Health inspection·December 11, 2024

The following reflects the findings of the California Department of Public Health (CDPH) during an abbreviated standard survey. Facility Reported Incident: CA00929784 The inspection was limited to the specific Facility Reported Incident investigation and does not represent the findings of a full inspection of the facility. A Class B Citation was issued for Facility Reported Incident: CA00929784 §483.25. 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 11/25/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a resident's fall in the facility. The facility failed to ensure Resident 1 was not left unattended and alone when sitting up in a wheelchair when Certified Nursing Assistant 1 (CNA1) was on break and Licensed Vocational Nurse 2 (LVN2) left the unit unattended to warm up food when. Resident 1 was admitted with a history of repeated falls at home. The facility assessed Resident 1 as a high risk for falls. As a result, on 11/08/2024 at 8pm, Resident 1's suffered a fall from a wheelchair and sustained a left eyebrow laceration (skin tear) with bleeding and swelling. Resident 1 was transferred to a general acute care hospital (GACH) for further evaluation and management. GACH applied three sutures (a stitch or row of stitches holding together the edges of a wound or surgical incision) on Resident 1's laceration. During a review of Resident 1s admission record indicated Resident 1, a 97 year old female, was originally admitted to the facility on 9/9/2024, with diagnoses that included lack of coordination (poor muscle control that causes clumsy movements), hypertension (HTN - high blood pressure), repeated falls, difficulty walking, and cognitive communication deficit (Difficulty with language comprehension and expression reasoning, attention, memory, organization, and planning). During a review of Resident 1's Fall Risk Evaluation form dated 9/09/2024 at 8:13pm, the fall risk evaluation indicated Resident 1 scored 12 (total score of 10 or higher is considered at high risk for potential falls). The fall risk evaluation form indicated Resident 1 had three or more falls in the past three months (dates no specified), the resident was disoriented x3 at all times, and the resident was chairbound. During a review of Resident 1's care plan (CP) titled The Resident is at Risk for Falls r/t (related to) Confusion... gait/balance problems initiated 9/09/2024 and revised on 11/09/2024, the CP goal indicated the resident will be free of falls through review date, and that the resident will be free of minor injury through the review date.... The CP interventions included to anticipate and meet the resident's need and to provide a safe environment. During a review of Resident 1's History and Physical report completed on 9/10/2024, indicated Resident 1 could not make her own medical decisions but could make needs known. During a review of Resident 1s Minimum Data Set (MDS - resident assessment tool) dated 9/16/2024, indicated Resident 1s cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. The MDS indicated Resident 1 required partial to moderate assistance with eating and oral hygiene, required substantial to maximum assistance for toileting hygiene, upper and lower body dressing and putting on/taking off footwear, and was non-ambulatory. The MDS indicated sit to stand was not attempted n Resident 1 due to medical condition or safety concern. During a review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR - is a technique used to provide a framework for communication between members of the health care team) form and progress notes dated 11/08/2024, indicated that on 11/08/2024 at around 8pm Resident 1 was found on the floor by the doorway of Room 108 in a prone (face down) position. The SBAR indicated Resident 1 sustained a skin tear on the left eyebrow with minimum bleeding and swelling. During a review of Resident 1's Change in Condition (CIC) Evaluation notes dated 11/08/2024 at 8:20pm, the CIC indicated that on 11/08/2024 at around 8pm, Resident 1 was found on the floor across the resident's (Resident 1) by the doorway in prone position. Resident 1 sustained skin tear on the left eyebrow with minimal bleeding; Ice pack was placed on the left eyebrow; and 911 (emergency response telephone number) paramedics (medical professionals who specializes in emergency treatment) called. During a review of Resident 1's Interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of their clients) Progress Notes-Falls dated 11/13/2024 at 10:24am, indicated, "... The resident [Resident 1] has experienced multiple falls at home prior to admission... The resident returned to the facility within 24 hours with stitches on her forehead..." The IDT notes further indicated the IDT believes that resident engaged in a spontaneous action, moving her wheelchair across the hallway, and sliding out of it possibly while reaching forward for the siderail. During a review of Resident 1's Progress Notes New dated 11/25/2024 at 10:46am, the progress notes indicated that on 11/08/2024 at 8pm, Resident 1 had unwitnessed fall and that the resident sustained a skin tear on the left eyebrow with minimal bleeding and swelling... Wheelchair was involved in the fall. During a review of Resident 1's Progress Note New dated 11/25/2024 at 11:23pm, indicated Resident 1"Skin Issues Note: Left (L) eye (eyelid) laceration with 3 sutures..." During an interview with Licensed Vocational Nurse 1 (LVN1) on 11/25/2024 at 11:45am, LVN1 stated Resident 1 was alert and oriented to name, with confusion that increased in the afternoon. LVN1 stated Resident1 lacks situational awareness, needs constant re-direction, and tends to stand up even though the resident has limited mobility. During an interview with the Assistant Director of Nursing (ADON) on 11/25/2024 at 1:30pm, the ADON stated Resident 1 was assessed and care planned as a high fall risk. The ADON stated on the day of the fall incident11/08/2024, Resident 1 was seated up on a wheelchair. The ADON stated RN1 investigated the fall and determined that CNA2 was assigned to Resident 1. The ADON stated CNA2 checked on Resident 1 before going to lunch and Resident 1 was on a wheelchair inside the resident's room. The ADON stated that according to LVN2, LVN2 was coming from downstairs and heard a resident call for help, LVN2 went towards the call for help and found Resident 1 on the floor with a laceration to the left eyebrow. During a telephone interview with LVN2 on 11/08/2024 at 1:49pm, LVN2 that on 11/08/2024 at 7:30pm, she went downstairs to warm up her (LVN2) food. LVN2 stated that on the way up she heard someone fall and then ran towards the fall and found Resident 1 on the floor. LVN2 stated Resident 1 had a laceration to the left eyebrow. During an interview with Registered Nurse 1 (RN1) and CNA1 on 11/08/2024 at 1:58pm, RN1 stated Resident 1 was seated in a wheelchair across fromm Room 101 when RN1 heard Resident 1 calling for help. RN1 stated RN1 observed Resident 1 with a laceration to the left eyebrow and rendered first aid to Resident 1. CNA1 stated CNA1 went on break and that the charge nurse (LVN2) also went to heat up her food downstairs. CNA1 stated that on her way back from break, she heard a fall like noise and found Resident 1 on the floor with a laceration. CNA1 stated Resident 1 was transferred to GACH. During an interview with LVN3 on 11/25/2024 at 2:33pm, LVN3 stated leaving a resident who has a history of repeated falls who has been assessed as high risk for falls unattended puts the resident at risk for fall which could result in severe injury such as fractures and even death. During an interview the ADON and RN1 on 11/25/2024 at 2:36 pm, when asked what the risks are for leaving a Resident with a history of recurrent falls on a wheelchair unattended, both the ADON and RN1 refused to answer. During a review of the facility's policy and procedures (P&P) titled "Fall management Program" dated 11/7/2016 indicated, "a resident who sustains multiple falls as defined as more than 1 fall.....will be considered a high risk to for and as a result may sustain a major injury. These Residents may: I. require more frequent observation of activities and whereabouts. II. require a structured environment or routine." The facility failed to adequately supervise and monitor Resident 1 to prevent falls. Resident 1 had a history of recurrent falls and was assessed as a high risk for falls. As a result, on 11/08/2024 at 8pm, Resident 1's suffered a fall from a wheelchair and sustained a left eyebrow laceration with bleeding and swelling. Resident 1 was transferred to a GACH for further evaluation and management. GACH applied three sutures on Resident 1's laceration. This violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.