admitted to the facility on or about 8/6/21. Hospital records show that R1 began Hospice services while R1 was at the facility from 8/12/21 and continued until there discharge to home on 12/15/21. LPA received copies of hospital records on 2/7/23, 2/13/23 and 3/6/23.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20220707132241

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: CHRISMAN COMMUNITY	FACILITY NUMBER: 347005332
	VISIT DATE: 03/10/2023

NARRATIVE

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Summary of hospital records:
Prior to R1’s admission to this facility, hospital records dated 7/17/22, when R1 had an emergency admission for altered level of consciousness, R1 was observed to have, but not limited to: Sacrum-intact (not open); but with blanchable redness (photo provided), Heels-intact, but with blanchable redness, Feet-intact, but with left great toe abrasion with scab, as well as (R1) is at risk for skin breakdown, Patient repositioned every 2 hours while hospitalized.
On 7/21/21, R1 was again admitted to the hospital following a fall at R1’s home. Hospital records noted: No fractures noted. R1 was found to have multiple bruises of different stages to all parts of body. No lesions, irritations, or redness.
7/23/21- Discharged to skilled nursing facility (SNF). Records not obtained. (R1) discharged 8/6/21 to (Chrisman Community), as noted in medical record “Unable to participate”.

While at this licensed care home, on 8/11/21- Emergency Department for Nausea and vomiting. Records found: No lesions, irritations, or redness. Hospital records note “… Amy (licensee Emilia “Amy” Ardelean) from (Chrisman Community. (R1) is bed bound, needs assistance even with standing and pivoting and cannot sit in w/c (wheelchair). …R1was SOB and n/v (writers note- N/V- nausea/ vomiting)…” Hospital records of 8/11/21 note a conversation with R1’s Power of Attorney (POA), noted are but not limited to: “POA says (R1) needs higher level of care. (Hospital worker) Verified a B&C can manage a bed bound patient. POA wants (R1) on Hospice…”

Hospital records indicate that Hospice services were initiated approximately 8/14/21. Records noted conversation with POA, on 9/4/21 record. “ LCSW completed virtual telephone visit with (POA) reporting that (R1) is being well care for at board and care. (POA) stated that (R1) has not had any falls, no pain concerns and is being provided with a safe environment. (POA) stated that he is glad that (R1) is at a safe place.”

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20220707132241

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: CHRISMAN COMMUNITY	FACILITY NUMBER: 347005332
	VISIT DATE: 03/10/2023

NARRATIVE

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Relevant notations in hospital records of Hospice care:
9/6/21 Hospice RN (nurse) visit records recorded recommendation to continue 2-hour repositioning and “Wound #3, type: skin excoriation, location: perianal area. SN/ALF staff to perform twice a day…
9/9/21 Hospice records noted that during a MSW visit, R1 commented, “ Patient reported that she feels well care for and supported at board and care”.
9/22/21 MSW noted (R1) comfortable and stable at this time. Also noted that POA commented that R1 is well cared for at this time.
10/1/21 21 MSW noted that family member of R1 commented that R1 is well cared for at this time.
10/11/23 RN notes- wound #3 unchanged. Secondary to (R1) diarrhea, #4 redness to perineal area developed. R1 “thin” with 75% food intake 3 times daily.
10/13/21- Hospice records noted “LCSW completed virtual telephone visit with POA whom reported R1 continues to be well care for at board and care with no falls reported.”
10/13/21- RN notes- R1 continues to have 75% food intake 3 times daily, pain is managed, #4 (perineal) site slightly larger and closed. No further notation of #3.
10/25/21, After-hours RN contacted for R1 change of condition. Notes reported R1 had vomited, was weak and unresponsive.
10/26/21 RN visit notes R1 awake and alert. Food intake reduced to twice daily 50% of meals consumed. R1 developed Edema to lower extremities. Wound # 4 noted by RN as healed.
11/1/21 RN notes- R1 continues to have bladder incontinence and constipation. Food intake at 75% three times daily (noted as fair), Edema continues to lower extremities. Stage II pressure injuries to left and right buttocks (Noted as wounds #5 and #6, no other wounds active at this time) that had previously resolved. Low sodium regular diet, and repositioning and elevate legs as R1 tolerates. Turning noted as exacerbating R1’s pain.
11/3/21- MSW noted “LCSW completed virtual telephone visit with family member reporting that R1 is stable and being well care for at facility can see R1 declining as she is not speaking much anymore having good and bad days. Family member stated (they and POA) continue to visit R1 at facility able to advocate for her needs.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 25-AS-20220707132241

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: CHRISMAN COMMUNITY	FACILITY NUMBER: 347005332
	VISIT DATE: 03/10/2023

NARRATIVE

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11/4/21 RN visit- Wound status unchanged. Recommended staff continue 2-hour repositioning as R1 tolerates. Food intake continues to be “poor”. Catheter treatment initiated. Status and care plan communicated by RN to family regarding pressure injuries, edema, constipation and medications.
11/8/21- RN visit- Wounds slightly decrease from previous measures. RN also noted Palliative Performance Score (PPS) and UPPER ARM CIRCUMFERENCE – between 8/12/21 and 11/8/21, PPS Score: 30% (unchanged) and upper arm circumference on 8/12/21(cm): 28.5 and on 11/8/21 arm circumference (cm): 26. Food intake is noted as “fair”.
11/12/21 RN Note- wounds #5 and #6 increased to stage III. Orders continued. Air Mattress ordered. RN communicated information to R1, caregiver, licensee and POA.
11/17/21 RN visit- Noted wounds unchanged since 11/15/21 RN visit. Additionally noted ,” all symptoms well managed; Wound care provided; No s/s of infection; (R1) love (R1’s)new LAL bed.”
11/22/21- RN notes- R1 pain in abdomen and sacral coccyx area. Turning exacerbates pain. Recently added main management medication. Wounds #5 and #6 deteriorated to “unstageable” and increased in size. Status and care plan communicated with facility staff and POA.
11/25/21- RN Notes. Wounds unchanged from 11/22/21. UTI not resolved, antibiotics changed. Food intake vacillates between Fair and Poor. Pain continues and managed with prescribed medications. Senna restarted for constipation.
12/7/21- RN Notes- Wound .5 cm smaller, New antibiotic started for UTI, pain continues, intake poor. RN communicated with staff, unable to reach POA or Licensee. 12/8/21, RN contacted licensee.
12/9/21- MSW note- LCSW completed virtual telephone visit with POA whom was appreciative for the call. POA shared R1 is comfortable with no pain concerns. R1 decided ( to move R1 home with family). Target discharge to home is 12/15/21.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 25-AS-20220707132241

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: CHRISMAN COMMUNITY	FACILITY NUMBER: 347005332
	VISIT DATE: 03/10/2023

NARRATIVE

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12/13/21- RN notes- RCFE staff communication noted that R1 refuses repositioning and heel protection most of the time. RN noted barriers to wound healing as Malnutrition (poor intake), infection and decline of repositioning. Wounds #6 and #7 have joined together. New order for Lasix for edema, deteriorating sacral pressure ulcer and new treatment order, continue with Clindamycin for infection as ordered.
Note: reports regularly document that R1 is able to express their needs.

On 12/15/21, R1 moved from the facility to home.
12/15/21- 1/25/22 R1 Home Hospice care reports review found R1’s food intake varied between good to poor, R1 had variable compliance to positioning, 1/10/21 food intake was noted as declining, 1/17/21 R1 developed ulcers on their heels and family were noted to comment that R1 does not like positioning on their side. On 1/18/21 Hospice chaplain noted that R1 is troubled by their weight loss.

It was alleged that all aspects of care performed by the medical professional and facility staff for resident's healing wound were not documented in the resident's file. On 7/15/22, when LPA Yang began the investigation, Administrator, Claudia Mahai, stated resident’s family member was present at the facility on 2/29/2022 and 7/5/2022 to gather original documents to make copies because facility's copy machine was not working. Mahai and Licensee, Emilia “Amy” Ardelean, both told LPAs that a family member removed files from the facility and did not return them. Neither party produced the resident’s file for this investigation. Hospice records reviewed noted regular communication and written order communicated to facility caregivers, the licensee, family and R1’s POA. The Department was therefore unable to substantiate whether records were maintained while R1 was in care.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 25-AS-20220707132241

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: CHRISMAN COMMUNITY	FACILITY NUMBER: 347005332
	VISIT DATE: 03/10/2023

NARRATIVE

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Facility staff did not properly rotate resident. Records documented that caregivers understood the direction for regular 2-hour repositioning. Throughout R1’s stay on Hospice it was not noted that staff failed to offer that assistance. R1 was regularly documented as being able to make their wishes known. Hospice records noted that R1 regularly refused to reposition and that turning exacerbated R1’s pain. The Department was therefore unable to substantiate that facility staff failed to properly rotate R1.

Facility staff did not properly care for the resident's wound. Throughout the Hospice medical records, staff were noted to understand the wound care instructions. Furthermore, records did not indicate that wounds were not being properly care for. The Department was therefore unable to substantiate that R1’s wounds were not properly cared for by facility staff.

Facility staff did not ensure resident's total daily diet met the needs of the resident. Throughout the Hospice medical records, R1’s food intake was noted to vary between good and poor, both at the facility and while in care at home. Between 8/12/21 and 11/8/21, Hospice records noted minimal weight loss as measured by upper arm measurements

As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means 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.

Exit interview with administrator and report provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC9099 (FAS) - (06/04)

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