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 943336. 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 #943336 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 interview and record review, the facility failed to ensure the Interdisciplinary team (IDT- a group of professionals from different fields in the nursing facility that work together to address a patient's needs) evaluated one of three sampled residents (Resident 1) who was a high fall risk, had a history of falls, and had a diagnosis of Dementia (a progressive state of decline in mental abilities), for the discontinuation of the one-on-one monitoring (1:1 - one healthcare professional provides supervision to one resident). After discontinuing the 1:1 monitoring the facility failed to conduct a fall risk assessment (medical evaluation used to determine how likely a resident is to fall), evaluate and update the care plan (CP- a document that outlines a resident's needs, treatment, and expected outcomes), and provide adequate supervision. These failures resulted in Resident 1 sustaining a fall with a fracture (broken bone), experiencing pain and requiring admission with surgical intervention (a medical procedure that involves physically altering the body to treat or prevent a medical condition) at the acute hospital. On 2/11/25, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding a resident fall which resulted in a fracture. Resident 1 is a 76-year-old female who was admitted to the facility on 1/9/2025 with a diagnoses including: history of falling, Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia, and spinal stenosis (a narrowing of the spinal column that occurs over time and can put pressure on the spinal cord [a tube-shaped bundle of nerves that runs from the brain to the lower back]) lumbar region (lower back) with neurogenic claudication (a condition that causes pain, weakness, or numbness in the legs while walking or standing), need for assistance with personal care, and difficulty in walking. During a review of Resident 1's admission 1/13/25, Minimum Data Set (MDS - an assessment tool) under section C (which assesses cognitive patterns), the 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 3 (Severe cognitive impairment). The MDS under the section "GG (which assesses functional abilities and goals)," indicated, Resident 1 required supervision or touching assistance (the helper provides verbal cues or touching/steadying assistance as resident completes activity, assistance may be provided throughout the activity or intermittently) to move from a sitting to standing position, move from chair to bed or bed to chair, pick up objects from the floor from a standing position due to medical condition and/or safety concerns. During a review of Resident 1's "Fall Risk Evaluation (FRE)," dated 1/9/25, the FRE indicated, Resident 1 had a score of 19 (high risk for falls). The FRE indicates, "Upon admission and quarterly, at a minimum, thereafter, observe the resident status in the 11 clinical parameters. . .by assigning a corresponding score which best describes the resident. If the total score is 10 or greater, the resident should be considered a high risk for potential falls. Prevention protocol should be initiated immediately and documented on the care plan." During a review of Resident 1's CP dated 1/9/25, the CP indicated, to anticipate and meet Resident 1's needs. During a review of Resident 1's "Progress Notes (PN)," dated 1/28/25, the PN indicated, Resident 1 had an unwitnessed fall at approximately 9:25 p.m. (on 1/28/25) and complained of right knee pain. The PN indicated on 1/29/25, Resident 1 was sent to the acute hospital due to complaint of right knee pain. During a review of the acute hospital "ED (Emergency Department) Physician Notes (EDPN), dated 1/29/25, the EDPN indicated, "Pt (Patient- Resident 1) BIBA (brought in by ambulance) for fall. Pt (Resident 1) is from [facility] and had an unwitnessed fall at the Nurses station around 2100 (9 p.m.) last night. Pt (Resident 1) is complaining of Right Knee/Hip/Lower back pain (no specific pain information given) from the fall. . . The patient (Resident 1) is a female with history of dementia . . ." During a review of the acute hospital "History and Physical (H+P)," dated 1/29/25, the H+P indicated, Resident 1 had, "frequent falls . . . who presents to the hospital after having a ground-level fall at [facility]. The patient [Resident 1] was in a wheelchair when she fell forward out of the wheelchair landed on her right side. [Resident 1] was complaining of right-sided pain (no specific information given about pain) . . . X-ray (medical imaging technique that uses radiation to create a picture of the inside of the body) is positive for a right comminuted (producing multiple bone splinters) intertrochanteric (hip) fracture. . ." The EDPN indicated Resident 1 was given morphine (narcotic pain medication for severe pain) four mg (milligram- a unit of measurement) in the ED." During a review of the acute hospital "Discharge Summary (DC)," dated 2/1/25, the DC indicated, "Patient (Resident 1) was taken the (sic) OR (Operating Room) for (surgical procedure) intramedullary (hollow center of the bone) nailing (a metal rod placed into the bone to stabilize a break) of the right femur (thigh bone). . . Medications to Continue . . . acetaminophen-Hydrocodone (a narcotic drug) . . . 5 mg -325 mg oral (by mouth) tablet . . 2 (tablets) every 6 hours as needed for severe pain." During an interview on 2/11/25 at 2:26 p.m. with Director of Nursing (DON), DON stated Resident 1 had an unwitnessed fall in front of the nurse's station on 1/28/25 at approximately 9:25 p.m. DON stated Resident 1 was at the nurse's station at the time of the fall due to Resident 1 being confused (exhibiting an inability to understand) and needing to be monitored/supervised closely by staff to prevent falls. During an interview on 2/11/25 at 3:33 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated on the night of the incident (1/28/25) Resident 1 was confused and attempting to get out of her wheelchair or bed without assistance. CNA 1 stated staff would place Resident 1 at the nursing station to monitor/supervise her due to her high risk for falls. CNA 1 stated staff would place Resident 1 in her bed when she was exhausted, to rest and sleep. CNA 1 stated Resident 1 used to be on 1:1 monitoring (not sure of the dates) but it was discontinued (not aware by who) prior to her fall incident on 1/28/25. CNA 1 stated on 1/28/25 she was at the nurse's station, Resident 1 was behind her (approximately five feet- [unit of measurement]), but she was not monitoring/supervising Resident 1. CNA 1 stated she heard a loud noise, turned around, and observed Resident 1 lying on the floor. During an interview on 2/11/25 at 3:45 p.m. with CNA 2, CNA 2 stated Resident 1 had 1:1 monitoring (not sure of the dates) but was no longer on 1:1 monitoring at the time of the fall on 1/28/25. CNA 2 stated she was about three feet away from Resident 1 prior to her fall (1/28/25) but was not directly monitoring/supervising Resident 1. During an interview on 2/11/25 at 4:03 p.m. with Nursing Supervisor (NS), NS stated prior to Resident 1's fall incident on 1/28/25, Resident 1 was on 1:1 monitoring to prevent falls (not sure of when the 1:1 started and when it was discontinued). NS stated on 1/28/25, Resident 1 was found lying on the floor and complaining of right leg pain. NS stated the facility process was to place high risk for fall residents on 1:1 monitoring, "If they [referring to residents] are a really high fall risk and staff . . . express (they) are not able to keep up [with the resident]." During a review of Resident 1's Electronic Medical Record (EMR), on 2/11/25 at 1 p.m., there was no evidence the facility conducted an IDT meeting to discuss if Resident 1 was safe to have the 1:1 monitoring discontinued, there was no fall risk evaluation (FRE), and there was no updated care plan noted after discontinuing the 1:1 monitoring for Resident 1. During a concurrent interview and record review on 2/20/25 at 1:10 p.m. with Administrator, Resident 1's EMR, dated 1/2025 was reviewed. Administrator stated Resident 1 was started on 1:1 monitoring on 1/11/25 due to staff being overwhelmed with Resident 1 trying to get up without assistance. Administrator stated the 1:1 monitoring was discontinued on 1/17/25. Administrator stated the facility did not conduct an IDT meeting to discuss if Resident 1 was safe to discontinue the 1:1 monitoring, there was no fall risk evaluation (FRE) done after the discontinuation of the 1:1 monitoring and prior to the fall incident on 1/28/25, and there was no updated care plan with updated interventions to assist the resident from falling. Administrator stated there should have been an IDT meeting to discuss if Resident 1 was safe enough to discontinue the 1:1 monitoring, to complete a fall risk assessment and to update the CP. Administrator stated the staff (not identified) last observed Resident 1 on 1/28/25 at 8:54 p.m. and the unwitnessed fall happened at 9:25 p.m. (31 minutes after last observation). During an interview on 2/25/25 at 9:41 a.m. with CNA 3, CNA 3 stated she was assigned to Resident 1 on 1/28/25 (day of the fall). CNA 3 stated Resident 1 was on 1:1 monitoring in the past (not sure of the dates). CNA 3 stated prior to the fall incident on 1/28/25 Resident 1 attempted to get up without assistance at least four times by the nurse's station and at least twice in her room (from 2:30 p.m. to 9 p.m.). CNA 3 stated she was helping another resident when Resident 1 fell on 1/28/25. CNA 3 stated she did not ask any other staff member to monitor/supervise Resident 1 because, "We [referring to staff] all knew to put [Resident 1] in the nurse's station and monitor [Resident 1]." During a review of the facility's policy and procedure (P&P) titled, "Care Planning- Interdisciplinary Team," dated 3/2022, the P&P indicated, "The interdisciplinary team is responsible for the development of resident care plans. . ." During a review of the facility's P&P titled, "Fall Risk Assessment," dated 3/2018, the P&P indicated, "The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. . ." During a review of the facility's P&P titled, "Falls and Fall Risk, Managing," dated 3/2018, the P&P indicated, "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. . . Resident conditions that may contribute to the risk of falls include . . . cognitive impairment (how well a person thinks, remembers, and learns) . . . Resident-Centered Approaches to Managing Falls and Fall Risk . . ." This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and represents a Class "A" citation.