Health inspection·March 19, 2025

42 CFR § 483.25(d) 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. 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 - 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. On 1/30/2025, the California Department of Public Health (CDPH), received a facility reported incident (FRI) regarding Resident 4 who had an unwitnessed fall in the facility and sustained right femoral neck fracture (a break in the upper part of the thigh bone, just below the hip joint). On 2/4/2025 CDPH conducted an unannounced visit to the facility to investigate the FRI allegation. The facility failed to: 1. Ensure staff implemented the fall risk prevention program for Resident 4, which included landing pads on the floor near the bed, bed in low position, and bed and chair alarms. 2. Ensure Certified Nursing Assistant (CNA) 4 and CNA 5 were informed of Resident 4's high risk for falls to ensure implementation of interventions to prevent the resident from falling. 3. Ensure Resident 1's interventions under care plan titled, "Resident is High Risk for Injury /Accidents And Repeat Falls," dated 11/20/2023 were updated after the resident's fall on 1/4/2024 and then again on 1/26/2025, to include interventions to use call light for assistance with transfers, to provide landing pads, to keep bed in low position, and to have bed and chair alarm. 4. Ensure staff followed the facility's policy and procedure (P&P) titled, "Safety and Supervision of Residents," revised 7/2017, which indicated "The care team will target interventions that will reduce individual risks related to hazards in the environment including adequate supervision and assistive devices (equipment that can help you perform tasks and activities)" by not identifying appropriate interventions to prevent falls as required by the P&P. 5. Ensure the facility's P&P titled "Care Plans-Comprehensive," revised 10/2010, was followed which indicated "the Care Planning/Interdisciplinary team ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) is responsible for the review and updating care plans: when there has been a significant change in the resident's condition, when the desired outcome is not met after the resident fell a second time. As a result, Resident 4 had an unwitnessed fall on 1/26/2025 that resulted in right femoral neck (upper part of the thigh bone, just below the hip joint) fracture (broken bone) and right humerus (upper arm bone extending from the shoulder to the elbow) fracture. On 1/27/2025 Resident 4 was transferred to a General Acute Care Hospital (GACH) where the resident underwent a right hip cephalomedullary nail (nail inserted to the bone to help restore its shape and alignment) surgery and non-weight bearing (person should not put any weight on a specific extremity, usually after an injury ) to right upper extremity with arm sling (helps support and immobilize an injured arm, elbow, shoulder). A review of Resident 4's Admission Record, indicated Resident 4, a 90- year- old female, was admitted originally to the facility on 4/14/2016, and readmitted on 2/4/2025, with diagnoses including fracture of unspecified right femoral neck, right humerus fracture, history of falling, muscle weakness and bilateral (both) primary osteoarthritis (a condition that occurs when the cartilage [flexible tissue] that lines your joints is worn down ) of both hips. A review of Resident 4's Minimum Data Set ([MDS]-resident assessment tool) dated 11/20/2024, indicated Resident 4 had moderately impaired cognitive skills (ability to think, understand, learn, and remember) for daily decision making and required substantial/ maximal assistance (helper does more than half the effort) with toileting hygiene, showering or bathing. The MDS indicated Resident 4 required partial or moderate assistance (helper does less than half the effort) with upper and lower body dressing, personal hygiene, bed mobility, toilet transfer and transfer to and from a bed to a chair. The MDS did not indicate Resident 4 had a history of falls since admission on 4/14/2016.The following MDS assessments: 2/23/2024, 5/23/2024 and 11/20/2024 did not include a history of falls. A review of Resident 4's IDT's Conference Record dated 11/20/2024 indicated Resident 4's high fall risk was not addressed by the IDT. A review of Resident 4's Fall Risk Evaluation (indicates a person's level of risk for falling, with higher scores signifying a greater risk) dated 11/20/2024, indicated Resident 4 score was 14 (a score of 10 and above represents high risk for fall, a person has a significantly increased likelihood of experiencing a fall due to factors like poor balance, muscle weakness, certain medications, or environmental hazards) and generally requires interventions. A review of Resident 4's Care Plan titled, "Resident is High Risk for Injury /Accidents And Repeat Falls" related to poor safety awareness, unsteady gait/balance, functioning beyond capabilities dated 11/24/2023, indicated the goal for Resident 4 was not to have injury/accident or falls and to minimize the risk for falls through the review date on 12/8/2023. The Care Plan interventions included frequent visual checks (regularly assessing residents), monitoring and to implement fall precautions (not specified). A review of Resident 4's Nurses Progress Notes dated 1/4/2024, and timed at 4:30 p.m., indicated a change in condition ([COC] - a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional condition) when Resident 4 was found lying on the floor on 1/4/2024. The Nurses Progress Notes indicated Resident 4 tried to transfer herself from the toilet back to her wheelchair without calling for help. A review of Resident 1's IDT Progress Notes dated 1/5/2024 indicated Resident 1 went to the bathroom without calling for assistance. The IDT Progress Notes indicated Resident 1 transferred herself from toilet to a wheelchair, forgot to lock the wheelchair, lost her balance, and landed on the floor. The IDT Progress Notes indicated Resident 1 was educated to use the call light after using the bathroom and to lock wheelchair brakes. A review of Care Plan titled, "Resident is High Risk for Injury /Accidents And Repeat Falls," dated 11/24/2023, indicated it was not evaluated and updated after Resident 1's fall on 1/4/2024 to include the intervention of use of call light to call for assistance with transfers and to lock wheelchair brakes. A review of Resident 4's COC dated 1/27/2025 and timed at 12:05 a.m., indicated Resident 4 had a fall on 1/26/2025 at 11:15 p.m. and was complaining of body pain on a right side (shoulder and knee). The resident's pain level was rated seven out of 10 on a pain rating scale from zero to 10 (pain screening tool using numerical value to assess the level of pain where zero is no pain and 10 is the worse pain possible pain level rated seven to nine represented severe pain). The COC indicated Resident 4's physician was notified and an order to transfer Resident 4 to GACH via 911 was received and carried out. A review of Resident 4's right femur (thigh bone) X-ray from the GACH dated 1/27/2025, indicated a right femoral neck fracture. A review of Resident 4's right humerus (long bone in the upper arm extending from the shoulder to the elbow) X-ray dated 1/27/2025 obtained at the GACH, indicated a proximal (near the center of the body) humerus fracture (broken bone in the upper part of the right arm). A review of Resident 4's GACH Records titled "Operative Report," dated 1/27/2025, indicated Resident 4 had right hip cephalomedullary nail surgery. A review of Resident 4's Physical Therapy Evaluation and Plan of Treatment dated 1/30/2025, indicated Resident 4 showed significant decline in her functional mobility with decreased muscle strength on bilateral lower extremities, decreased balance and inability to ambulate (walk) at this time. During an interview on 2/4/2025, at 9:42 a.m., CNA 1, stated there were no landing pads placed on the floor near the resident's bed, or bed alarm on Resident 4's bed, and her bed was not in a low position before the resident's fall on 1/26/2025 at around 11:15 p.m. CNA 1 stated for residents, who are at high risk for fall, "the facility keeps the bed low, places a pad alarm on the bed and wheelchair and have staff to do frequent visual checks (not specified)." During an interview on 2/4/2025, at 10:45 a.m. Licensed Vocational Nurse (LVN) 5 stated "Resident 4 slid off the bed while trying to remove her pants and fell off the bed on 1/26/2025 at 11:15 p.m." LVN 5 stated Resident 4 required assistance with transferring between surfaces, walking, dressing and toileting. LVN 5 stated Resident 4 did not have a landing pad, the resident's bed was not in a low position, and there was no bed alarm present on a bed prior to Resident 4's fall on 1/26/2025. During a telephone interview on 2/4/2025, at 1:38 p.m., CNA 4 stated on 1/26/2025, at around 11:15 p.m. Resident 4 was on the floor near Resident 4's wheelchair and was asking for help. CNA 4 stated Resident 4's bed was not in the low position and there was no bed alarm present on Resident 4's bed. CNA 4 stated no one informed her during the huddle (short meeting where healthcare professionals share information about residents and discuss patient safety and care plans) that Resident 4 was a high risk for falls. CNA 4 stated residents who have unstable gait (manner of walking) or are getting out of bed without using the call light for assistance are a high risk for falls. CNA 4 stated it was important to identify residents who are at risk for falls so staff can perform frequent visual checks on the residents (in general) to prevent occurrence of falls and to provide needed help in a timely manner. During a telephone interview on 2/4/2025, at 2:31 p.m., CNA 5 stated on 1/26/2025 at 9:00 p.m. she made her last round and Resident 4 was sleeping in bed. CNA 5 stated she did not know Resident 4 was a high risk for falls. During an interview on 2/4/2025, at 3:41 p.m., LVN 1 stated Resident 4 was in bed sleeping on 1/26/2025, at 11:05 p.m. LVN 1 stated Resident 4 was found on the floor lying on her right side and was complaining of right shoulder pain on 1/26/2025 at 11:15 p.m. LVN 1 stated "Resident 4 wanted to remove her pants and thought she could do it by herself when the fall happened." LVN 1 stated "Resident 4 liked to do things on her own." During a concurrent interview and record review on 2/4/2025, at 12:17 p.m. with RN Supervisor (RNS 1), Resident 4's Fall Risk Assessment dated 11/20/2024, was reviewed. RNS 1 stated a resident's fall risk assessment is done upon admission, after 72 hours of admission, quarterly, and as needed if there are incidents of falls. RNS 1 stated the last Resident 4's Fall Risk Assessment was completed on 11/20/2024 with a score of 14. RN 1 stated a score of 14 meant Resident 4 was a high risk for falls. RNS 1 stated landing pads, bed alarm and wheelchair alarm were ordered on 1/29/2025 after Resident 4's fall on 1/26/2025. RNS 1 stated when a resident is identified as high risk for falls, staff should initiate interventions including application of landing pads on the floor, bed alarm, and wheelchair alarm, place the bed in a low position, declutter a resident's environment and place a call light within reach. RNS 1 stated not properly identifying a resident who was a high risk for fall could lead to injury and occurrence of falls. During a concurrent interview and record review on 2/4/2025, at 11:14 a.m. with PT 1, the PT Treatment Encounter (week of 1/20 to 1/24/2025) was reviewed. PT 1 stated Resident 4 could get out of bed and transfer from bed to chair with stand by assistance (when someone is nearby to help prevent injury or provide physical assistance if needed) and close supervision prior to Resident 4's fall on 1/26/2025. PT 1 stated Resident 4 required contact guard assist (physical contact from the helper to prevent fall) for lower body dressing. PT 1 stated Resident 4 could do lower body dressing, but staff had to be there for safety. During a concurrent interview and record review on 2/4/2025, at 12:52 p.m. with Minimum Data Set Coordinator (MDSC1), Resident 4's Fall Risk Assessment dated 11/20/2024 and IDT Notes dated 11/20/2024 were reviewed. MDSC 1 stated a resident Fall Risk Assessment should be done upon admission and during quarterly assessments. MDSC 1 stated Resident 4's Fall Risk Assessment dated 11/20/2024 score was 14 which indicated Resident 4 was a high risk for falls. MDSC 1 stated the IDT meeting conducted on 11/20/2024 did not address Resident 4's high risk for falls. MDSC 1 stated if a resident scored 14, the facility would develop a plan of care for high risk for fall and would conduct an IDT review to address fall prevention interventions. MDSC 1 stated Resident 4's high risk for falls should have been communicated with the other team members of the IDT and staff members to ensure implementation of interventions including frequent visual checks, placement of landing pads, bed in a low position, and alarm pads on bed and wheelchair. During a telephone interview on 2/4/2025, at 2:38 p.m. RNS 2 stated she saw Resident 4 in her room at 10:55 p.m. on 1/26/2025. RNS 2 stated Resident 4 was sleeping in her bed at that time. RNS 2 stated on 1/26/2024, at 11:15 p.m., Resident 4 was found on the floor crying, grimacing in pain, and guarding her right shoulder. RNS 2 stated Resident 4 was complaining of a lot of pain in her right shoulder. RNS 2 stated when she interviewed Resident 4, Resident 4 stated she was trying to remove her pants when she fell. RNS 2 stated Resident 4 was transferred out to the GACH on 1/27/2025 and returned to the facility on 1/29/2025. RNS 2 stated it was important to identify residents who were a high risk for fall to implement a fall risk prevention program, including having landings pads, bed in low position, bed alarm, and wheelchair alarm in order to prevent falls and injury. During an interview on 2/4/2025, at 8:10 a.m. and subsequent interview on 2/5/2025, at 11:39 a.m. the Director of Nursing (DON) stated Resident 4 liked to be independent and would not call the staff for help. The DON stated Resident 4 informed the DON that she tried to remove her pants by herself when she fell. The DON stated the MDS Coordinator should have communicated Resident 4's fall risk assessment score of 14 (score of 10 and above represents high risk for fall) to the staff and to MDSC 1 to ensure a fall risk prevention program is implemented. The DON stated Resident 4 had a history of a previous fall on 1/4/2024 and the resident needed to have the bed in a low position, landing pads on the floor, and bed alarm and wheelchair alarm. The DON stated although Resident 4's assessment indicated the resident was a high risk for falls, the facility staff did not implement a fall risk prevention program to prevent the resident's falls and injury. The DON stated for the residents with a fall risk assessment score of 10 and greater the facility had to implement fall prevention protocol including bed in lowest position, green star on the door and a resident's chart, and safety devices such as bed alarm, chair alarm, and a landing pad on the floor. A review of facility's P&P titled "Safety and Supervision of Residents" revised 7/2017, indicated the IDT will analyze information obta