Health inspection·April 14, 2025

The following reflects the findings of the California Department of Public Health during the investigation of complaint CA00941982. Event ID: ZETM11 Class A Citation was written. 42 CFR §483.21. Comprehensive Person-Centered Care Planning. (a) Baseline Care Plans. (a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must- (i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- (A) Initial goals based on admission orders. 42 CFR § 483.40 Behavioral health services. Each resident must receive, and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. 42 CFR § 483.25 (d) Accidents. The facility must ensure that - (d)(1) The patient environment remains as free of accident hazards as is possible; and (d)(2) Each patient receives adequate supervision and assistance devices to prevent accidents. Cal. Code Regs. Tit § 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. Cal. Code Regs. Tit. 22, § 72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 1/23/25 at 1:15 P.M., an unannounced onsite visit to the facility was conducted related to a complaint regarding quality of care and resident safety. Resident 1 was identified by two nurse practitioners (to be at risk for suicidal ideation (SI-when you think about, consider or feel preoccupied with the idea of death and suicide). The nurse practitioners made written recommendations to prevent Resident 1's suicide and suicidal attempts including close monitoring and removing medications and potential weapons from Resident 1's vicinity. On 1/20/25, nursing staff found Resident 1 inside her room, with her left wrist bleeding from cutting herself with a butterknife and had ingested approximately 90 Metformin (medication to treat high blood sugar levels) pills. Resident 1 was sent to the hospital and was admitted in the intensive care unit (ICU - patient whose condition is extremely serious, possibly life-threatening) in critical condition. Resident 1 was placed on life support and underwent hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) for treatment and recovery in critical condition. The facility failed to: 1.Develop and implement Resident 1's care plan based on nurse practitioners written recommendations. This includes but is not limited to closely monitoring resident and removing medication and potential weapons in Resident 1's vicinity based on Resident 1's documented suicidal risk. 2. Provide necessary behavioral health care based on Resident 1's documented suicidal risk. 3. Closely supervising suicidal Resident 1 and removal of accident hazards (like weapons and medication) to prevent suicide attempts. 4. Implement facility policy and procedures including "Safety and Supervision of Residents" and "Care Plans, Comprehensive Person-Centered". Resident 1 was readmitted to the facility on 10/17/24, with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body), per the facility's admission Record. A review of Resident 1's History and Physical (H&P), dated 10/17/24, was conducted. The H&P indicated Resident 1 had left sided weakness and was admitted to the facility for rehabilitation. The H&P indicated Resident 1 had the capacity to make her own medical decisions. A review of Resident 1's Minimum Data Set (MDS - a federally mandated assessment tool), dated 10/17/24, was conducted. The MDS indicated Resident 1's brief interview for mental status (BIMS-ability to recall) score was 15/15 (a score of 13 to 15 suggests the patient is cognitively [process of acquiring knowledge and understanding] intact). A review of Resident 1's psychiatric assessments, completed by Nurse Practitioners (NPs 1 and 2), was conducted. According to the psychiatric assessments, Resident 1 was assessed by the NP 1 and NP 2 on 11/19/24, 12/5/24, 12/26/24, 1/2/25, and 1/16/25. NP 1 and NP 2 documented the following: 11/29/24 - NP 1 documented that Resident 1 was at moderate risk for SI and recommended monitoring of Resident 1. NP 1 documented Resident 1 had Major Depressive Disorder (MDD, a mood disorder that causes a persistent feeling of sadness and loss of interest) and was placed on trazodone (anti-depressant medication). 12/5/24 - NP 1 documented Resident 1 had suicide attempt one month ago by overdosing herself on pills. NP 1 documented Resident 1 was at high risk for SI. NP 1 recommended monitoring of Resident 1. NP 1 documented that sertraline (anti-depressant medication) was added to Resident 1's medication regimen. 12/26/24 - NP 2 documented Resident 1 required close monitoring with the same recommendations documented on 11/29/24 and 12/5/24. 1/2/25 - NP 2 documented Resident 1 required close monitoring. 1/16/25 - NP 2 documented Resident 1 required close monitoring. All psychiatric assessments completed by NP 1 and NP 2 on 11/29/24, 12/5/24, 12/26/24, 1/2/25, and 1/16/25 for Resident 1, provided the resident three questions. Resident 1 answered all questions with the same answers. Below were the questions and the answers provided by Resident 1: "Have you wished you were dead or wished you could go to sleep and not wake up?" Resident 1 answered "Yes." "Have you actually had any thoughts of killing yourself?" Resident 1 answered "Yes". "Have you been thinking about how you might do this? Yes-patient reports thinking about overdosing on medication." A review of Resident 1's nursing progress notes, dated 1/20/25 at 12:29 P.M., was conducted. License Nurse (LN) 1 documented "At 1000, the resident (Resident 1) was seen in her room attempting self-harm by cutting her wrist with a butter knife and reporting she had ingested approximately 90 metformin pills that she had in her possession from her daughter bringing them to her from the [name of pharmacy]. She also reported taking a zip lock bag with other unidentified pills. Empty metformin bottle and an empty zip lock found in residents' possession ...The butter knife was removed from the patient's possession and secured. Laceration and bleeding noted on resident's left wrist with a scant amount of bleeding noted at the time of intervention ..." On 1/23/25 at 2:21 P.M., an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated Resident 1 was alert and was aware of what was going on around her. CNA 1 stated Resident 1 did not seem to be depressed. CNA 1 stated there was no communication from the LNs regarding the need to monitor Resident 1 and was not aware of the Resident 1's SI risk. CNA 1 stated the staff did not know Resident 1 kept medications with her belongings. On 1/23/25 at 1:27 P.M., an interview and joint record review of Resident 1's medical record was conducted with LN 1. LN 1 stated on 1/20/25, LN 4 called him to check Resident 1 in her room because she was cutting her wrist. According to LN 1, Resident 1 was "actively" cutting herself with a metal butterknife. According to LN 1, he took away the metal butterknife from Resident 1 and noticed that the resident was bleeding. LN 1 stated he noticed an empty bottle of metformin (antidiabetic medication) on Resident 1's lap. According to LN 1, he asked Resident 1 what she did, and Resident 1 told him she ingested 90 pills of metformin and some pills from a plastic bag. LN 1 stated he did not know what other medications Resident 1 ingested. LN 1 stated Resident 1 did not verbalize her depression. LN 1 stated the NP placed Resident 1 on anti-depressant medications. LN 1 stated he was not aware of the NPs' recommendation to monitor Resident 1. LN 1 stated he was not aware that Resident 1 had suicidal Ideations. LN 1 reviewed the psychiatric assessment and note completed by NP 1 on 11/29/24. LN 1 stated, "I don't know about this note, this is the first time I saw the notes. We don't monitor [name of resident 1]." LN 1 stated he was not sure if the other LN knew about Resident 1's SI. LN 1 stated there was no communication related to Resident 1's SI and the need for Resident 1 to be monitored. On 1/23/25 at 3:27 P.M., an interview and joint record review of Resident 1's medical record was conducted with LN 2. LN 2 stated she did not receive communication related to Resident 1's SI and was not aware the resident needed to be monitored. LN 2 stated she was not aware of the NPs' psychiatric assessments and recommendations. LN 2 stated the facility's protocol was to monitor residents with SI. LN 2 stated they (staff) were not aware Resident 1 had history of overdosing herself with medications. LN 2 shook her head when she read NP 1's notes regarding Resident 1's SI and the resident's plan to overdose on medications. LN 2 stated, "This is the first time I am reading this." LN 2 stated the protocol was when a resident was assessed with SI, the staff would have to closely monitor the resident. LN 2 stated there was no care plan and interventions developed related to Resident 1's SI to keep the resident safe. On 1/23/25 at 5:11 P.M., an interview and joint record review of Resident 1's medical record was conducted with LN 3. LN 3 reviewed the psychiatric assessment and note completed by NP 1 on 11/29/24. LN 3 stated, "I have not seen the psych notes that she (Resident 1) had passive SI. This is my first time seeing this note." On 3/6/25 at 1:30 P.M., a telephone interview with CNA 2 was conducted. CNA 2 stated she was assigned to provide care to Resident 1 on 1/20/25. CNA 2 stated Resident 1 did not eat all her meals which she usually did. CNA 2 stated she was not aware that Resident 1 had SI, and that the resident needed to be monitored. CNA 2 stated staff did not open the nightstand drawers of residents who were continent (ability to control the release of urine and/or bowel movement). CNA 2 stated, "We did not know she had some medications there; we don't check." On 3/6/25 at 2:28 P.M., a telephone interview with NP 1 was conducted. NP 1 stated she saw Resident 1 on 11/29/24 and alerted the charge nurse that Resident 1 was at moderate to high risk for SI, according to the suicide risk assessment and that the resident needed close monitoring. NP 1 stated the facility staff should be communicating with each other since Resident 1 was at moderate to high risk for suicidal ideation. NP 1 stated Resident 1 should have been closely monitored which meant Resident 1 should have been placed on a one-on-one monitoring. NP 1 stated the other concern was Resident 1 had access to a butterknife, and medications that staff were not aware the resident had. NP 1 stated Resident 1 had a diagnosis of MDD because she met the criteria of having a recurrent thought of death or trying to harm herself. NP 1 stated she did not communicate Resident 1's SI to social services. A review of the text message of NP 1 to the facility was conducted. The message dated 12/5/24 at 9:46 P.M. indicated, NP 1 informed the facility that Resident 1 was at moderate to high risk of suicide, to ensure there were no medications or weapons in the resident's room and that the staff would have to checked Resident 1 more often. A review of Resident 1's hospital psychiatry (psych) consults notes, dated 1/20/25 at 1:19 P.M., indicated the interview with Resident 1 was limited due to lethargy (decrease in consciousness), nausea and vomiting. The psych notes indicated Resident 1 "Endorses a month of worsening depressed mood and SI". The psych notes indicated Resident 1 had symptoms of depressed mood, insomnia, hopelessness, decreased energy, and worsening suicidal ideation. A review of Resident 1's emergency department (ED) physician notes dated 1/21/25 at 2:06 P.M., indicated Resident 1 had worsening SI over the past month and planned to end her life. The ED notes indicated that while Resident 1 was in the ED, Resident 1's vital signs were significant with tachycardia (heart rate over 100 beats per minute) in addition to tachypnea (rapid, shallow breathing). The ED notes indicated Resident 1's lab results were abnormal, and Resident 1 became more agitated, somnolent (a state of strong desire for sleep, or sleeping for unusually long periods) and altered mental status. The ED notes indicated Resident 1 was admitted to the ICU in critical condition and to proceed with hemodialysis. On 3/20/25 at 12:28 P.M., a telephone interview with the Director of Nursing (DON) was conducted. The DON stated no one alerted her on the text message from NP 1. The DON stated the LNs should have informed her about the message to ensure she knew what was happening in the facility and ensure resident safety. The DON stated the expectation was to make sure there would be no repeated incident. A review of the facility's policy titled Safety and Supervision of Residents, revised July 2017, indicated, "...Resident safety and supervision and assistance to prevent accidents are facility-wide priorities...2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes...Individualized Resident centered Approach to Safety ..2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents, 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision..." A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, indicated, "A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident...1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident..." Resident 1 was identified by two nurse practitioners to be at risk for suicide. The nurse practitioners made written recommendations to prevent Resident 1's suicide and suicidal attempts including close monitoring and removing medications and potential weapons from Resident 1's vicinity. On 1/20/25, nursing staff found Resident 1 inside her room, with her left wrist bleeding from cutting herself with a butterknife and had ingested approximately 90 Metformin pills. Resident 1 was sent to the hospital and was admitted in the ICU in critical condition. Resident 1 was placed on life support and underwent hemodialysis for treatment and recovery in critical condition. The facility failed to: Develop and implement Resident 1's care plan based on nurse practitioners written recommendations. This includes but is not limited to closely monitoring resident and removing medication and potential weapons in Resident 1's vicinity