507004251-11-16-2021-27-AS-ADGA-C8TV85-20211116151209

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 11/16/2021
Date Signed: 11/16/2021 03:12:16 PM

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:	PACIFICA SENIOR LIVING MODESTO		FACILITY NUMBER:	507004251
ADMINISTRATOR:	THERESA L PETTAPIECE		FACILITY TYPE:	740
ADDRESS:	2325 ST PAUL'S WAY		TELEPHONE:	(209) 491-0800
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	73	CENSUS: 51	DATE:	11/16/2021
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	02:55 PM
MET WITH:	Theresa Pettapiece, Executive Director		TIME COMPLETED:	03:45 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	Licensing Program Analyst (LPA) Arlene Garcia arrived at this facility unannounced to conduct a case management visit. This visit is to deliver a civil penalty regarding substantiated neglect and lack of supervision allegations. LPA Arlene Garcia met with Theresa Pettapiece, Executive Director and explained the purpose of the visit. On June 6, 2020, the Department concluded a complaint investigation which alleged the following: staff did not address resident’s change in level of care; resident developed a pressure injury while in care; staff did not notify authorized representative of resident’s change in level of care. The allegations were substantiated, and the licensee was cited for violating California Code of Regulations (CCR), Tittle 22 § 87615 Prohibited Health Conditions, 87466 Observation of the Resident, and 87463 Reappraisals. The investigation revealed R1’s July 30, 2019 health certification form-Physician Report stated, “ambulatory.” R1’s pre-placement appraisal date July 31, 2019 stated, “yes, able to walk without any physical assistance (e.g., walker, crutches, other person), or able to walk with a cane.” On August 1, 2019, R1 had a medical visit, and an August 2, 2019 medical note indicated R1 appeared to be frail. Additionally, a medical written document from R1’s care physician indicated R1 was a moderate fall risk, and recommended a raised toilet seat with bars, a walker, and a grab-bar. However, R1’s August 9, 2019 facility Needs and Services Plan: section care level description-ambulation stated, “ambulates independently with or without an assistive device. R1 was also assessed at level 2; status checks 8 per shift, bathing assistance 3 per week, stand by assistance with dressing, verbal reminders toileting, and meals reminders. Moreover, the August 9, 2019 Needs and Service Plan did not include a fall risk prevention plan and stated, “no falls.” On August 22, 2019, a medical note indicated R1 was a high fall risk. Continued...

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PACIFICA SENIOR LIVING MODESTO	FACILITY NUMBER: 507004251
	VISIT DATE: 11/16/2021

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On August 20, 2019, an End of Shift Note indicated that R1’s buttocks had redness, which was not reviewed by a facility nurse (S3) until August 25, 2019, five days later. In addition, the facility sent an initial physician communication note regarding the redness on R1’s buttocks on September 6, 2019. The September 6, 2019, physician communication note stated, “R1 has redness on bottom and open sore… just observed this morning on right butt.” R1 was sent out to the hospital on September 6, 2019 and was diagnosed with an unstageable pressure injury.

Additionally, during an interview with the RCD, she stated, “to my knowledge I did not know R1 had an open sore”. On an August 31, 2019, facility note, it was noted that R1’s responsible party requested specific standing orders. It was determined the facility did not follow August 31, 2019, standing orders and did not stand R1 up every half hour for five seconds. In addition, narrative charting notes show R1 was rotated one time on September 4, 2019. According to the Mayo Clinic, “You can help prevent bedsores by frequently repositioning yourself to avoid stress on the skin…other strategies include taking good care of your skin, maintaining good nutrition and fluid intake, quitting smoking, managing stress, and exercising daily.” As a result, the licensee did not ensure R1’ skin integrity health changes were being assessed. The facility staff also neglected to follow clinical 03 wound and skin care, which states, “evaluate and manage resident skin care needs with an individualized service plan…the RCD will keep the family informed throughout the healing process…notify the physician immediately.”

Lastly, the Executive Director/Administrator stated, “A second assessment is done 30 days after admission and again every 6-months or if there is a change in the resident’s condition.” There was only one assessment given during a file review, which was dated August 9, 2019 and reviewed with R1’s responsible party. The licensee did not ensure to conduct reassessments. The licensee did not include health condition changes in the facility’s needs and service plan and review the changes with R1’s responsible party. As a result, the responsible party was not informed of R1’s changes as R1’s health condition changes were not documented in the needs and service plan.

Continued...

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PACIFICA SENIOR LIVING MODESTO	FACILITY NUMBER: 507004251
	VISIT DATE: 11/16/2021

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Facility policy GP 06-Service Plan reports individualized service plan are used to plan for and meet resident needs using an interdisciplinary approach. This policy also includes: The Resident Care Director (RCD), who creates the plan with the resident and family and ensures the responsible party signs the service plan and provides a copy. The RCD will also update the service plan when changes are necessary. Additionally, all service plans are kept in a service plan binder that is available to care staff. The licensee did not meet R1’s needs because they did not follow or implement their GP 06-Service Plan policy and did not address R1’s health change that required fall prevention services.

Moreover, the facility’s 7.69 fall management policy states, “ the staff member who responds to the fall is to complete an occurrence first responder work sheet, and the Resident Care Director (RCD) will use the Post-Fall Tracking & Intervention form to analyze each fall and implement new interventions as warranted. This process will be initiated upon the first fall and analyze each subsequent fall as directed on the form.

During the months of August and September of 2019, R1 fell nine times while residing at Pacifica Senior Living Modesto. R1 sustained the following falls:

August 3, 2019 - R1 was observed on floor by a Care Staff. Care staff notified a Med-Tech, and it was reported R1’s chair did not have a sensor pad. In addition, Care Staff was informed R1’s sensor pad needed to be present with resident at all times.
August 9, 2019 - R1 was walking around at the back patio holding a stick and fell. Sustained skin tear on left hand. First aid applied.
August 10, 2019 - R1 was walking in the morning…got out of bed and fell and hit R1 head on the floor. Ambulance was called. R1 sustained abrasions to the back of R1 head and to elbows. R1 returned from the Emergency Room (ER) with head staples.
August 11, 2019 - R1 got up in the middle of the night and fell on the floor. Later, R1 was observed on floor at 5:30 a.m. No injury was observed, and the family was notified. 2nd fall.
August 23, 2019 - R1 was observed on the floor, and no injuries were observed at 9:48 p.m.

Continued...

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PACIFICA SENIOR LIVING MODESTO	FACILITY NUMBER: 507004251
	VISIT DATE: 11/16/2021

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August 26, 2019 - R1 was observed on floor in the living area by R1 wheelchair. R1 had a cut on the corner of left corner of R1’s eye First aid applied, and R1’s spouse was notified.
August 29, 2019 - R1 was observed on floor next to R1’s bed. R1 sustained bruises to right hip at 12:10 a.m. After R1 was seated safely back in bed, R1 was observed on the floor again around 12:20 a.m. R1 was found next to R1 bed. At this time, R1 was observed to have a lump and bruise on R1 forehead. Cold compress was applied to affected area, and R1 was sent to ER.

Also, the Post-Fall Tracking & intervention forms were not found in R1’s file. R1 sustained the following injuries from falls: skin tears, abrasions to head and elbows, staples on head, cut to left eye, bruises on hips, bump and bruises on forehead, swelling on head, scrapes on bilateral legs, dried scabs on legs, and unable to walk after multiple falls. The Mayo Clinic states, “Falls are one of the most common adverse events among hospitalized patients. Falls that result in an injury can increase a patient's length of stay and increase the risk of complications and mortality, particularly among older adults.”

It was learned R1 fell six times before receiving any fall prevention equipment. The Hospital ordered fall prevention equipment on August 29, 2019 due to two falls R1 sustained on this day. At the 12:10 a.m. fall, R1 was observed with bruises on his right hip. R1 sustained a head injury as a result of a second fall at 12:20 a.m.. R1 was sent to the Emergency Room on this day and was diagnosed with a hematoma and swelling. Additionally, on September 3, 2019, the facility did not implement R1’s fall prevention equipment (sensor pad). On September 3, 2019, the licensee did not ensure R1’s Needs and Service Plan was updated to include a fall prevention plan and to include R1’s wheelchair care service need.

Furthermore, the facility did not recognize R1’s increased risk of developing a pressure injury and did not take preventative measures. During an interview, the RCD described the stages of a pressure injury. The RCD reported stage 1 as redness and stage 2 as the skin starting to open. The Mayo Clinic stated, “warning signs of bedsores or pressure ulcers are…unusual changes in skin color or texture.” The Mayo Clinic also stated, “for people who use wheelchairs, bedsores often occur on skin over the following sites…tailbone or buttocks.”

Continued...

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: PACIFICA SENIOR LIVING MODESTO	FACILITY NUMBER: 507004251
	VISIT DATE: 11/16/2021

NARRATIVE

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Based on the complaint investigation, it was determined the facility did not address R1’s health condition changes. A medical evaluation from the hospital note stated, “patient with a poor prognosis and believed to be irreversible… On palliative care…believed to live another 2 weeks.” Six days after discharge, R1 passed away on September 19, 2020.
At the time of the complaint visit on June 2, 2020, the licensee was informed that a 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 death, or protracted loss or impairment of a 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, 11/16/2021 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. A copy of the LIC 421D was given to Theresa Pettapiece, Executive Director and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. Theresa Pettapiece, Executive Director signature on this report acknowledges receipt of these rights, found on page 2 of LIC 421D.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

LIC809 (FAS) - (06/04)

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