Health inspection·May 1, 2025

The following reflects the findings of the California Department of Public Health during the investigation of facility reported incident number 941821. The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility. A deficiency was written for facility reported incident number 941821 at F-tag 689/G. 42 Code of Federal Regulations part §483.25(d)(1)(2) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. Based on observation, interview, and record review, the facility failed to follow the care plan (comprehensive documents outlining the care and services to be provided by the facility to residents) to provide supervision during transfers and failed to complete the Fall Risk Evaluation (FRE is a comprehensive assessment to determine a resident's likelihood of falling and identifies potential contributing factors) for one of three sampled residents (Resident 1). Resident 1 had generalized muscle weakness, a history of falls, was at risk for falls, and had Alzheimer's Disease (Brain disorder that progressively damages memory, thinking, and reasoning skills) when Resident 1 got up unsupervised to use the toilet and fell in her room. This failure resulted in Resident 1 sustaining a fall with fracture (broken bone), requiring a hospital admission, and surgical intervention at the acute care hospital. An unannounced visit was conducted on 1/23/25 to investigate a facility reported incident when Resident 1 had a fall and sustained a hip fracture. Resident 1 was a 90-year-old female, admitted on 5/4/23 with the diagnoses of Alzheimer's Disease, Schizoaffective Disorder (false perception of reality with mood symptoms), Cognitive Communication Deficits (inability to communicate), Spondylosis (degeneration of the spine), Osteoarthritis (degeneration of joints causing pain and stiffness), Generalized Muscle Weakness, Difficulty Walking, Need for Assistance with Personal Care, and History of Falling. During a review of Resident 1's "Admission Record (AR)," dated 1/23/25, the AR indicated Resident 1 was admitted to the facility on 5/4/23 with diagnoses including Alzheimer's Disease, Schizoaffective Disorder (false perception of reality with mood symptoms), Cognitive Communication Deficits (inability to communicate), Spondylosis (degeneration of the spine), Osteoarthritis (degeneration of joints causing pain and stiffness), Generalized Muscle Weakness, Difficulty Walking, Need for Assistance with Personal Care, and History of Falling. During a review of Resident 1's Minimum Data Set (MDS) (a comprehensive assessment tool), dated 8/6/24, under section C (which assesses cognitive patterns), Brief Interview for Mental Status ((BIMS - a cognitive screening tool used in long term care facilities to assess a resident's cognitive function, ranging from 0 to 15, with lower scores indicating greater cognitive impairment. It assesses memory and orientation. Score of 13 to 15 is intact cognition, 8 to 12 is moderate impairment in cognition and 0 to 7 is severe impairment) score was 5. The MDS indicated Resident 1 needed assistance and supervision with personal hygiene, toileting, getting up and transferring from bed, chair and toilet, and used a wheelchair as a mobility (moving) device. During a review of Resident 1's Fall Prevention Care Plan (FPCP), initiated 5/4/23 and last revised 2/17/24, the FPCP indicated the following fall prevention interventions: resident's call light within reach and encourage the resident to use it for assistance (initiated 5/14/23); educate resident about safety reminders (initiated 5/4/23); encourage resident to participate in activities (initiated 5/4/23); anticipate and meet the resident's needs (initiated 8/16/23); ensure resident is wearing appropriate footwear (initiated 8/16/23); follow facility fall protocol (initiated 8/16/23); physical therapy as needed (initiated 8/16/23); safe environment (initiated 8/16/23); bed and wheelchair in lock position (initiated 11/16/23); keep bed in lowest position when care not being provided (initiated 11/16/23); and pressure pad alarm in bed and wheelchair to alert staff when resident attempting to get up unassisted (initiated 2/17/24). During a review of Resident 1's "Activities of Daily Living Care Plan (ADLCP)," dated 3/16/24, the ADLCP indicated, "TRANSFER: [Resident 1] requires supervision with 1 person staff between surfaces and as necessary." During a review of Resident 1's FRE, dated 8/6/24, the FRE indicated Resident 1 was at risk for falls. The FRE indicated Resident 1 had a history of falls, was confused, and had predisposing health conditions that increased the risk of falls. Three of the four sections of the FRE were blank: Section AS_2 Gait Balance (where the facility has to indicate if the resident has balance problems while standing or walking); Section AS_3 Medications (where the facility has to indicate if the resident is taking medications that increase the risk of falls such as medications to treat hypertension [high blood pressure], psychotropics or medications that affect the mood or cognition), and Section AS_4 Clinical Suggestions (where the facility has to indicate interventions to prevent falls for the resident). The FRE contained fields for staff to indicate fall preventions interventions to be implemented for Resident 1, such as "Assist Resident with ambulation and transfers..." and "Utilize toileting program". The fields for these interventions were unselected and blank. During a review of Resident 1's "Situation Background Assessments and Recommendations (SBAR)" note, dated 1/21/25 at 9:20 a.m., the SBAR indicated: "Situation: unwitnessed fall. Background: Alzheimer's disease, difficulty in walking; Assessment: [Licensed Nurse 1] was passing medications to the next room when the pressure alarm on the bed began beeping. [Licensed Nurse 1] went in the room, [Licensed Nurse 1] found the [Resident 1] lying on the floor. ... [Resident 1] complained of pain in her left hip... [Resident 1] verbally stated she was heading to the bathroom. ... [Resident 1's Physician] was contacted and receive order to transfer [Resident 1] to the hospital for further evaluation and treatment. ... Ambulance arrived and transported [Resident 1] to hospital." During a review of the hospital's "History and Physical" (H&P) dated 1/21/25, the H&P indicated: "Chief Complaint: report of fall ...complains of left hip pain. Assessment/Plan: acute [sudden, recent] left femoral neck [thigh bone] fracture s/p [status post/after] fall." During a review of the hospital's "Operative and Procedure Reports (OPR)," dated 1/23/25, the OPR indicated: "Operative Diagnosis: Left Traumatic Intertrochanteric Femur [hip] Fracture. Procedure: Left Hip Intertrochanteric fracture fixation [hip surgery] with a cephanomedullary nail [surgical device to treat fracture]." During an interview with Licensed Nurse (LN) 1 on 1/23/25, at 11:41 a.m., LN 1 stated on 1/21/25 at around 9 a.m., she was in the hallway passing medications to residents when she heard Resident 1's bed alarm. LN 1 stated she went into Resident 1's room and found Resident 1 lying on the floor, next to her bed. LN 1 stated Resident 1 reported to her she fell while trying to go the bathroom and indicated left hip pain. LN 1 stated Resident 1 was taken to the hospital for evaluation and treatment. LN 1 stated the fall was unwitnessed. During a concurrent interview and record review on 2/28/25 at 1:20 p.m. with Director of Nursing (DON), Resident 1's "ADL (Activities of Daily Living) Flowsheets (where Certified Nursing Assistants document care)," dated January 2025 was reviewed. The ADL Flowsheets indicated no documentation Resident 1 was provided toileting supervision or assistance on 1/21/25 (date of fall incident). DON stated Resident 1 was not on a toileting program (scheduled toileting-fixed schedule). DON stated at the time of the fall Resident 1 had a bed alarm to alert staff when she gets out of the bed. DON stated staff relied on the bed alarm to know when Resident 1 was getting out of bed. DON stated at the time of the fall Resident 1 received the same supervision as all other residents, meaning that Certified Nursing Assistants (CNAs) checked on Resident 1 every two hours. DON stated CNAs did not document Resident 1's monitoring. During a concurrent observation and interview on 2/28/25, at 3:15 p.m., with Resident 2, who shared the same room with Resident 1, in her room, Resident 2's bed was next to Resident 1's bed and was directly in front of the bathroom and had an unobstructed view of the bathroom. Resident 2 stated she witnessed Resident 1's fall on 1/21/25. Resident 2 stated Resident 1 got out of bed and went to the bathroom unassisted by staff. After Resident 1 left the bathroom, and on her way back to her bed, Resident 1 lost her balance and fell to the floor. Resident 2 stated she pressed her call light to alert staff of Resident 1's fall. Resident 2 stated she heard no alarms or any noise when Resident 1 got out of bed. Resident 2 stated staff only came to the room to check on Resident 1 after she (Resident 2) pressed the call light. During a review of Resident 2's MDS dated 1/23/25, the MDS indicated Resident 1 had a BIMS score of 14 (scores of 13-15 means intact cognition). During a review of facility policy and procedure (P&P) titled, "Care Planning" dated 3/28/17, the P&P indicated, "Consistent with the facility's policy of providing appropriate care and services to residents admitted to the facility. Procedures: . . .6. Resident Care Plan must address the needs, strengths, and preferences of the resident as identified in the comprehensive assessment. . .. 7. Services that are furnished for resident to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being are to be included in the plan of care." During a review of facility policy and procedure (P&P) titled "Activities of Daily Living", dated 10/14/15, the P&P indicated: "Each resident will be assisted to achieve and maintain the highest level of self-care. All residents will be given the appropriate treatment and services to maintain or improve their abilities. Residents who are unable to carry out activities of daily living will receive the necessary services to maintain good hygiene. Staff will ensure resident has the adequate support when providing care. This includes the residents' ability to the following: transfers." During a review of facility policy and procedure (P&P) titled "Fall Prevention Policy", dated 10/14/15, the P&P indicated: "It is this facility's policy to prevent falls to the extent possible and within the control of the facility. Plans of care shall include interventions on the following: provision of monitoring and supervision to resident to prevent fall incident. Residents identified to be at greater risk for fall or further falls should be monitored closely to prevent further occurrence of fall incident." This violation presented either imminent danger that serious harm would result or a substantial probability that death or serious physical harm would result and represents a Class "A" citation.