Health inspection·May 9, 2025

§§483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). §483.25(d) Accidents The facility must ensure that §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. §72311. Nursing Service-General (a) Nursing service shall include, but not be limited to, 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 the 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. §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 3/14/2025, the California Department of Public Health (CDPH) received two complaints alleging a resident (Resident 1) was taking a nap when another resident (Resident 2) entered Resident 1's room and attempted to take Resident 1's cell phone. On 3/27/2025, the CDPH conducted an unannounced visit to the facility to investigate the complaints allegation. During the investigation, the CDPH determined Resident 2, who had a history of wandering into other residents' rooms, and who had an order for a one to one (1:1) sitter (a healthcare worker who provides constant, continuous observation to a single resident to ensure their safety and prevention potential harm), was unsupervised when he entered Resident 1's room on 2/25/2025, without Resident 1's consent, and attempted to take Resident 1's cell phone. The facility failed to : 1. Ensure Resident 2's Care Plan for wandering, dated 2/2/2024, with an intervention for Resident 2 to have a one to one sitter was implemented. 2. Ensure Resident 2, who had a history of wandering into other residents' rooms, and who had an order for a one to one sitter, was supervised to prevent him from entering Resident 1's room and attempting to take Resident 1's cell phone. 3. Ensure staff followed the facility's Policy and Procedure (P/P), titled, "Care Plan Comprehensive" dated 8/25/2021, that indicated the facility's interdisciplinary team ([IDT] a team of health care workers from different specialties working together to meet the residents' care needs/goals) in coordination with the resident and or the resident's family or representative must develop and implement a comprehensive person centered plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, physical, mental, and psychosocial needs. 4. Ensure staff followed the facility's P/P, titled, "Safety for Residents" dated 6/27/2022, that indicated "in response to unsafe behavior, the facility will maintain one to one supervision of residents until the behavior has subsided." These failures resulted in Resident 2 entering Resident 1's room on 2/25/2025 without Resident 1's consent or facility staff's knowledge and attempted to take Resident 1's cell phone causing Resident 1 to feel scared and violated. A review of Resident 2's Admission Record (Face Sheet) indicated Resident 2, a 34 year old male, was admitted to the facility on 2/09/2024, with diagnoses that included schizophrenia (a mental disease that is characterized by disturbances in thought), a mood disorder (a mental health condition that affects a person's emotional state involving extreme mood swings) and an anxiety disorder (a mental health condition characterized by excessive and persistent fear or worry impacting daily life). A review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool), dated 2/13/2025 indicated Resident 2 had moderate cognitive (ability to think and reason) impairment and a history of delusions (having false or unrealistic beliefs).The MDS indicated Resident 2 had a history of physical behaviors directed toward others, verbal behaviors directed toward others, and other behavioral symptoms which put others at significant risk for physical injury and significantly intruded on the privacy or activity of others. The MDS indicated Resident 2 was able to express ideas and wants and was able to understand others. A review of Resident 2's untitled Care Plan, dated 2/2/2024, indicated Resident 2 wanders inside the building in his wheelchair, related to impaired cognition, poor judgment, new admission, and a change in environment. The Care Plan's goal indicated Resident 2 would remain safe within the facility. The Care Plan interventions indicated Resident 2 would have a 1:1 sitter. A review of Resident 2's Physician Order Summary dated 6/7/2024, indicated Resident 2 would have a 1:1 sitter related to Resident 2's wandering and invading other resident's privacy. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, a 75 year old female, was admitted to the facility on 2/17/2025 with a diagnosis of generalized muscle weakness. A review of Resident 1's MDS dated 2/21/2025, indicated Resident 1 was able to make independent decisions that were consistent and reasonable. During telephone interview on 3/27/2025, at 10:30 a.m., Resident 1's Responsible Party (RP) 1, stated on approximately 2/25/2025, a man entered Resident 1's room's and tried to take her cell phone. RP 1 stated Resident 1 screamed for help and the man left the room. RP 1 stated Resident 1 felt scared, angry, and violated, that a man entered her room without her permission and tried to take her cell phone. During an interview on 3/28/2025, at 12:30 p.m., the Director of Nursing (DON) stated on 2/25/2025 (time unknown) she heard Resident 1 yell, "help me." The DON stated when she went to Resident 1's room she saw Resident 1 in bed with her cell phone in her hand and Resident 2 sitting in his wheelchair at the foot of Resident 1's bed. The DON stated Resident 1 looked upset and reported that Resident 2 tried to take her cell phone. The DON stated Resident 2's care plan indicated Resident 2 was to have a one to one sitter at all times. The DON stated Resident 2 was assigned a 1:1 sitter and Resident 2 should not have been in Resident 1's room. The DON, after reviewing the facility's Staff Assignment Sheet, stated he (the DON) could not determine who was assigned to Resident 1 as his one to one sitter. A review of the facility's P/P titled, "Care Plan Comprehensive" dated 8/25/2021, indicated the facility's IDT in coordination with the resident and or his family or representative must develop and implement a comprehensive person-centered plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, physical and mental and psychosocial needs that are identified in the comprehensive assessment. The P/P indicated that the comprehensive care plan includes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. A review of the facility's P/P titled, "Safety for Residents" dated 6/27/2022, indicated the purpose of the policy is to provide a safe environment for residents and facility staff. The P/P indicated in response to unsafe behavior, the facility will maintain one to one supervision of residents until the behavior has subsided. The facility failed to : 1. Ensure Resident 2's Care Plan for wandering, dated 2/2/2024, with an intervention for Resident 2 to have a one to one sitter was implemented. 2. Ensure Resident 2, who had a history of wandering into other residents' rooms, and who had an order for a one to one sitter, was supervised to prevent him from entering Resident 1's room and attempting to take Resident 1's cell phone. 3. Ensure staff followed the facility's P/P, titled, "Care Plan Comprehensive" dated 8/25/2021, that indicated the facility's IDT in coordination with the resident and or the resident's family or representative must develop and implement a comprehensive person centered plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, physical, mental, and psychosocial needs. 4. Ensure staff followed the facility's P/P, titled, "Safety for Residents" dated 6/27/2022, that indicated "in response to unsafe behavior, the facility will maintain one to one supervision of residents until the behavior has subsided." These failures resulted in Resident 2 entering Resident 1's room on 2/25/2025 without Resident 1's consent or facility staff's knowledge and attempted to take Resident 1's cell phone causing Resident 1 to feel scared and violated. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 1.