Editor's note: After publication of this article, the Tribune learned of a technical email glitch that made it difficult for Pacifica Senior Living to send and receive requests for comments via email. The Tribune is currently planning a follow up article regarding a press release that details the changes that Healdsburg Senior Living is hoping to implement under its new director.
Family Council is formed to try to address issues, bring change
A recent investigation into several quality of care and staffing concerns at Pacifica Healdsburg Senior Living found that the facility failed to serve good quality food, failed to keep the facility clean, failed to ensure that medications were inaccessible to residents and had insufficient staffing to meet residents’ needs, according to two complaint investigation reports filed last week by the California Department of Social Services Community Care Licensing Division.
The investigation also found that in one instance the facility did not notify the responsible party when a resident had a change of condition.
Additionally, a facility evaluation report that was completed on March 5 found that of the 13 staff reviewed, 10 did not have first aid training.
The Tribune reached out to Pacifica Senior Living five times over the course of several weeks in order to get a statement in response to the concerns with Healdsburg Senior Living. In a phone call with a Pacifica Senior Living spokesperson they said they would submit a press release with quotes from residents and information on new management with the new Healdsburg Senior Living administrator/executive director Tracey Mease. After being given a deadline for response, the Pacifica representative did not respond in time for comment.
The findings stem from complaint investigations that were completed on March 5 by the local Community Care Licensing Division licensing program analyst (LPA), Victoria Willis.
The first three complaints — which were submitted to the local community care licensing office on Oct. 1, 2020 — were substantiated and resulted in two Type A citations and one Type B citation.
Type A citations are given when there’s an immediate health and safety or personal rights impact. A Type B citation denotes a potential health and safety or personal rights issue.
The first complaint alleged that resident apartments are not cleaned according to the agreed cleaning schedule and that there were instances in which fecal matter was observed on toilet seats and that used toilet paper and dirty gloves were left on the floor.
“During interviews of responsible parties, LPA (licensing program analyst Willis) learned that some have observed fecal matter on residents’ personal belongings and on the toilet,” the investigation report states. “Others observed floors being dirty and rugs not being vacuumed. Interviews also revealed that some families clean residents’ rooms while visiting and in at least one instance a private companion was hired to perform cleaning tasks that were not being completed.”
According to the report, resident rooms are generally cleaned once a week and if more frequent cleaning is required due to a spill or other reason the caregiver assisting the patient would be responsible for cleaning up, however, following interviews conducted by the licensing analyst, not all caregivers will clean as required and may leave it for housekeeping.
In terms of corrective activities, facility management agreed to submit written protocols outlining the expectation of all staff regarding the cleanliness of the facility as well as proof of training for all caregivers and housekeeping staff.
The second complaint claimed that residents’ food was of low quality.
Based on multiple interviews and review of pictures, LPA Willis learned that in the last year meals have not always been nutritionally balanced and at times did not include a protein or a vegetable.
“Interviewees described meat as fatty, dry and tough and in one instance, the meat had become discolored,” the report states.
According to the report, in response to the finding, facility administrator Mease agreed to submit facility food protocols outlining how often food is delivered to residents and how it’s assessed for quality.
The third complaint alleged that a cup of medicine that didn’t belong to a certain resident was left in a resident’s room. LPA interviews with facility staff confirmed that the medication did not belong to that resident and it was removed from the resident’s room by a staff member.
Once again, the facility administrator agreed to submit relevant materials that outlines staff training schedules that shows that all staff who assist with the self-administration of medication will be trained per regulation.
The second investigation of the other two complaints — the staffing and notification complaints — received on Jan. 5, 2021, resulted in two Type A citations after both complaints were substantiated.
The first complaint alleged that the facility is understaffed because many were absent due to testing positive for COVID-19. Based on several interviews by the LPA and virtual tours, the LPA learned that the facility had experienced insufficient staffing and staffing shortages in the Memory Care Unit due to a recent COVID outbreak.
According to Willis’ report, since her initial investigation and based on recent reviews with staff and community members, the staffing situation has improved.
Lastly, the complaint alleging that the doctor for two COVID-positive residents was not notified by the facility of the residents’ change of condition and was instead told by the families of the residents was also substantiated.
To help mitigate this deficiency the administrator will submit facility protocol outlining how residents are observed for changes and how they are documented and communicated to family and doctors if medical attention is required.
The verified complaints resemble several others that the facility has received over the years since Pacifica Senior Living Inc. took over the facility from Avalon Healthcare Management LLC. in 2018.
The complaints are also similar to the concerns that The Tribune reported on in January 2021.
Healdsburg Senior Living is still licensed under Avalon Healthcare Management LLC and the license under Pacifica Senior Living Inc. has been pending for a few years.
“The application for Change of Ownership (for Pacifica Senior Living to operate Healdsburg Senior Living) is still pending. The reason for the pending status is due to the Fire Clearance – the City of Healdsburg Fire Inspector has been scheduled by the current licensee to come out and complete testing of the fire panel. This must be completed prior to licensure,” said Scott Murray, a spokesperson for the California Department of Social Services.
Murray said if the applicant decided they were no longer interested in proceeding with the change of ownership and if they wanted to withdraw their application, then the current license with Avalon would remain intact.
Families’ concerns continue
The January Tribune article discussed the concerns of individuals who have loved ones at the facility. The concerns were centered around general staffing, oversight, communication and quality of care.
Since the article was published, The Tribune received several messages from people who had similar concerns regarding failures by the facility pertaining to staffing, food and lack of wound care.
One such message was from Chris Gatenby, whose mother died on Jan. 5 after having contracted COVID-19 while living at Pacifica Healdsburg Senior Living.
After a worker in the Memory Care Unit — where Gatenby’s mother resided — tested positive for COVID-19 Gatenby’s mother, Honor, tested positive for the virus on Dec. 23, 2020.
The day after Gatenby’s mother died, Gatenby’s sister Susan Stobba called Healdsburg Senior Living to notify them of the death and stated that she wanted all jewelry, photos, knick-knacks and such and would provide a list of the most important items to locate.
According to Gatenby, his sister’s call was not returned.
Stobba called the facility again on Jan. 7 and explained to the receptionist that she was going to come on Saturday to pick up Honor’s belongings and restated that she wanted all the jewelry, photos, curios and that she would bring boxes and packing materials so that fragile items could be properly packed.
In a letter to Pacific Senior Living, Gatenby said when Stobba traveled to Healdsburg to gather her mother’s belongings she was surprised to find the items in garbage bags outside the facility with signage showing her mother’s name.
According to Gatenby, the trash bags contained a mixture of clothing, toiletries, jewelry and easily breakable curios and the toiletries had broken open, damaging curios and fabrics.
“I do not have words adequate to describe the mental anguish that this incredibly callous, negligent and disrespectful treatment of Mrs. Gatenby’s items has caused our family,” Gatenby wrote in the letter. “These are difficult times, but that should not mean that corporate interests in the housing industry can get away with treating the dead seniors killed by uncontrolled virus outbreaks and their next-of-kin with such incredible disrespect.”
While the treatment of their mother’s possessions was troubling, Gatenby also alleges that there was negligence and failures by the facility pertaining to falls, lack of wound care and other violations.
Gatenby said his sister had provided him with photos and accounts of alleged prior neglect.
“Including but not limited to wound care so inadequate that a hand wound had maggots in it and Dr. Peng said he must operate due to the maggots. Lack of wound care was discovered again last year during a medical procedure being conducted away from your facility,” the letter states.
In the letter Gatenby said there was also an incident where his mother was not seat-belted while being transported in a bus and was thrown out of her seat.
“Injuries in that incident on Aug. 5, 2019 required hospitalization,” Gatenby wrote in the letter.
Ricky Serbin’s 90-year-old mother was a Healdsburg Senior Living resident, however, after experiencing similar concerns with staffing, food and communication he decided to move his mother to Vine Ridge Senior Living in Cloverdale.
Serbin said Healdsburg Senior Living was a “magical facility” with various programs, a thriving garden and frequent events for seniors, such as the annual plant sale and visits from school children. The level of care changed following the departure of the facility’s former director, he said.
“COVID hit within four weeks of her arriving (at Healdsburg Senior Living) and she never got to bond with anyone and she was isolated in her room all those months and was very, very fond of the staff. The staff was top notch, the aids and the nursing aids, and she still adores quite a few of them. It all changed in October when the director left,” Serbin said.
Serbin said after that his mother started hearing about staffing concerns, which became a stressful topic for her.
“My mom is a good listener and the staff would just come in in tears during the month of December, especially in January … and there was no senior management at all and my mom listened and took it all in and heard how burdened everyone was every single day in that place,” Serbin said. “It just culminated. We had no trust in the place and no communication despite so many attempts. We told them that we were leaving and we had decided to move my mother within 10 minutes of my house.”
Serbin said upon the announcement of his plan to move his mother, the management team asked for a phone conference to discuss the matter and ended up speaking with Serbin’s sister.
“They were very professional and they sounded like they were going to be on top of everything. The next morning at 8:30 a.m. my mother called me in pain — she had been there for four years and had never done that before — and no one was picking up at skilled nursing and 9 a.m. I finally reached the person who had been on the phone with my sister the day before and she recognized my name and said she’ll check on her for the pain and we went over which hospital she would need to go to (if needed),” Serbin said.
Serbin alleged that the individual he spoke with did not check in on his mother.
“The next day a long-time aid who’s been employed there for a very long time asked my mother for my phone number and called on my private line and told me if it was her mother in there she would get her out today,” Serbin said.
His mother did eventually end up going to the emergency room that night around 9 p.m. for the pain she was having that morning and was fine.
“It took 12 hours,” Serbin said and when asked if he meant it took 12 hours for them to address the issue and take her into the hospital he said “yes, that’s correct.”
He said by that point they had already decided to move his mother to Vine Ridge, but nonetheless it wasn’t an easy decision.
“It wasn’t an easy decision to make to move a 90-year-old, but I just saw no change at all, no hope for change … It was sad,” Serbin said.
He said now his mother is thriving at Vine Ridge and that it’s been great that he can also visit her outside every day, and that she’s allowed to have communal dining.
“She was shut alone in her room with the most terrible food you could imagine,” Serbin said of her experience at Healdsburg Senior Living. “It was served on plastic and was inedible. It was consistently horrible. It didn’t use to be that way and my mom is the easiest to please. She had an aid who was there with her at least 18 hours a week and she sent us the pictures of the food and said ‘You can’t believe what they’re feeding them,’ so I was bringing her food four times a week. It was the only way she would eat and now at Vine Ridge they have a chef, they’re eating communally and everything is delicious.”
Serbin said of Healdsburg Senior Living, “How did the place go to hell so fast?”
Despite the copious concerns, some people are hopeful that things can change for the better at Healdsburg Senior Living with the help of the recently formed family council.
“Right now, there is a family council being formed with the help of the ombudsman’s office. According to state laws we do have the power to request documentation from them and they have to comply,” said Shannon Barton-Wren, whose mother is a Healdsburg Senior Living resident.
She said the family council consists of a panel of family members and volunteers.
“The goal is basically to give family members (of facility residents) the opportunity to collaborate and share concerns, share thoughts and also it’s not always about them having an issue, but about the challenges of having a family member in long term care so it's really a wonderful concept. Sadly, we don’t have very many of them in Sonoma County,” said Crista Barnett Nelson, the executive director of Senior Advocacy Services, an ombudsman program and elder justice initiative organization based in Petaluma.
According to the California Advocates for Nursing Home Reform, “They also offer a forum to enhance communications with the facility administration and staff and offer peer support for the relatives and friends of residents. Family councils are not merely ‘gripe’ sessions. An effective family council allows its members to meet without facility staff (and thus, without fear of retaliation), share concerns, and submit the group's concerns in writing to the administrator.”
Family councils each get together on their own and facility staff are only allowed to come if they are invited.
“If they (the family council) submit their request for answers in writing then the facilities are required to respond by 14 days,” Barnett Nelson explained.
According to the state licensing complaint investigation report submitted by Willis on March 15, the family council submitted a request for information on Feb. 22, 2021, however, the facility failed to respond to the written concerns brought by the council within the required 14-day time frame. The failure resulted in a Type B citation.
Barnett Nelson said the ombudsman’s role in the family council is to help them understand their rights and serve as a resource.
Barnett Nelson also said that Senior Advocacy Services is aware of the quality of care concerns at Healdsburg Senior Living.
“Families have invited us to help them advocate for their family members. Our goal really is to help the residents. We’ve been participating and looking to solve some of the challenges they have had over there once they had the change of management,” she said.
Barton-Wren said the family council is currently conducting weekly Zoom meetings to figure out their goals and what to put on their “to-do list.”
“We had a list of things that we sent to management. We have a person on staff who is our go-between, and we communicate with that staff member and then they take our concerns to Tracey (the executive director) ... The people are frustrated, these are our mothers and fathers that we’re fighting for,” Barton-Wren said. “I think because of that (the council) there is renewed hope that maybe we can get this ship righted. Maybe we can fix it.”