496801635-11-30-2021-21-AS-VWIS-C99P2W-20211130095636

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801635
Report Date: 11/30/2021
Date Signed: 11/30/2021 09:56:49 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	HEALDSBURG SENIOR LIVING COMMUNITY		FACILITY NUMBER:	496801635
ADMINISTRATOR:	DAVIS, DWAYNE		FACILITY TYPE:	740
ADDRESS:	725 GROVE STREET		TELEPHONE:	(707) 433-4877
CITY:	HEALDSBURG	STATE: CA	ZIP CODE:	95448
CAPACITY:	82	CENSUS:	DATE:	11/30/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Cynthia Morris, Operations Support		TIME COMPLETED:	10:10 AM

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	A Case Management visit was conducted on November 30, 2021 to follow up on a substantiated Personal Rights allegation. Present at the facility were Victoria Willis, Licensing Program Analyst (LPA); and Cynthia Morris, Operations Support. On September 18, 2020, the Department concluded a complaint investigation alleging the following: the licensee failed to seek timely medical attention which resulted in a resident (R1) sustaining pain and suffering that required hospitalization. The licensee failed to notify authorized representative of an incident regarding a resident. The allegations were substantiated and the licensee was cited for violating the California Code of Regulations (CCR) Title 22, § 87466 for Observation of the Resident, which requires that “Licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional & social functioning & appropriate assistance is provided when such observation reveals unmet needs. When changes such as...deterioration of mental ability or a physical health condition are observed, Licensee shall ensure that such changes are documented & brought to the attention of the resident's physician & the resident's responsible person, if any.” This requirement was not met as a result of the facility failing to bring R1s observed change in physical health condition to the attention of R1s physician and responsible person. Continued on LIC809C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: HEALDSBURG SENIOR LIVING COMMUNITY	FACILITY NUMBER: 496801635
	VISIT DATE: 11/30/2021

NARRATIVE

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Continued from LIC809

The investigation revealed that on February 24, 2020, multiple facility staff indicated that R1 had an unwitnessed fall from R1s bed sometime between the hours of 1910 and 1930 and was found on the floor laying on their left side next to R1s bed. Based on facility records and multiple interviews, R1 was identified as having made ongoing complaints of pain between February 24, 2020, the date of R1s unwitnessed fall, and February 27, 2020, the date R1 was sent to the hospital. In addition, staff identified R1 to audibly be in pain as well as having a physical change of condition in the appearance of their leg and knees. Although the unwitnessed fall occurred on February 24, 2020 the facility did not seek medical attention until February 27, 2020.

Upon admission to the hospital on February 27, 2020, the hospital records identified R1 had right leg pain just above the knee and x-ray showed questionable right distal femur fracture. Attending Physician’s Report date February 27, 2020 further states that R1 grimaced in pain when pressure was placed in the area and R1 was unable to tolerate knee immobilizer nor an ace bandage. R1 was identified as a poor historian, would not walk, had bruises around the left knee and left leg contractures. R1 was identified as not a surgical candidate due to age. R1’s treatment plan identified pain management and proper positioning. R1 was discharged back to the Skilled Nursing portion of the facility. The hospital physician stated during an interview that R1’s injury would be consistent with a fall out of a chair, or during some type of patient transfer from a bed to a chair. Interviews and documentation indicate that during an exam of R1 at the hospital, the doctor could move R1’s left leg without any complaint of pain however R1 screamed in pain when the doctor moved R1’s right leg.

Continued on LIC809C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: HEALDSBURG SENIOR LIVING COMMUNITY	FACILITY NUMBER: 496801635
	VISIT DATE: 11/30/2021

NARRATIVE

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Continued from LIC809C

According to R1’s care plan, which was last updated on March 11, 2018 prior to the fall, it stated that R1 had a diagnosis of Dementia, was a fall risk and required a wheelchair. It also addressed that R1 required total assist for medication, toileting, ambulating and transfers. Upon return from the hospital to the facility’s Skilled Nursing Facility, R1’s care plan was updated on March 19,2020 (but not signed). The Admission Record identifies the principal diagnosis an unspecified fracture of the lower end of the right femur and subsequent encounter for closed fracture with routine healing. Facility’s report to R1’s Primary Care Physician (PCP) stated that R1 was able to stand and pivot. This report is inconsistent with the fact that according to medical documentation and interviews with medical professionals, prior to the fall, R1 was wheelchair bound and unable to stand at all even with assistance. When questioned, the facility staff stated that they did not actually observe R1 stand and pivot but rather assumed it. The facility’s “Order Request/Clarification” provided to the R1s PCP indicated a fall out of bed on February 26, 2020, however, interviews further identified that during an exam conducted on March 3, 2020 while R1 was in the hospital R1s PCP stated that by looking at the bruises around the left knee, the coloring was consistent with an injury that was over one day old. R1s PCP further stated that they could move R1s left leg without any complaint of pain, but R1 screamed in pain when PCP moved R1s right leg.

Lastly, interviews and facility record reviews confirmed that the facility did not notify R1’s PCP or R1’s responsible party until R1 was sent to the hospital on February 27, 2021. This was despite the unwitnessed fall that occurred on February 24, 2021.

Continued on LIC809C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: HEALDSBURG SENIOR LIVING COMMUNITY	FACILITY NUMBER: 496801635
	VISIT DATE: 11/30/2021

NARRATIVE

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Continued from LIC809C

Based on observation, interviews, and record reviews the licensee did not seek timely medical attention which resulted in R1 sustaining pain and suffering that required hospitalization which is a serious bodily injury. The licensee also did not notify authorized representative, R1s conservator, of an incident regarding a resident.

At the time of the complaint visit, on September 18, 2020, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty was still being determined and 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 serious bodily injury. Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of 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.”

Today, November 30, 2021, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49, for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was issued on September 18, 2020, the amount of the civil penalty today will be $9,500.

A copy of the LIC 421D was given to Cynthia Morris, Operations Support and originals were signed.

Exit interview conducted. Appeal Rights provided. A copy of the report issued. Cynthia Morris, Operations Support signature on this report acknowledges receipt of these rights, found on page 2 of LIC 421D.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

LIC809 (FAS) - (06/04)

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