Health inspection·February 11, 2025

F689: G Free of Accident Hazards/Supervision/Devices §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 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 of 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 of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 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 1/6/25 the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident (FRI) regarding resident safety. The facility failed to provide Resident 1 supervision, by failing to ensure that Resident 1 who is a high fall risk was not left unattended in the common area near the nursing station. on 12/18/2024 at 3:30 PM. This deficient practice resulted in Resident 1 had an unwitnessed fall from the wheelchair on 12/18/2024 and sustaining a nasal (nose) fracture. A review of Resident 1's admission record indicated Resident 1 an 83 year old male was originally admitted to the facility on 2/1/2018 with diagnoses that included dementia (loss of cognitive functioning, thinking, remembering, and reasoning), osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), diabetes mellitus type II (lifelong (chronic) disease in which there is a high level of sugar (glucose) in the blood), spinal stenosis (a condition in which the spinal canal is too small for the spinal cord and nerve roots.), abnormalities of the gait (balance), and difficulty walking. A review of Resident 1s Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 10/21/2024, indicated Resident 1's cognition (the mental ability to understand and make decisions of daily living) was severely impaired and the resident required partial/moderate (helper does less than half the effort) assistance from staff with eating, substantial maximum assistance (helper does more than half the effort) with oral hygiene, upper body dressing and personal hygiene, was totally dependent on facility staff for toileting hygiene, shower/bathing, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 1 was non-ambulatory (unable to walk). A review of Resident 1's history and physical dated 12/28/2024, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's "Nursing - Fall Risk Observation/Assessment" dated 10/21/2024, indicated Resident 1 was at high risk for falls. A review of Resident 1's care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) for "At Risk for Falls" dated 5/26/2022, indicated interventions (specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition) to prevent falls included bed in low position, call light within reach, keep call light within reach, explain all procedures and purpose prior to starting, and close observation. The care plan indicated a revised date of 12/19/2024, however the interventions all were dated 5/26/2022. A review of Resident 1's Change in condition evaluation note dated 12/18/2024 at 4:14 PM, indicated the resident had a fall that was "associated with no or minor injury". The note indicated the resident's physician was notified and the resident was to be sent to the local hospital for evaluation. A review of Resident 1's acute care emergency service report dated 12/18/2024, indicated Resident 1 arrived in the emergency room at 5:44PM on 12/18/2024 from facility where he (Resident 1) reportedly had an unwitnessed fall from the wheelchair, and resident was found lying face down next to the wheelchair. A review of Resident 1's computerized tomography scan (CT: a type of imaging that uses X-ray techniques to create detailed images) of the face dated 12/18/2024 at 11:11pm, indicated an impression of comminuted (shattered) and displaced (out of place) nasal fractures. During an interview on 1/6/2025 at 11:13 am Resident 3 (roommate of Resident 1) stated Resident 1 was alert but could be confused at times. Resident 3 stated Resident 1 understood little English. Resident 3 stated he (Resident 3) had tried to get out of bed several times in the past (unable to recall dates and times During an interview on 1/7/2025 at 11:30AM, Licensed Vocational Nurse 1 (LVN1) stated Resident 1 was difficult to understand because he (Resident 1) spoke and understood minimal English. LVN 1 stated Resident 1 was not alert and oriented and was to never be left in a wheelchair unattended because the resident was non-ambulatory and had been assessed to be at high fall risk for falls. During an interview on 1/7/2024 at 11:50AM, the Director of Staff Development (DSD) stated Resident 1's family hired a companion (CP1) who spoke Resident 1's native language. The DSD stated the companion had been going to the facility for a long time (unable to state how long). The DSD stated the Resident's companion would at times wheel Resident 1 to and from his (Resident 1's) room on the 3rd floor to the 2nd floor open air patio for fresh air, to the Rehabilitation room for physical, and occupational therapy services. During an interview on 1/7/2025 at 12:50PM, the Director of Nursing (DON) stated on 12/18/2024 at 3:45 PM, Resident 1 was found on the floor by 3rd floor nursing station in prone position (lying face down on one's stomach). The DON stated upon assessment Resident 1's nose was noted slightly deviated (shifted out of place) to the right with a small cut on the bridge with scant amount of blood. The DON stated Resident 1 was assessed and deemed to be stable, and first aid was immediately rendered. The DON stated Resident 1 was transferred to the hospital for evaluation and higher level of care. The DON stated prior to Resident 1's fall, the resident was with CP1, whose job was to provide social stimulation to the Resident 1 in the resident's native language. The DON stated the Resident 1's companion (CP1) had been spending time with Resident 1 and would wheel the resident to the common dining and activity area to watch movies, outdoor patio on the 2nd floor and to the 6th floor for rehab services. The DON stated on 12/28/2024 at 1 PM, LVN2 observed CP1 wheeling Resident 1 to the open-air patio on the 2nd floor, and the resident was seated calmly in his wheelchair. The DON stated around 12/28/2024 at 3:30 PM, CP 1 left the Resident in the common area near the nursing station and did not notify the staff that she was leaving. A review of the facility's policy and procedures (P&P) titled "Safety and Supervision of Resident" dated 1/2024 indicated, "facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment." A review of the facility's P&P titled "Safety and Supervision of Residents" with a revision date of January 2024, indicated systems approach to safety included "1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors. and then adjusts interventions accordingly. 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment." The facility failed to provide Resident 1 supervision, by failing to ensure that Resident 1 who is a high fall risk was not left unattended in the common area near the nursing station. on 12/18/2024 at 3:30 PM. This deficient practice resulted in Resident 1 had an unwitnessed fall from the wheelchair on 12/18/2024 and sustaining a nasal (nose) fracture. The above violation had a direct relationship to the health, safety, and security of Resident 1.