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Multiple Violations Found at Petaluma Nursing Homes

Cited for bevy of issues, including not having proper care plans for residents, not attending to patients in a timely manner and letting elder residents wander out of facilities, federal health inspection reports show.


With the senior population exploding in Sonoma County and elsewhere in the country, nursing homes and assisted living facilities are doing brisk business.

But an investigation into Petaluma nursing homes shows numerous violations at the facilities, ranging from the minor to potentially life-threatening.

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At Petaluma Health and Rehabilitation, residents’ call bells were often not promptly answered, leaving bedbound patients waiting for more than 30 minutes, according to a 2011 survey report conducted by Department of Health and Human Services inspectors.

A resident who said he had been sexually abused by staff and asked to contact the police was not allowed to do so while others spoke of nurses who walked in on them while they were using the bathroom and woke residents up at night with their loud chatter. Other violations include failing to properly deal with a resident who was verbally abusing other residents and not locking patients’ beds, resulting in falls when the beds rolled away.

Amanda Moore, executive director of the 98-bed facility, said the company has addressed the violations and is providing a high level of care.

“These violations occurred under a different administrator and since that time we’ve been through a complete overhaul,” Moore said, adding that the 2012 survey was significantly better.

Despite that, the facility, owned by Evergreen At Petaluma LLC, a Vancouver-based company, received the lowest possible rating by the federal government, 1 out of 5 stars. Since 2005, it has also accrued an estimated $90,000 in fines from the California Department of Public Health and last year was sued by a Petaluma woman who said the facility caused her mother to suffer from malnutrition and dehydration as a result of improper care.

At Golden Living Center, a 99-bed facility near Petaluma Valley Hospital, health inspectors cited the facility for not having a tracking system to oversee recommendations from outside doctors that caused some patients to not receive needed medical treatment.

During a 2011 site visit, a resident said that the dead body of her roommate was not removed for more than several hours, at which time she was served lunch. The resident said she was distressed and had to get up and pull a curtain closed in order not to see the body.

Dorothy McReynolds, the director of admissions at Golden Living, said the incident was unfortunate and something that has never happened before or since the inspection.

“The residents have a choice about where they eat their lunch,” McReynolds said. “No one is locked up in there. They are free to get up and leave.”

Other violations found by inspectors in 2011 included a delay in responding to calls, with residents sometimes waiting 20 or more minutes before an attendant appeared, and a failure to keep and complete accurate records for all patients.

The facility, owned by Fresno-based Beverly Health & Rehabilitation, has been fined an estimated $100,000 over the past seven years for a variety of violations, some of which it has appealed.

Asked about the findings, a company spokeswoman, Kelli Luneborg, issued the following statement:

“We value and support the state survey process…and use it as part of our ongoing program to develop our LivingCenter into a model of quality patient care in our community. Following any survey in which a deficiency may be found, we take immediate action to correct the issue and ensure that we are in compliance. We are committed to providing quality care to our patients and residents.”

McReynolds, the facility’s admissions director, echoes the sentiment, pointing to the dozens of greeting cards families have sent the facility thanking them for their work, and awards the site has received, including for quality of care and employee satisfaction.

“We care a lot or we wouldn’t be here,” she says.

Windsor Care Center on Hayes Lane did somewhat better, although the facility was cited last year after a resident with memory problems wandered out of the center and could not be found for close to 24 hours.

An inquiry into the facility revealed that door alarms were not activated and gates not locked. Like Golden Living, Windsor Care is rated a two-star facility. It has also racked up an estimated $200,000 in fines from the California Department of Public Health for a number of violations.

The implications of the findings are significant considering that Sonoma County’s senior population is exploding, with people 85 years or older estimated to quadruple by 2040, according to the Sonoma County Area Agency on Aging.

In fact, by that date, there will be one senior for every three working-age adults, meaning that it’s likely that new nursing homes and assisted living facilities will have to be built to keep up with demand.

“With people living longer and moving into care facilities more often, if we don’t have the infrastructure to deal with our aging population, we are all in trouble,” says Stan Lawson, co-owner of Sequoia Senior Solutions, a Petaluma-based company that provides in-home care to seniors.

Crista Chelemedos, the executive director of Senior Advocacy Services, a nonprofit that runs an ombudsman program for all long-term care facilities in the North Bay, says there are many good nursing homes in Sonoma County. But there are also many others that look the other way when staff violate rules and are hesitant to report problems to outside agencies.

“Just because you are sick, you don’t lose your right to dignity and respect,” Chelemedos said. “We all have the right to those basic fundamental rights to make decisions for ourselves and have our needs addressed.”

Her advice to people looking for a facility for an aging family member?

Look past the feel-good glossy brochures and read the survey reports that provide a detailed account of what goes on inside.

Then, realize that you too will get old one day, and have a plan in place for when you are no longer able to take care of yourself.

“As you start to age, it’s important that you have a relationship with someone who will be your advocate, whether it’s a relative, a friend or your lawyer,” says Elece Hempel, executive director of Petaluma People Services Center which runs programs for seniors and provides referrals.

“Unfortunately when people get to a skilled nursing facility, they are often the only one left. Their spouse has died, so have their friends. You need to plan for that, just like you plan for a house fire or an injury by having insurance. But people don’t want to think about it.”

Have you had to select a nursing home? Where did you turn for help?

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K September 10, 2012 at 07:07 PM
I'm a retired nurse and had to spend 10-days in a SNF in Walnut Creek. I waited 3-days for a needed trapeze. CNA's did not answer my call bell, even had one standing outside my door while I waited for help to go to the bathroom. I was served food that I was allergic to. The toilet didn't flush properly. I assembled the nursing director, social worker, kitchen supervisor, etc. and listed my complaints & violations. All but the toilet problem were corrected immediately. My advantage was having worked in such a facility and supervised CNAs. I also was mentally competent, strong & assertive. Getting into a facility was not a choice. I had multiple complications from a hip replacement including asst-op femur fracture. Patients go wherever the discharge planner sends them. That's how it works. I also had a chat with the ombudsman. This can happen to anyone.
Betty Harrison September 10, 2012 at 10:53 PM
K, thank you for advocating for all the rest of us who are not medical professionals. Plenty of people out there need work... there's no need for management to tolerate slackers when the majority of people in their 20s are under or unemployed. There is no room in either nursing or teaching for people who do not like their work.
E OBrien September 11, 2012 at 01:58 AM
I wouldn't put my DOG in Golden Livingcenter. My mother died there needlessly. The young Hispanic caregivers were wonderful however. They DO care and show it in many ways to the 'inmates". God Bless them and their hard work.
Steve O'Neill September 11, 2012 at 04:01 AM
As a lawyer who has sued a number of Sonoma County care facilities, I am glad to see the spotlight shine on bad care. There are three bits of advice I would offer those who place their loved ones in these places: don't sign their arbitration agreements, you don' have to; visit frequently, it's the best deterrent against bad care; and get familiar with the local ombudsman, and with California Advocates For Nursing Home Reform (CANHR), an advocacy group that fights to improve senior care.
K September 13, 2012 at 02:39 AM
Excellent advise. I would add one more thing. Appoint someone or more than one person to make inquiries and advocate on your behalf. Many elderly people are afraid to complain because they fear retaliation from staff members. I was not only the elderly patient above, but I had to do this numerous times on behalf of family members. Patients In these facilities are extremely vulnerable. And, most are not there by choice.

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