Other·June 25, 2025

The following reflects the findings of the California Department of Public Health during the investigation of Complaint Numbers 946330 and 946745. The inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. A deficiency was written for Complaint Numbers 946330/946745 at F688/G. F688 Increase/Prevent Decrease in ROM/Mobility §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. 22 CCR § 72315 (e) Each patient shall be encouraged and/or assisted to achieve and maintain the highest level of self-care and independence. Every effort shall be made to keep patients active, and out of bed for reasonable periods of time, except when contraindicated by orders of a licensed health care practitioner acting within the scope of his or her professional licensure. 22 CCR §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. 22 CCR §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. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating, and updating the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional license promptly of: (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies, or services as prescribed under conditions which present a risk to the health, safety or security of the patient. On 2/20/25 at 10:00 a.m., an unannounced visit was conducted to investigate a complaint regarding Resident 1 not receiving therapy services, resulting in a decline in activities of daily living. Resident 1 was a 61-year-old female who was admitted to the facility on 2/27/24, with diagnoses including metabolic encephalopathy (condition where the brain does not receive enough nutrients or oxygen to function properly, leading to altered brain function). . .Type 2 diabetes mellitus without complications (condition in which the body has trouble controlling blood sugar and using it for energy). . .Personal history of transient ischemic attack (TIA-episode of nervous system (complex network of cells, tissues, and organs that controls and coordinates all bodily functions) dysfunction due to inadequate blood supply). Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided: 1. A restorative nursing program (program where restorative nursing assistants [RNA]-assist residents with performing exercises to maintain their ability to perform daily activities and tasks, impacting their quality of life and overall well-being and independence) from February 2024-December 2024, due to the licensed provider's failure to enter the order after documenting the recommendation in the clinical note. 2. Physical therapy (PT-exercises, massages and various treatments used to relieve pain, help you move better or strengthen weakened muscles) and Occupational therapy (OT-focuses on everyday tasks and activities that people value and need to do, such as self-care, work, play, and social participation) as ordered by the physician in August 2024 and December 2024 These failures resulted in a decline in Resident 1's bed mobility (ability to move around in bed, including scooting, rolling, and moving from lying to sitting and back) which can lead to a decline in Resident 1's ability to participate in daily activities of living (ADL's) and the potential for developing pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time). Findings: During a review of Resident 1's "Admission Record" (AR) dated 3/26/25, the AR indicated, Resident 1 was admitted to the facility on 2/27/24, with diagnoses including metabolic encephalopathy (condition where the brain does not receive enough nutrients or oxygen to function properly, leading to altered brain function). . .Type 2 diabetes mellitus without complications (condition in which the body has trouble controlling blood sugar and using it for energy). . .Personal history of transient ischemic attack (TIA-episode of nervous system (complex network of cells, tissues, and organs that controls and coordinates all bodily functions) dysfunction due to inadequate blood supply). During a review of Resident 1's Quarterly Minimum Data Set (MDS-resident assessment tool) dated 2/7/25, the MDS indicated, "Brief Interview for Mental Status (BIMS-used to identify cognitive impairment with a range of scores from 0-15 with lower scores equating to more impairment) . . .08 (moderately impaired cognition-the ways people think, process information, and make judgments)." 1. During a review of Resident 1's "PT Discharge Summary (PDS)" dated 2/27/24, the PDS indicated, "Discharge Recommendations: discharge to restorative. . .Restorative Program Established/Trained = Restorative Bed Mobility Program. . .Prognosis (outcome of a disease) to Maintain CLOF (current level of function-how well a resident is currently able to perform everyday tasks and activities in their daily life) = good with consistent staff follow-through. . ." During a review of Resident 1's Admission MDS dated 5/22/24, the MDS indicated, "Restorative Nursing Programs. . .Number of days. . .0 (look back period 5/16/24-5/22/24)" During a review of Resident 1's Quarterly MDS dated 8/21/24, the MDS indicated, "Restorative Nursing Programs. . .Number of days. . .0 (look back period 8/15/24-8/21/24)" During a review of Resident 1's "PT Evaluation & Plan of Treatment" (PEPT) dated 10/17/24 (approximately eight months after RNA program was recommended on 2/27/24), the PEPT indicated, "Current Referral. . .Pt (patient) presents to therapy with significant deficits in bed mobility and functional transfers (safe and effective movement from one surface or position to another), as well as increased risk for falls (to move downward, typically rapidly and freely without control, from a higher to a lower level), immobility and further deconditioning (decline that occurs due to prolonged inactivity or reduced physical activity)." During an interview on 3/24/25 at 11:17 a.m. with Director of Rehabilitation (DOR-a healthcare leader who plans, administers, and directs the operation of the rehabilitation program), DOR stated Resident 1 received PT services from 2/8/24-2/26/24 and when Resident 1 was discharged from PT services, there was an RNA (Restorative Nursing Assistant) program recommended by the physical therapist. DOR stated the facility's practice was for the PT to provide the nursing department with RNA program recommendations, nursing department was to input the physician orders and schedule the RNA program. DOR stated the RNA program recommended on 2/27/24 for Resident 1 was a bed mobility program designed to keep Resident 1 active, avoid general decline (like bed mobility and transfers) and help to minimize, decrease or prevent pressure ulcers. During a concurrent interview and record review on 3/24/25 at 12:21 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's clinical record was reviewed. LVN 1 stated when PT recommended Resident 1 for an RNA program on 2/27/24, it was the responsibility of the PT to enter the RNA program physician orders into the clinical record and it was her (LVN 1) responsibility to schedule the RNA program. LVN 1 was unable to provide documentation indicating the RNA program was provided to Resident 1 (2/27/24). LVN 1 stated there was no physician order for RNA program in the clinical record nor was there a record of the RNA program being provided. During a concurrent interview and record review on 3/25/25 at 3:24 p.m. with DOR, Resident 1's clinical record was reviewed. DOR was unable to locate the physician orders for the RNA program to be provided when Resident 1 was discharged from PT on 2/27/24. DOR stated the physician orders should have been entered in the clinical record by nursing and Resident 1 should have been provided with the RNA program recommended on 2/27/24 to prevent/minimize resident from developing a pressure ulcer. During an interview on 3/26/25 at 12:14 p.m. with RNA, RNA stated she could not recall Resident 1 being provided with an RNA program (2/27/24-12/2024). During a concurrent interview and record review on 4/1/25 at 3:55 p.m. with Director of Nursing (DON), Resident 1's clinical record was reviewed. DON was unable to provide documentation indicating an RNA program was provided and there was no care plan (outlines specific healthcare needs, goals, and interventions for an individual resident) developed for RNA program. DON stated the RNA program was not provided when PT recommended it on 2/27/24. During a review of the facility's policy and procedure (P&P) titled "Restorative Nursing Services" dated 7/2017, the P&P indicated, "Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative (restore to a good condition or a useful and constructive activity) services. . .resident may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative services. . .restorative goals and objectives are individualized and are resident-centered, and outlined in the residents plan of care. . ." 2. During a review of Resident 1's "Order Summary Report" (OSR-Physician's orders) dated 8/31/24, the OSR indicated, "Occupational therapy evaluation and treatment as indicated. . .start date 8/29/24. . .Physical therapy evaluation and treatment as indicated. . .start date 8/29/24. . ." During a review of Resident 1's OSR dated 12/31/24, the OSR indicated, "Occupational therapy evaluation and treatment as indicated. . .order date 12/31/24. . .Physical therapy evaluation and treatment as indicated. . .order date 12/31/24. . ." During a review of Resident 1's Quarterly MDS dated 8/21/24, the MDS indicated, ". . .Functional Abilities and Goals. . .Functional Limitation in Range of Motion (ROM- extent and direction to which a joint can move). . .No impairment. . .roll left and right. . .02. . .sit to lying. . .03 (Partial/moderate assistance-helper does more than half the effort) . . .lying to sitting on side of bed. . .03. . ." During a review of Resident 1's "OT evaluation & Plan of Treatment" (OTPT) dated 8/30/24, the OTPT indicated, "Patient Goals: "I wanted to get stronger" as pt (patient) stated. . .Patient demonstrates good rehab (rehabilitation-restoring function) potential as evidence by ability to follow multi-step directions and motivated to participate. Focus on Plan of Treatment = Restoration. . .Reason for skilled services (specialized form of nursing) . . .patient presents with impairments in mobility and strength resulting in limitations and/or participation restrictions in the areas of self-care and general tasks and demands which requires skilled (treatment provided by licensed therapist) OT services to increase independence with ADLs (activities of daily living) and increase functional activity tolerance. . ." During a review of Resident 1's Quarterly MDS dated 11/21/24 (three months after OT evaluation was completed and after the last MDS [8/21/24]), the MDS indicated, "Functional Abilities and Goals". . .Functional Limitation in Range of Motion. . . 2 (impairment on both sides [a decline from MDS 8/21/24]) lower extremities (hip, knee, ankle, foot). . .roll left and right. . .01 (dependent -helper does all of the effort [a decline from MDS 8/21/24]). . .sit to lying. . .88 (not attempted due to medical condition or safety concerns). . .lying to sitting on side of bed. . .88. . ." During a review of Resident 1's Significant change MDS dated 2/4/25 (three months after prior assessment 11/21/24), the MDS indicated, "Functional Abilities and Goals. . .Functional Limitation in Range of Motion. . . 2 (impairment on both sides) lower extremities (hip, knee, ankle, foot). . .roll left and right. . .01 (dependent -helper does all of the effort). . .sit to lying. . .01. . .lying to sitting on side of bed. . .01. . ." During a concurrent interview and record review on 3/25/25 at 3:24 p.m. with DOR, Resident 1's clinical record was reviewed. DOR stated Resident 1 had developed foot drop (condition where it is difficult or impossible to lift the front part of the foot, causing it to drag on the ground while walking, often due to nerve or muscle weakness) due to a TIA. During an interview on 3/26/25 at 11:38 a.m. with DON, DON stated she was made aware of Resident 1's decline during the investigation and stated physician orders were received on 8/29/24 and 12/31/24 for Resident 1 to be evaluated and treated by PT and OT to assess Resident 1 for a change in function and the need for therapy (PT/OT). DON stated Resident 1 did not receive a PT evaluation on 8/29/24 or 12/31/24 nor did she receive the PT and OT treatments that were ordered on 8/29/24 and 12/31/24. DON stated, when Resident 1 was noted with a decline the nurses should have made her or therapy aware so the facility could get to the root cause of what was happening and intervene. DON stated somewhere between nursing and therapy communication fell between the cracks and nothing was put into place when Resident 1 declined and there should have been. During an interview on 3/27/25 at 10:36 a.m. with DOR, DOR stated Resident 1 had physician orders for PT and OT evaluations and treatment on 8/29/24 and 12/31/24. DOR stated Resident 1 received an OT evaluation on 8/31/24 but did not receive OT treatment or PT evaluation and treatment. DOR stated when the OT evaluation was completed a need for treatment was identified but due to Resident 1's insurance (provides financial protection against healthcare costs) not covering therapy treatment services, only the OT evaluation was completed. DOR stated Resident 1 was dropped from OT therapy on 8/31/24 and no PT services were provided. DOR stated RNA program should have been established to continue the bed mobility program and it would have prevented some of the decline in Resident 1's bed mobility. During a review of the facility's policy and procedure (P&P) titled, "Functional Impairment - Clinical Protocol" dated 3/2018, the P&P indicated, "Upon admission to the facility, whenever a significant change of condition occurs, and periodically during a resident/patient's stay, the physician and staff will assess the resident/patient's function along with their physical condition. . .The staff and physician will identify