Health inspection·April 3, 2024

42 CFR §483.25(c) Mobility (1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and (2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. (3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. 42 CFR §483.10(g)(14) Notification of Changes (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention. (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) 22 CCR §22 72315 Nursing Services - Patient Care (e) Each patient shall be encouraged and/or assisted to achieve and maintain the highest level of self-care and independence. Every effort shall be made to keep patients active, and out of bed for reasonable periods of time, except when contraindicated by orders of a licensed health care practitioner acting within the scope of his or her. professional licensure. (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures, and deformities. Such care shall include: (3) Maintaining proper body alignment and joint movement to prevent contractures and deformities (g) Each patient requiring help in eating shall be provided with assistance when served and shall be provided with training or adaptive equipment in accordance with identified needs, based upon patient assessment, to encourage independence in eating. 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 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: (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. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: . . . (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety, or security of the patient. On 2/13/2024, during a Recertification Survey the California Department of Public Health (CDPH) identified that the facility failed to: 1. Assist Resident 47 with ambulation during Restorative Nursing Aide ([RNA] a nursing aide program that help residents to maintain their function and joint mobility) treatment to maintain function and ability to move in accordance with the Physical Therapy Discharge Recommendation and Treatment Note dated 1/3/24. 2. Ensure Resident 47's physician (Medical Doctor [MD] 1) was notified of the resident's decline in his function to walk and subsequently stopped walking. 3. Ensure RNAs notified nursing and physical therapy staff of Resident 47's decline in walking. 4. Ensure RNA 1 and RNA 2 followed the facility's Policy and Procedure (P&P) titled, "Resident Mobility and Range of Motion," by ambulating Resident 47 as ordered to maintain or improve mobility. As a result, Resident 47's experienced a significant decline in mobility from being able to walk 85 feet with moderate assistance with a platform walker ([PFW] a type of assistive device with forearm supports to provide extra support during walking) to not being able to walk. A review of Resident 47's Admission Record, the record indicated Resident 47, a 76 year-old-male, was admitted to the facility on 6/14/23 with diagnoses including type 2 diabetes mellitus (condition in which the body does not metabolize blood sugar correctly), chronic kidney disease, unilateral primary osteoarthritis (loss of protective cartilage that cushions the ends of the bones) of the right and left knee, difficulty in walking, and muscle weakness. A review of Resident 47's Joint Mobility Assessment ([JMA] assessment of joints to monitor joint range of motion) dated 10/10/23, indicated Resident 47 had both upper extremities (BUE) and both lower extremities (BLE) within functional limits with no impairment. The Joint Mobility Assessment indicated, Physical Therapist (PT-healthcare professional who specialize in evaluating and treating individuals with physical impairments or disabilities) recommendation for Resident 47 to ambulate with RNA using a platform walker. A review of Resident 47's Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 12/19/23 indicated Resident 47 had no impairment in cognitive skills (ability to think, understand, learn, and remember) for daily decision making and did not exhibit behavior of rejection of care. The MDS indicated Resident 47 did not have any functional limitations in range of motion ROM on either side of BUE and BLE. The MDS also indicated Resident 47 required partial or moderate assistance (helper does less than half the effort) from staff for eating, oral hygiene, upper and lower body dressing, and from lying to sitting on side of the bed. The MDS indicated Resident 47 was dependent on two staff assistance (staff does all the effort or the assistance for the resident to complete the activity) to walk 10 feet, walk 50 feet with two turns and walking 150 feet was not attempted. A review of Resident 47's care plan titled ,"The Resident is at Risk for Injury, Pain and Discomfort" related to right knee chondrocalcinosis (a condition in which (mineral ) deposit in joints cause pain), right knee osteoarthritis, back pain with bilateral sciatica (type of pain that radiates down both legs from the back), right knee joint effusion (extra fluid around the joint), left knee osteoarthritis, chronic midline low back pain with left sided sciatica, left great toe amputation, history of laminectomy (surgical procedure that remove a portion of the spinal bone to relieve pressure on nerves)" dated 6/15/23 with target date of 3/18/24, indicated the goal for Resident 47 was to be able to participate in daily activities. The care plan's intervention included the following: 1. RNA to perform active range of motion (AROM- movement of a joint without any assistance from an external force) exercises to BUE daily five times a week for four weeks (5x/wk. for 4 wks.) as tolerated. 2. RNA to perform AROM to BLE daily 5x/wk. for 4 weeks as tolerated. 3. Encourage exercise as well as rest periods, monitor medication (unspecified) effectiveness and for medication adverse effects (undesirable harmful effect resulting from medication). 4. Notify MD 1 as needed, monitor presence of pain during daily care, transfer, or positioning. A review of Resident 47's care plan titled, "Resident Has Alteration in Physical Functioning Related to Disease Condition...at Risk for Decline in Joint Mobility...Decline in Activities of Daily Living ([ADL] basic activities such as eating, dressing, toileting)," dated 6/15/23 with a target date of 3/18/24, indicated a goal for Resident 47 was to develop some area in physical function and achieve some degree of independence and be able to meet ADL needs with staff assistance. A review of Resident 47's Physician's Order Summary Report dated 2/14/24 indicated a physician's order dated 7/30/23 for RNA to perform AROM exercises to Resident 47's BUE once a day 5x/wk. for 4 weeks as tolerated, and an order dated 8/1/23 for RNA to perform BLE AROM daily 5x/wk. for 4 weeks as tolerated. A review of Resident 47's physician's order indicated an order for RNA program for assisted ambulation using platform walker once a day, five times a week for 4 weeks or as tolerated was discontinued on 2/12/24, This order was entered on 2/13/24 with no start date indicated. A review of Resident 47's Physical Therapy (PT) Evaluation and Plan of Treatment dated 12/4/23 indicated Resident 47's prior level of function (before PT's evaluation on 12/4/23) was independent with rolling, sit to lying position, from lying to sitting position on a side of the bed, required supervision, or touching assistance with sit to stand, from bed to chair transfer, and walking 10 feet. The PT Evaluation and Plan of Treatment indicated Resident 47's discharge plan was to live at home with support from others. The PT Evaluation and Plan of Treatment indicated Resident 47 required substantial maximal assistance to roll from left to right, sit to lying, lying to sitting on a side of the bed, sit to stand, bed to chair transfers, and walking was not attempted due to environmental limitations (unspecified). A review of Resident 47's PT Treatment Encounter Note dated 12/29/23 indicated Resident 47 required contact guard (physical steadying assistance) minimal assistance (less than 25% physical assistance) with bed mobility, moderate assistance for transfers and that the resident was able to ambulate 85 feet with moderate assistance and PFW. A review of Resident 47's PT Treatment Encounter Note dated 1/2/24 indicated Resident 47 required contact guard or minimal assistance with bed mobility, moderate assistance for transfers, and that the resident was able to ambulate 85 feet with moderate assist with PFW. A review of Resident 47's PT Treatment Encounter Note dated 1/3/24 (last PT treatment) indicated Resident 47 required moderate assistance for transfers, was able to ambulate 85 feet with two persons moderate assistance using PFW and with one person following with a wheelchair (WC) behind. The PT Treatment Encounter Note indicated Resident 47's gait (ambulation) training with RNA was completed using PFW with moderate assistance and required another person following with WC due to resident having episodes of knee buckling (knees feel weak). However, Resident 47 was able to self-correct and maintain proper base of support (contact points beneath a person and supporting surface to provide balance when walking), step length, and continuity of steps. The PT Treatment Encounter Note indicated Resident 47 was very cooperative and tolerated the treatment session well. A review of Resident 47's PT Discharge Summary dated 1/3/24 indicated the discharge reason was "the resident achieved highest practical level of functioning." The PT Discharge Summary indicated discharge recommendations were "see RNA order." A review of Resident 47's Joint Mobility Assessment dated 1/10/24 indicated Resident 47's BUE and BLE were within functional limits without any impairments in upper and lower extremities. The Joint Mobility Assessment indicated the recommendation for "RNA for ambulation using platform walker." A review of Resident 47's January 2024 Documentation Survey Report (record of nursing assistant tasks) for RNA, the report indicated for RNA to ambulate Resident 47's with PFW 5x/wk. for 4 weeks as tolerated. Resident 47's January 2024 Documentation Survey Report indicated on 1/10/24 Resident 47 ambulated 20 feet for 15 minutes and on 1/12/24 Resident 47 ambulated 50 feet for 20 minutes. The January 2024 Documentation Survey Report indicated RNAs did not ambulate Resident 47 from 1/13/24 through 1/31/24, a total of 18 days. A review of Resident 47's RNA Weekly Summary dated 1/11/24, the Weekly Summary indicated RNA walked Resident 47 five times a week from 1/3/24 to 1/10/24, used PFW as the assistive device and walked 25 feet. A review of Resident 47's RNA Weekly Summary dated 1/18/24, the Weekly Summary indicated Resident 47 was seen by RNA five times the week of 1/11/24 to 1/17/24, and provided the resident with ambulation, AROM of BUE and BLE treatment, used a front-wheeled walker as the assistive device and walked zero feet. The RNA Weekly Summary also indicated Resident 47 "Complains of pain. Not able to walk with the RNA after medicine (unspecified) given." A review of Resident 47's RNA Weekly Summary dated 1/25/24, the Weekly Summary indicated Resident 47 was seen by RNA five times the week of 1/18/24 to 1/24/24, provided the resident with ambulation, AROM of BUE and BLE treatment, used FWW and walked zero feet. The RNA Weekly Summary also indicated the resident "Complains of pain. Not able to walk with the RNA after medicine (unspecified) given." A review of Resident 47's RNA Weekly Summary dated 2/1/24, the Weekly Summary indicated Resident 47 was seen by RNA five times the week of 1/25/24 to 1/31/24, provided the resident with ambulation, AROM of BUE and BLE treatment, used FWW platform and walked zero feet. The RNA Weekly Summary indicated the resident "Complains of pain. Not able to walk with RNA." A review of Resident 47's RNA Weekly Summary dated 2/8/24, the Weekly Summary indicated Resident 47 was seen by RNA five times the week of 2/1/24 to 2/7/24, provided the resident with ambulation, AROM of BUE and BLE RNA treatments, used PFW as the assistive device and walked zero feet. The RNA Weekly Summary indicated the resident "Complains of pain. Not able to walk after standing up." A review of Resident 47's February 2024 Documentation Survey Report for RNA to perform Resident 47's ambulation with PFW, 5x/wk for 4 weeks as tolerated, the report indicated Resident 47 did not walk with any RNA from 2/1/24 to 2/14/24, a total of 14 days. A review of Resident 47's medical record indicated there were not any change of condition (COC) reports or reports of Resident 47's inability to ambulate with RNA, or any assessment of Resident 47's decline and interventions to address Resident 47's decline during January 2024 and February 2024. During a concurrent observation and interview on 2/13/24 at 10:15 a.m., in Resident 47's room, Resident 47 was in bed and was observed able to move a little bit both legs underneath the blanket. Resident 47 stated he was walking using a walker with PT, but it had been about a month since the last time he walked. Resident 47 stated no staff had been walking with him since physical therapy stopped on 1/3/2024. During a concurrent observation and interview on 2/14/24 at 10:06 a.m., in Resident 47's room, Resident 47 was in bed. Resident 47 stated he had not walked and wanted to walk again. Resident 47 stated he was walking before but now he was not walking. Resident 47 stated he had not done any walking with RNA and performed exercises (unspecified) on his own in the bed. During a concurrent observation and interview on 2/14/24 at 3:13 p.m., in Resident 47's room, Resident 47 was in bed on his back and stated he did not receive any RNA treatment today (2/14/24). During a concurrent observation and interview on 2/15/24 at 10:49 a.m., in Resident 47's room, RNA 1was observed to conduct treatment session to Resident 47. Resident 47 was observed s