Health inspection·March 27, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement and monitor the effectiveness of interventions of a care plan for one resident (Resident 1) of three sampled residents when Resident 1 had a fall on 3/3/25 and the facility did not ensure: 1. A physician's order for Physical Therapy (PT) so Resident 1 could receive PT; 2. Nursing staff documented frequent room checks had been conducted; and, 3. The Pharmacist's recommendations to monitor Resident 1 for behaviors which could be objectively (data or information collected free from biases or opinions) measured and quantified (measured as a numerical value). This failure resulted in another fall on 3/14/25 in which Resident 1 obtained a left intertrochanteric (a bone below the hip joint) fracture (a break) and a T3 (the 3rd bone of the middle spine) fracture that changed Resident 1's mobility from independent to chairbound. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] for dementia (a progressive state of decline in mental abilities) and anxiety disorder (a condition characterized by persistent and excessive worry or fear that can interfere with daily life and cause significant distress). A review of Resident 1's order summary report indicated physician's order dated 10/18/23 which indicated, Rehab [a course of treatment designed to optimize functioning and reduce disability] potential: (Fair,). A review of a care plan initiated on 11/14/23 indicated Resident 1 was a moderate risk for falls related to psychoactive drug (a drug that affect a person's mental state and behavior) use. A review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 1/15/25, indicated Resident 1 completed the activity of moving from a sitting to standing position, moving from a chair or bed to another chair, and walk 150 feet independently; the helper only assisted prior to or following the activity. This MDS also indicated Resident 1 did not use a mobility device (i.e. a wheelchair, walker, etc.). Page 1 of 4 055331 055331 03/27/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0689 Level of Harm - Actual harm Residents Affected - Few A review of a Medication Administration Record (MAR), dated March 2025, indicated Resident 1 received lorazepam (a medication used to treat anxiety disorders by slowing activity in the brain) 1 milligram (mg-a unit of measure) every 12 hours for anxiety. A review of Resident 1's progress note dated 3/3/25 at 2:58 p.m., indicated, [Resident 1] had an unwitnessed fall around 14:40pm [2:40 p.m.] today in the dining room .was found on the floor .had hit his head on the floor .had a 3 cm [centimeter, a unit of measure] x [by] 2 cm laceration [a cut or tear in the skin caused by trauma or injury] to the back of the head .had a left-hand skin tear 2 cm x 2 cm .transferred to [a hospital] for further evaluation. 1. A review of Resident 1's IDT [Interdisciplinary Team-different professionals gathering to discuss resident needs] progress note dated 3/4/25 at 3:24 p.m., indicated, .Post Fall IDT Meeting .[In attendance were] .DOR [Director of Rehabilitation (oversees PT)] .Nursing . BIMS [Brief Interview for Mental Status, a tool used to determine impairment in a person's cognition (understanding and thought process) with a range from 0-15, with higher scores indicating better cognition)] score of 02 [severely impaired cognition] Prior to hospitalization functional mobility [the ability to move efficiently and effectively] was independent walking .New orders have been reviewed, and care plans have been updated. Fall intervention recommendations .[are] PT eval [evaluation] will be completed .wheelchair for ambulation [to walk] .Post hospitalization [Resident 1] requires assistance with all ADL's [Activities of Daily Living, i.e. toileting, transferring, etc]. A review of a care plan initiated 3/4/25 indicated Resident 1 had an actual fall which resulted in a laceration to the head and wrist related to poor communication/comprehension, psychoactive drug use, and unsteady gait (manner of walking). The care plan also indicated Resident 1's goal was to resume usual activities without further incident and staff were expected to implement the following goals to assist Resident 1 to meet his goal: -PT consult for strength and mobility, -Provide activities that promote exercise and strength building where possible, -Provide frequent room checks when in bed with offers of assistance with toileting, -Assist resident when ambulating, and -Educate the caregivers about safety reminders. A review of a facility document titled PT Evaluation & Plan of Treatment dated 3/5/25, indicated, Plan of Treatment .therapeutic exercises, gait training therapy, therapeutic activities .Frequency: 3 time(s) [per] week .Duration: 26 days .Intensity: Daily .Period: 3/5/25- 3/30/25 .Reason for Therapy .[Resident 1] requires skilled PT services to increase functional activity tolerance [a person's ability to engage in daily activities without excessive fatigue or pain], increase independence with gait, increase LE [lower extremity] ROM [range of motion] and strength, minimize falls and promote safety awareness in order to perform functional mobility [the ability to move effectively and independently to perform everyday activities] with reduced risk of falls .[Resident 1] is at risk for: falls and further decline in function . A review of Resident 1's MDS dated [DATE] indicated Resident 1 required a helper to provide verbal cues and/or touching/steadying while he completed the activity of moving from a sitting to standing 055331 Page 2 of 4 055331 03/27/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0689 Level of Harm - Actual harm Residents Affected - Few position; Resident 1 required a helper to lift, hold, or support the trunk [central part of body including chest, abdomen, pelvis and back] but provide less than half of Resident 1's effort to move from a chair or bed to another chair; and Resident 1 was unable to walk at least 10 feet. A review of Resident 1's order summary report indicated an order dated 3/12/25 which stipulated, Resident Requires Reclining Wheelchair. A review of Resident 1's care plan dated 3/14/25, indicated Resident 1 had an actual fall on 3/14/25 and to .Assist resident with ambulation, offer assist to the bathroom q [every] 2 hours .Pharmacy consult to evaluate medications .PT consult for strength and mobility. A review of a hospital document titled Imaging Results dated 3/14/25 at 5:17 p.m., indicated, .[X-ray of] Hip .Acute [a sudden occurrence] left greater trochanteric fracture seen on CT [Computed Tomography- a type of x-ray) from same day prior .CT [of] Spine .Partially visualized acute T3 vertebral body [the thick, front part of the bones that make up the spinal column which holds the weight of a person's head and trunk] fracture with 25% height loss and anterior wedging deformity [a wedge-shaped deformity of the front of front part of the bones that make up the spinal column], new compared to 3/3/25 . A review of the facility's untitled document dated 3/19/25 indicated, On March 14, 2025, [Resident 1] was found on the floor next to his bed, entangled in his privacy curtain. Prior to the incident, [Resident 1] had been in bed. Upon investigation, it was determined that the [Resident 1] became tangled in the curtain, leading to the fall .[Resident 1] was admitted to the hospital on [DATE]. According to the transfer documentation received upon the resident's return .[Resident 1 sustained] a T3 vertebral fracture and a left intertrochanteric hip fracture. The resident underwent appropriate medical treatment and was discharged back to the facility on March 19, 2025 .Interventions Implemented .Initiated one-on-one [1:1, one staff member to provide supervision and care one resident] sitter supervision to ensure increased safety and supervision until the resident is assessed to be stable .Conducting frequent monitoring and repositioning as needed. Continuing fall risk assessments and implementing interventions to prevent future incidents .Providing assistance with .ADLs, mobility, and transfers as needed. Follow-Up Actions .Coordination with therapy services to support mobility and rehabilitation. Maintaining open communication with the resident's physician . A review of Resident 1's order summary report printed on 3/27/25 at 3:23 p.m. indicated no active order for PT treatment as indicated in Resident 1's PT Evaluation & Plan of Treatment dated 3/5/25. During an interview on 3/27/25 at 3 p.m., the DOR confirmed Resident 1 had not participated in PT after the evaluation and plan of treatment conducted on 3/5/25. 2. During an interview on 3/27/25 at 11:15 a.m., Certified Nursing Assistant A (CNA A) stated fall preventions measures included rounding (checking on residents) to ensure safety. She stated she usually rounded on residents about every two hours but did not chart it. During an interview on 3/27/25 at 1:27 p.m., Licensed Nurse C (LN C) stated she monitored her residents who were fall risks. She stated the communication used for monitoring fall risk residents was placed on a communication sheet which was updated every shift and passed along to the next shift. The LN C stated it was not part of the resident's medical record. During an interview on 3/27/25 at 1:53 p.m., the Director of Nursing (DON) and the Director of 055331 Page 3 of 4 055331 03/27/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0689 Level of Harm - Actual harm Residents Affected - Few Staff Development (DSD) stated after Resident 1's falls, .monitoring were used. We also did fall evaluations and assessments. Both the DON and DSD stated documentation of fall interventions should be in the electronic medical record, but neither could find it. The DSD then stated monitoring was on a paper form. The DON then stated, It should be in [the electronic medical record system], but I don't know where it is. The DON stated the expectation was nursing staff document each time fall monitoring interventions were conducted. During an interview on 3/27/25 at 2:30 p.m., the Assistant Administrator (AA) stated he was uncertain about the resident fall monitoring process but would ask Medical Records if they could find any documentation regarding fall monitoring. During an interview on 3/27/25 at 2:52 p.m., the DON stated no fall monitoring documentation for Resident 1 could be found. 3. A review of Resident 1's document titled Consultant Pharmacist Medication Regimen [the plan followed when taking medication] Review dated 3/14/25 indicated, For Recommendations Created Between 3/1/2025 and 3/14/2025 .Can we monitor behaviors and side effects of medications for lorazepam? Behaviors should be able to be objectively measured and quantified. During an interview at 4/21/25 at 12:27 p.m., the DSD and AA explained monitoring behaviors on the MAR indicated whether a behavior was observed. The DSD confirmed the responses yes and no in the MAR indicated whether a behavior was observed. The DSD stated the behavior the staff observed would have been agitation. The DSD confirmed agitation was not noted on the MAR as a behavior to monitor, and no other side effects of lorazepam were listed for nurses to monitor. The DSD further confirmed the facility had not correctly monitored Resident 1 for lorazepam side effects for his high fall risk status. The DSD and AA acknowledged many interventions, such as the frequent monitoring and weekly summaries had not been documented in the medical record to evaluate whether they were working. The DSD stated, Care plans were not updated as they should have been, including the weekly summaries . The DSD and the AA both stated this fall has been a true learning experience .and [staff] is working to make changes to reflect the care given. A review of facility document titled Fall Management Program, dated 3/13/21, indicated .If a fall risk factor is identified, document interventions on the Resident's care plan. Document interventions for every Resident regardless of fall risk evaluation score .The licensed nurse will evaluate the Resident's response to the interventions on the Weekly Summary and update the Resident's care plan as necessary . During a review of facility document titled Comprehensive Person-Centered Care Planning , dated 9/7/23, indicated The baseline care plan must include .healthcare information necessary to properly care for each resident .address resident-specific health and safety concerns to prevent decline or injury and would identify needs for supervision, behavioral interventions .It should also reflect changes to approaches .resulting from significant changes in condition or needs. 055331 Page 4 of 4