Health inspection·March 8, 2024

The following reflects the findings of the California Department of Public Health during a standard abbreviated survey regarding investigation of a complaint CA00862319 and Facility Reported Incident CA00862208. Event ID: 7LFN11 Exit date: 2/8/24 Representing the Department: 39238 Health Facilities Evaluator Supervisor, 33651, Health Facilities Evaluator Manager I; 32398, Health Facilities Evaluator Nurse. State Citation AA was issued. F689 §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 9/25/23, an unannounced standard abbreviated survey was conducted at the facility, a complaint regarding Accidents and facility reported incident regarding Quality of Care/Treatment were investigated. The facility failed to follow the Minimum Data Set (MDS, a standardized assessment tool for residents' functional status to help identify health problems and to identify the proper care needed) assessment to provide staff supervision and/or physical assistance for nine of nine residents (Residents 1,2,3,4,5,6,7,8 and 9) when these nine residents left their rooms/units and went outside of the facility to smoke at the old smoking area, located at the corner of the facility near a major street and the facility's parking lot. The facility failed to follow four of eight residents' (Residents 2,3,5, and 8) MDS assessment to provide staff supervision and/or staff physical assist when these four residents left their rooms/units, went outside of the facility to smoke, and traversed (traveled across or through) on the sidewalk to and from the new smoking area, which was in a gated garden with a locked gate near the facility parking lot. The sidewalk was adjacent to the facility parking lot. These failures resulted in Resident 1 crossing the street via an electronic scooter (electric powered mobility scooter for adults) from the old smoking area without staff supervision on 9/22/23. Resident 1 was hit by a car in the street. Resident 1 was sent to the hospital and died in the hospital on 9/22/23. These failures had potential to likely put the other eight residents (Residents 2, 3, 4, 5, 6, 7, and 9) at risk when crossing the parking lot and/or street and likely to be hit by a car (vehicle) without staff supervision. 1a. Review of Resident 1's "Order Summary Report" indicated he was admitted to the facility on 8/22/23, with diagnoses including right ankle and foot acute osteomyelitis (an infection in the bone) and alcohol abuse. Review of Resident 1's acute hospital "Admission/Discharge Information" signed on 8/21/23, indicated, he had a right below the knee amputation (BKA). Review of the facility's unusual occurrence report received by the Department on 9/25/23, indicated that on 9/22/23, Resident 1 went outside the facility to smoke and decided to take his motorized scooter across the street. The report further indicated Resident 1 was struck by a car. Review of the police report dated 9/22/23, indicated that Resident 1 was crossing the street at 1990 Fruitdale Ave. with his motorized wheelchair headed north towards the north sidewalk of Fruitdale Ave. Review of Resident 1's acute hospital records dated 9/22/23 indicated, "[years old] man was in a wheelchair in the street and was involved in a collision with a vehicle throwing him 10' (10 feet) from the wheelchair. Bystanders witnessed the event and provided "Good Samaritan" aid to the patient with rapid CPR [cardiopulmonary resuscitation]." Further review of Resident 1's acute hospital record dated 9/22/23 indicated, Resident 1 sustained 3 centimeters (cm, unit of measurement) posterior scalp laceration (an injury at the back of the head involving skin tear) with underlying skull fracture (fracture in the head) and laceration to forehead (skin tear in the front of the head). Resident 1's time of death was 11:13 a.m. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 8/29/23, indicated he needed supervision with one-person physical assist for locomotion off unit (how resident moves to and returns from off-unit locations (e.g., areas set aside for dining, activities, or treatments). "If facility has one floor, how resident moves to and from distant areas on the floor. If in a wheelchair, self-sufficiency once in a chair." Review of Resident 1's MDS dated 8/29/23, indicated he had Brief Interview for Mental Status score of 14 (score of 13 to 15 indicates intact cognition [able to follow commands]). His MDS indicated current use of tobacco was answered no. Review of Resident 1's "Physical Therapy PT Evaluation & Plan of Treatment" dated 8/23/23, indicated Resident 1's long term goal # 3 was, "Patient will increase ability to safely propel self in wheelchair 200 feet with independence for grasp/release of items, for safe maneuvering in small spaces and for safety awareness. (Target: 9/19/2023)." Review of Resident 1's "Physical Therapy PT Discharge Summary" electronically signed on 9/4/23 indicated, Resident 1's long term goal # 3 was discontinued. The record indicated Resident 1's physical therapy was discontinued on 9/4/23. The comments indicated wheelchair mobility distance 50 feet with supervision or touching assistance. The comment section of the "Physical Therapy PT Discharge Summary" indicated "Barriers include S/P [status post] amputation on R LE [right lower extremity] amputation on L LE [left lower extremity], NWB [non weight bearing] L LE,...decreased cardiopulmonary [heart and lungs] tolerance, and decreased safety." During an interview with Certified Nursing Assistant A (CNA A) on 9/26/23, at 2:40 p.m., CNA A stated on 9/22/23, she saw Resident 1 outside the facility after breakfast. CNA A stated there were no staff that went with the residents when they went to smoke that day. CNA A further stated she had not observed any staff supervising residents who smoke. CNA A verified Resident 1 had a right BKA and needed a one person assist. CNA A stated Resident 1 had used a motorized scooter and a regular wheelchair. CNA A further stated on 9/22/23, she saw three nurses running from the charting room towards the main entrance of the facility and did not know what was going-on at that time. When asked if there was protective equipment for residents who smoke, like a smoking apron, CNA A stated she did not know what a smoking apron was. During an interview with Licensed Vocational Nurse H on 9/27/23, at 2:54 p.m., LVN H stated Resident 1 went to the smoking area about 45 minutes to an hour after breakfast. LVN H stated license nurses had direct visual and were able to talk to residents who smoke outside. LVN H further stated they were allowed to visualize the residents who smoke through the charting room and nurses were able to talk to the residents through the sliding door. LVN H stated she checked Resident 1 every 5 minutes or "so". When asked what was the time window for the medication pass, LVN H stated "typically" on the floor at 9 a.m. and finishing medication pass during the incident. LVN H stated she did not see Resident 1 go into the street. LVN H stated Resident 1 was assessed to use the motorized scooter. During a telephone interview with the Physical Therapy (PT) on 9/29/23, at 12:43 p.m., he reviewed Resident 1's daily notes and stated Resident 1 had right BKA and non-weight bearing on left lower extremity. The PT explained, supervision means a person needs to be near the resident for safety. The PT further explained when a goal was discontinued it means the goal was not met. During a telephone interview with the Minimum Data Set Nurse (MDSN) on 9/29/23 at 3:22 p.m., the MDSN stated Resident 1's MDS dated 8/29/23 indicated Resident 1's functional status for locomotion off unit was supervision with one person assist. The MDSN stated supervision means oversight and cueing. The MDSN explained that based on the assessment, Resident 1 needed staff supervision. The MDSN further stated Resident 1 had one side lower extremity impairment with mobility devices such as a walker and wheelchair. During an interview with the regional director of clinical services (RDCS) on 9/26/23 at 1:34 p.m., the RDCS stated Resident 1's used of motorized scooter was not formally assessed. During an interview with the Director of Nursing (DON) on 10/5/23, at 1:26 p.m., the DON stated prior to the incident on 9/22/23, the facility's smoking area was by the sidewalk by the corner of the building. Residents who smoke will tell the nurse when they go to smoke. The resident does not need to sign in and out when they go out to smoke. The DON further stated the facility was a non-smoking facility. The DON added, there were no reasonable rules given to Resident 1 because there was no admission agreement signed by the resident. The DON stated there should be an admission agreement, and "unfortunately" it was not signed. Review of the "XI. Facility Rules and Grievance Procedure" of the "CALIFORNIA STANDARD ADMISSION AGREEMENT FOR SKILLED NURSING FACILITIES AND INTERMEDIATE CARE FACILITIES" indicated "You agree to comply with reasonable rules, policies, and procedures that we establish. When you are admitted, we will give you a copy of those rules, and policies, and procedures, including a procedure for you to suggest changes to them." During an interview with the MDSN on 1/19/24, at 2:55 p.m., the MDSN stated the importance of the admission agreement was for the resident or responsible party to know the facility's policy and the care to be provided. Review of the facility's "RESIDENT RESPONSIBILITIES AND RULES OF CONDUCT", indicated "...10. Resident may not leave the premises without signing out to their respective nurses' station...11. If the facility is a smoking facility, smoking is permitted only in designated areas. Smoking regulations are posted throughout the facility. Smoking regulations must be followed at all times. Some smoking restriction may apply to individual residents..." 1b. Review of Resident 2's face sheet (a document that contains the information of the resident) indicated Resident 2 was re-admitted to the facility on 9/14/23 with diagnoses including hemiplegia (loss of muscle function of one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction (stroke, damage to the brain tissues due to loss of oxygen) affecting left non-dominant side, muscle wasting and atrophy (decreased in size), anxiety disorder (feelings of worry and fears) and depression (persistent loss of interest in activities). Review of Resident 2's MDS indicated Resident 2's BIMS (brief interview for mental status) score was 9 (score of 8 to 12 indicates cognition was moderately impaired). Resident 2's locomotion off unit (how resident moved to and return from off-unit locations, such as areas set aside for dining, activities, or treatments) required limited assistance with one-person physical assist. Resident 2's MDS indicated Resident 2 required a wheelchair as his mobility device. 1c. Review of Resident 3's "Order Summary Report", indicated he was admitted to the facility on 7/31/23, with diagnoses including acquired absence of left leg below the knee (BKA, below the knee amputation), schizophrenia (severe mental disorder affecting how a person thinks, feel, and behaves). Review of Resident 3's face sheet indicated a family member was his responsible party (RP, a person who is accountable in making decision on behalf of the resident). Review of Resident 3's MDS dated 9/13/23, indicated he had a BIMS score of 12 and he needed supervision (oversight, encouragement, or cueing) with one-person physical assist for locomotion on unit (how resident moves and returns from his room) and locomotion off unit (how resident moves around outside his room or distant areas). Resident 3 required a wheelchair as his mobility device. 1d. Review of Resident 4's face sheet indicated Resident 4 was re-admitted to the facility on 5/4/21, with diagnoses including anemia (body does not have enough healthy red blood cells), history of falling, and muscle weakness. Review of Resident 4's MDS dated 6/20/23, indicated Resident 4's BIMS score was 14 (cognitively intact). Resident 4's locomotion off unit required supervision with one-person physical assist. Resident 4 required a wheelchair as his mobility device. 1e. Review of Resident 5's face sheet indicated Resident 5 was admitted to the facility on 6/16/23, with the diagnoses including difficulty in walking, other specified disorders of the brain, and muscle wasting and atrophy (decreased in size). Review of Resident 5's MDS dated 6/18/23, indicated Resident 5's BIMS score was 10. Resident 5's locomotion off unit required supervision with setup. Resident 5 required a wheelchair as his mobility device. 1f. Review of Resident 6's face sheet indicated Resident 6 was admitted on 8/15/23, with diagnoses of difficulty in walking, muscle wasting and atrophy. Review Resident 6's MDS dated 8/24/23, indicated Resident 6's BIMS score was 15. Resident 6's locomotion off unit required supervision with one-person physical assist. Resident 6 required a wheelchair as his mobility device. 1g. Review of Resident 7's face sheet indicated Resident 7 was admitted to the facility on 8/25/23, with diagnoses including muscle wasting and atrophy, muscle weakness, anxiety disorder. Review of Resident 7's MDS dated 9/4/23, indicated Resident 7's BIMS score was 15. Resident 7's locomotion off unit activity occurred only one or twice with one-person physical assist. Resident 7 required a wheelchair as his mobility device. 1h. Review of Resident 8's face sheet indicated Resident 8 was admitted to the facility on 9/20/23, with diagnoses of abnormalities of gait and mobility, along with anemia. Review of Resident 8's MDS dated 9/26/23, indicated Resident 8's BIMS score was 15. Resident 8's locomotion off unit required supervision with one-person physical assist. Resident 8 required a wheelchair as his mobility device. 1i. Review of Resident 9's face sheet indicated Resident 9 was admitted to the facility on 8/22/23, with diagnoses including abnormal posture, fall, psychoactive substance (a chemical substance that could change the perception or mood) abuse, hemiplegia (loss of muscle function of one side of the body) and hemiparesis (weakness of one side of the body). Review of Resident 9's MDS dated 8/31/23, indicated Resident 9's BIMS score was 15. Resident 9's locomotion off unit required supervision with one-person physical assist. Resident 9 required a wheelchair as his mobility device. 2. During an observation and interview with the facility Regional Vice President (RVP) and the Regional Director of Clinical Service (RDCS) on 9/27/23, at 3:45 p.m., both RVP and RDCS used a measurement device to measure the distance between the facility main entrance area to the old smoking area and to the new smoking area. The RVP and RDCS stated the distance between the facility main entrance area to the old smoking area was 180 feet. The distance from the main entrance area to the new area smoking area was 80 feet. During an observation at the new smoking area on 9/26/23, at 11:30 a.m., a locked gate was between the new smoking area and the sidewalk. The sidewalk was adjacent to the facility parking lot. The sidewalk was leading to the facility main entrance. There were six residents sitting in their wheelchairs while smoking in the smoking area. During an interview with CNA D on 9/26/23, at 11:37 a.m., CNA D stated she was "just" assigned to watch the residents to smoke in the new smoking area today (9/26/23). CNA D stated there was no staff to supervise residents to smoke at the old smoking area before. CNA D stated she was just told to sit and watch the resident in the new smoking area. She stated she did not get any training regarding how to supervise these residents in the new smoking area in case an emergency occurred. CNA D stated residents came and went freely by themselves, and no staff supervised and accompanied the residents when they wheeled themselves on the sidewalk to and from the new smoking area. During an observation on 9/26/23, at 11:50 a.m., Resident 3 was observed to wheel himself via a wheelchair to the new smoking area through the sidewalk by himself. No staff accompanied or supervised him at the sidewalk.