Health inspection·May 2, 2025

The following reflects the findings of the California Department of Public Health during the investigation of Facility Reported Incident number CA00949763. A Class A Citation was written. 42 CFR §483.25(d) Free of Accident Hazards/Supervision/Devices 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 CR §72523: §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 § 72541. Unusual Occurrences. Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. On 3/17/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident about a fall. The facility failed to ensure: 1) Certified Nurse's Aide (CNA) 2, closely monitored and supervised Resident 1 while assigned as Resident 1's one to one (1:1- a caregiver provides dedicated, focused attention and assistance to a single individual, ensuring their needs and well-being are met with personalized support) sitter on 3/02/2025 on the 11 PM to 7 AM shift. 2) CNA 2 immediately notified a licensed nurse that Resident 1 fell on 3/03/2025 at 4:30 AM to ensure timely assessment and intervention(s) for the resident. 3) CNA 2 was not assigned as a 1:1 sitter for two residents (Residents 1 and 5) on 3/02/2025 on the 11 PM to 7 AM shift 4) Resident 1, who was a high risk for falls, had a care plan (CP - a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient) for 1:1 sitter to closely monitor and supervise to prevent the resident from falling. 5) CNA 2 was close and at arm's length to immediately assist Resident 1 when the resident was getting out of bed on 3/03/2025 at 4:30 AM. As a result, on 3/03/2025 at 4:30 AM, Resident 1 fell and sustained a left hip fracture (break in a bone). On 3/03/2025 at 11:58 PM, Resident 1 suffered severe pain and mild swelling to the left hip. Resident 1 sustained a comminuted (broken in three or more pieces) mildly displaced intertrochanteric fracture (a type of hip fracture where the broken pieces of the bone have moved or separated between the two bones that protrudes [sticks out]) of the left hip. On 3/04/2025 at 00:00 (midnight) AM, Resident 1 was transferred to a general acute care hospital (GACH) for further evaluation and care. A review of Resident 1's Admission Record was admitted to the facility on 1/14/2025 with the following diagnoses: generalized muscle weakness (lack of physical or muscle strength), difficulty in walking (inability to walk which includes problems standing, moving, and loss of balance), and unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems). A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 1/20/2025, indicated, Resident 1 had severely impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated, Resident 1 used a walker and a wheelchair (devises used to assist a person walk or move from place to place when one has a disability or injury). The MDS indicated, Resident 1 needed maximal assistance with toileting hygiene (maintaining cleanliness before and after using the toilet) due to urinary and bowel incontinence (lack of voluntary control over urination or bowel movement). A review of Resident 1's initial Fall Risk Assessment dated 1/15/2025, indicated, Resident 1 fall risk score was 18 (a fall risk score of 10 or above represents high risk for falls). A review of Resident 1's Fall Risk Assessment dated 3/03/2025 indicated, Resident 1 score for fall was 19 (high fall risk). A review of Resident 1's Interdisciplinary Team (IDT - a group of different healthcare professionals working together towards a common goal for a resident) Progress Notes dated 1/15/2025 at 2:27 PM, indicated, IDT recommended a 1:1 sitter to ensure safety for Resident 1. A review of the facility's In-Service Education (a professional development for workers aimed to enhance their skills, knowledge, and competence to improve job performance) sign-in sheet dated 1/09/2025, indicated, CNA 2 signed confirming that CNA 2 received training on "Preventing falls in the elderly." A review of Resident 1's history and physical (H&P - a physician's complete patient examination) dated 1/15/2025, indicated, Resident 1 was confused and disoriented , had impaired mobility (a condition that limits or prevents a person's ability to move or perform physical tasks, ranging from fine motor skills to gross motor skills like walking) and activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), and generalized weakness. The H&P also indicated Resident 1 lacked the capacity to make medical decisions. A review of Resident 1's CP on impaired ambulation (act of walking) dated 1/15/2025, indicated, Resident 1 had difficulty in walking. The CP goal indicated stand-by assist (SBA) for ambulation, and that Resident 1 used a front wheel walker (FWW) for mobility. The CP interventions included gait training (focuses on improving a person's ability to walk, often involving exercises to strengthen muscles, improve balance, and enhance overall mobility), and caregiver education (equip caregivers with the knowledge and skills needed to effectively care for others). A review of Resident 1's CP on ADLs dated 1/16/2025, indicated, Resident 1 demonstrated ADL decline because of generalized weakness, decreased overall safety awareness, and fall risk. The CP goal indicated Resident 1 will demonstrate improved safety awareness and decreased risk of fall. The CP interventions included caregiver education. A review of the facility's In-Service Education sign-in sheet dated 2/04/2025 indicated, CNA 2 signed in and received education on "What to do when a patient fall." The In-service education lesson plan indicated that after a fall, the resident is not moved until assessed by a physical therapist (PT - healthcare professional who helps people improve their movement and physical function, manage pain, and recover from injuries and chronic conditions through a variety of treatments) or charge nurse. A review of Resident 1's Psychology Notes (a standardized tool used by psychologists to record resident's mental and emotional state, behavior and any changes in their condition, to inform care planning and treatment) dated 2/07/2025, indicated, Resident 1's dementia impacted Resident 1's awareness (not specified) required continued monitoring. A review of the facility Nursing Assignment Sheet dated 3/02/2025 for the 11 PM to 7 AM shift, indicated, CNA 2 was assigned as a 1:1 sitter for Resident 1 and Resident 5 (Resident 1's roommate). A review of the facility Sitter Log Sheet (a document used to record information about the observation and/or assistance to a resident during a specific shift or period) dated 3/02/2025 on the 11 PM - 7 AM shift, indicated CNA 2 documented that Resident 1 was awake from 1 AM until 5 AM on 3/03/2025. There was no documentation that Resident 1 fell on 3/03/2025 at 4:30 AM. A review of Resident 1's CP on alteration in musculoskeletal (a system of muscles, bones, tendons, ligaments, joints, and cartilage that work together) status dated 3/03/2025 after the resident fell, indicated, Resident 1 had a fracture (a break or crack) of the left trochanter/femur (left hip bone) and pain to the left lower extremity (the part of the body that includes the hip, thigh, knee, leg, ankle, and foot) during movement. The CP goal indicated Resident 1 will remain free from pain or at a level of discomfort acceptable to Resident 1. The CP interventions included to assist Resident 1 with ADLs, mobility (ability to move freely and easily), and immobilize (reduce or eliminate movement) the left lower extremity, provide pain medicine as ordered by the physician, and transfer Resident 1 to GACH for further evaluation and treatment. A review of Resident 1's Nursing Progress Notes (captures the details of a patient's health status, treatment progress, and any changes in their condition over time) dated 3/03/2025 at 9:20 AM, indicated, Licensed Vocational Nurse (LVN) 1 documented that CNA 1 approached LVN 1 because Resident 1 complained of pain during perineal care (washing of the private parts). The Nursing Progress Notes indicated LVN 1 assessed Resident 1 and Resident 1 had pain on the left hip area ...and left leg area noted with mild swelling. The Nursing Progress Notes indicated LVN 1 instructed CNA 1 not to mobilize (move) Resident 1 and that LVN 1 notified Registered Nurse Supervisor (RNS). The nursing progress notes indicated Resident 1 was medicated with pain medicine, acetaminophen (mild pain reliever) 1000 mg (milligram - a unit of measure of mass [amount of material it contains] in the metric system) by mouth (PO) on 3/03/2025 at 9:21 AM. A review of Resident 1's Nursing Progress Notes dated 3/03/2025 at 9:25 AM, indicated, RNS assessed, Resident 1 had left hip area with pain upon touching the area, and 5 out of 10 pain level (5/10 - a numerical pain assessment tool where 0 [zero] pain is no pain, and 10 pain is the worst possible pain). RNS stated MD ordered for an x-ray (pictures of the inside of a body to look at bones and joints). RNS stated RNS called and left a message to family member of Resident 1 (FMR1) to call RNS back. A review of Resident 1's x-ray report dated 3/03/2025 indicated, Resident 1 had a comminuted (broken in three or more pieces) mildly displaced intertrochanteric fracture (a type of hip fracture where the broken pieces of the bone have moved or separated between the two bones that protrudes [sticks out]) of the left hip. A review of Resident 1's Nursing Progress Notes documented by LVN 2, dated 3/03/2025 at 11:09 PM, indicated, Resident 1 complained of left leg pain with a pain scale of 4/10, pain medicine, acetaminophen 1000 mg, was given on 3/03/2025 at 5:30 PM. The Nursing Progress Notes on 3/04/2025 at 6:30 PM, x-ray result was received which confirmed Resident 1 sustained a left hip fracture, and a medical doctor (MD) was informed who ordered to transfer Resident 1 to GACH for further evaluation. A review of Resident 1's Physician Order Summary Report dated 3/04/2025, indicated, a physician ordered Resident 1 to be transferred out from the facility to GACH on 3/03/2025 due to left hip fracture. A review of the facility Sitter Log Sheet dated 3/04/2025 [LP1]at 00:00 (midnight) AM, indicated, a sitter documented that Resident 1 was transferred to a GACH. During an interview on 3/17/2025 at 1:24 PM with CNA 1, CNA 1 stated that on 3/03/2025 at around 9 AM when CNA 1 attempted to turn Resident 1 onto the right side to perform perineal care (washing of the private parts) because Resident 1 was wet. Resident 1 started to scream. CNA 1 stated Resident 1 said something in Resident 1's native language. CNA 1 stated CNA 1 asked CNA 4 (who speaks Resident 1's native language) to translate what Resident 1 was saying. CNA 1 stated Resident 1 told CNA 4 "pain, pain, pain" in Resident 1's native language and immediately notified LVN 1 who immediately went to Resident 1's room and assessed Resident 1. CNA 1 stated LVN 1 instructed CNA 1 that Resident 1] should not get up ...because of pain. CNA 1 stated Resident 1 has dementia and forgets a lot ... I've seen [Resident 1] try to get out of bed without assistance. CNA 1 stated Resident 1 needs assistance from staff to get out of bed, because the resident is not stable on the feet because Resident 1 is weak, and is 101 years old ... During an interview on 3/17/2025 at 1:52 PM with LVN 1, LVN 1 stated that on 3/03/2025 at 9:20 AM CNA 1 called LVN 1 to Resident 1's room because Resident 1 was complaining of pain. LVN 1 stated Resident 1 was in the bed and was "crying." LVN 1 stated LVN 1 asked CNA 4 (speaks Resident 1's native language) to translate what Resident 1 was saying. LVN 1 stated CNA 4 reported that Resident 1 said that Resident 1 was in pain, Resident 1 fell in the middle of the night and that a man picked up the resident and put Resident 1 back to bed. LVN 1 stated Resident 1 made noises (did not specify) when touched on the left hip and when LVN 1 and CNA 1 attempted to perform perineal care because Resident 1 was wet from urine. LVN 1 notified RNS of Resident 1's change of condition (COC - a significant change in a resident's health or functional status) and administered acetaminophen 1000 mg to Resident 1. LVN 1 stated Resident 1 has episodes of trying to get out of bed sometimes; that's why there is a sitter. During an interview on 3/17/2025 at 2:25 PM with RNS, RNS stated that on 3/03/2025 at 9:25 AM LVN 1 reported to RNS that Resident 1 had pain to the left hip area. RNS stated RNS assessed and identified that Resident 1's left hip and left leg areas were swollen with no discoloration (any change in your natural skin tone). RNS stated Resident 1 said "dolor (pain)" and "ouch" during the assessment. RNS stated RNS asked CNA 4 to translate what Resident 1 was saying. RNS stated CNA 4 told RNS that Resident 1 answered yes when asked if in pain and then pointed to the [Resident 1's] left hip area. RNS stated Resident 1 told RNS that a guy picked Resident 1 up from the floor at 'Noche' (night). RNS stated RNS was called into [Resident 1's] on 3/03/2025 at 9:30 AM. RNS stated RNS knew nothing bad had happened to Resident 1 from the time nurses started their shift on 3/03/2025 at 7 AM. RNS stated RNS instructed LVN 1 to administer pain medicine to Resident 1, instructed the nursing staff not to move Resident 1, and contacted the MD and Resident 1's family regarding Resident 1's COC. RNS stated MD ordered an x-ray of Resident 1's left hip which was completed after RNS left work at 3:30 PM on 3/03/2025. RNS stated "[Resident 1] climbs out of bed, this is a daily thing and that is why we put a 1:1 sitter for the resident." RNS did not state how long CNA 2 has been Resident 1's sitter. During a telephone interview on 3/17/2025 at 3:35 PM with CNA 2, CNA 2 stated that on 3/03/2025 at around 4:30 AM, Resident 1 got out of bed and "I rushed to [Resident 1] because [ Resident 1] was struggling. CNA 2 stated that Resident 1 started lowering himself, "so I assisted [Resident 1] to the floor." CNA 2 stated CNA 2 asked CNA 5 to ass