Health inspection·March 26, 2025

F689 42 CFR §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.

F684 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

F656 §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 patient 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 - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40. 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 1/31/2025, the California Department of Public Health (CDPH) received a facility reported incident (FRI) indicating that Resident 1 had a fall and sustained a right clavicle (a long bone that connects the shoulder blade and the breastbone, allowing free movement of the arm) fracture (broken bone). On 2/12/2025, an unannounced visit was conducted at the facility to investigate the FRI. As a result of the investigation, CDPH determined that the facility failed to: 1. Implement Resident 1's "Alzheimer (a brain disorder that gradually destroys memory and thinking skills) and Dementia (condition of a person losing the ability to think, remember and reason) Care Plan" dated 10/28/2024, to ensure: Licensed Vocational Nurse (LVN) 1 and Certified Nurse Assistant (CNA) 1 explained procedure prior to care, remind safety measures with frequent verbal reminders, reassured resident safety, monitored and anticipated resident needs when transporting Resident 1 in a wheelchair. 2. Follow facility's policy and procedure (P&P) titled "Dementia Care Assessment" dated 1/2017, to identify and develop resident centered care plan, and addressed how to safely transport Resident 1 using wheelchair when resident have episodes of forgetfulness, confusion and poor safety awareness to maximize resident safety. 3. Implement Resident 1's "At Risk for Fall Care Plan" dated 10/28/2024, to ensure: LVN 1 and CNA 1 instructed Resident 1 not to have sudden position changes, ensure to do frequent reminders regarding safety, provide adequate staff assistance for safe transfer, and provide a safe environment by avoiding environmental hazard (using multiple ramps) when transporting Resident 1 in a wheelchair. 4. Follow Resident 1's Fall Risk Evaluation dated 1/28/2025 and facility's P&P, titled "Fall Risk and Prevention of Injury" dated 3/2019, to implement a plan of care to prevent fall, orienting the resident to their surroundings, and to keep Resident 1's environment free of unnecessary obstacles and used a safer route through the garage with less ramps to ensure Resident 1 did not fall when pushed in a wheelchair up and down the ramp (a slope or incline that connects two different surfaces) on 1/29/2025. As a result, Resident 1, who made a sudden movement while being wheeled in a wheelchair, fell and sustained a right forehead hematoma (bruise) with swelling, right forearm abrasion, right clavicle fracture and experienced severe pain. Resident 1 was transferred to General Acute care Hospital (GACH) for treatment and evaluation. A review of Resident 1's Admission Record, indicated Resident 1, a 88-year-old-female, was admitted on 10/22/2022, with diagnoses including dementia, metabolic encephalopathy (a brain disorder when chemical imbalance in the blood affects the brain function), hypertension (high blood pressure), intervertebral disc degeneration (refers to symptoms of back or neck pain caused by wear-and-tear), unspecified fall, and weakness. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and caring-screening tool), dated 1/24/2025, indicated Resident 1's cognitive (the ability to think and process information) skills for daily decisions making was moderately impaired. The MDS indicated Resident 1 could express ideas and wants and able to understand others. The MDS indicated Resident 1 required partial to moderate assistance (helper lifts or holds trunk or limbs and provides less than half the effort) with walking at fifty and one hundred fifty feet distance. The MDS indicated Resident 1 used a walker and did not use wheelchair. A review of Resident 1's At Risk for Falls and Injuries Care Plan dated 10/28/2024, indicated Resident 1 had episodes of confusion and forgetfulness, had poor safety awareness and history of falls, Resident 1 had episodes of trying to be independent beyond physical capability and did not use assistive device or call light for assistance, required assistance with mobility and transfers and have balance problems during transfers. The care plan goal was to ensure to minimize risk for falls and minimize injury secondary to fall. The interventions indicated to instruct Resident 1 not to have sudden position changes, provide a safe environment, provide adequate assistance during transfers and ensure to do frequent reminders regarding safety. A review of Resident 1's Alzheimer (a brain disorder that gradually destroys memory and thinking skills) and Dementia Care Plan dated 10/28/2024, indicated Resident 1 had episodes of confusion and forgetfulness, at risk for further decline in cognition and decision making. The care plan goal indicated Resident 1 will be oriented to time, place and person. The interventions indicated to explain all procedures prior to assisting care and provide reassurance as needed with frequent verbal reminders, give simple directions one at a time using short words and simple sentences, provide reassurance as needed with frequent verbal reminders as necessary, and monitor and anticipate needs. A review of Resident 1's Fall Risk Evaluation dated 1/28/2025, indicated Resident 1 had intermittent confusion, ambulatory, incontinent, balance problem with standing and walking, have gait problems, jerking, unstable when making turns, unsteady gait, shuffling gait, required use of assistive devices, took medications that cause lethargy (a state of feeling tired, sluggish, and lacking energy) or confusion, and had three or more predisposing diseases. The fall risk evaluation indicated Resident 1 scored 18. The fall risk evaluation indicated if a total score of 10 or greater, the resident should be considered a high risk for potential falls, a fall prevention protocol should be initiated immediately, and documented on the resident's care plan. A review of Resident 1's Licensed Personnel Progress Notes, dated 1/29/2025 at 10:20 am, indicated Maintenance Supervisor (MS) 1 called Registered Nurse Supervisor (RN) 1's attention at the nurses' station to inform Resident 1 was on the floor by the ramp (Ramp 2) outside the building. The progress notes indicated RN 1 immediately went to the site (location of Ramp 2), found Resident 1 sitting on the floor along the ramp, her back and head leaning against the seat of the wheelchair, had no change on level of consciousness, and had no bleeding. The progress notes indicated Family Member (FM) 1 and CNA 2 was at the site of incident (location of Ramp 2) and immediately called for help and assistance from another staff (RN 1). A review of Resident 1's SBAR (SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Notes, dated 1/29/2025, indicated Resident 1 had a witnessed fall on 1/29/2025. The SBAR notes indicated, Resident 1 had right lateral side of head purplish discoloration, abrasion on right elbow measuring approximately five centimeter (cm, unit of measurement) in length with minimal bleeding. The SBAR notes indicated the nurses applied ice packs to Resident 1's right side of the head and right shoulder, gave Tylenol (a pain reliever used to treat mild and moderate pain) 1 gram (unit of measurement) as ordered, and cleansed the resident's right elbow abrasion with normal saline and treated with hydrogel (medication for wound healing). The Change of Condition (COC) on the SBAR indicated Resident 1 complained of pain at level eight to nine and unable to move her right arm. The COC indicated the physical therapist came and applied an immobilizer (essential medical devices that are used to restrict the movement of the arm, providing support, stability, and protection during the healing process). The SBAR notes indicated Resident 1's attending physician (MD) was notified and the MD ordered to transfer Resident 1 to GACH for further evaluation. A review of Resident 1's physician order dated 1/29/2025, indicated to transfer Resident 1 to GACH for further evaluation and treatment. A review of Resident 1's Licensed Personnel Progress Notes dated 1/29/2025, indicated Resident 1 was transferred to GACH and transported by ambulance (a medically equipped vehicle used to transport patients to treatment facilities such as hospitals). A review of the GACH Records titled, "Emergency Department to Hospital Admission Note" (EDN), dated 1/29/2025, indicated Resident 1 had a closed displaced fracture of the clavicle. The EDN indicated Resident 1 had right forearm abrasion, right forearm pain, right shoulder pain, and sustained hematoma with swelling to the right forehead after a fall from wheelchair while going up a ramp. The EDN indicated Resident 1 was oriented to self and place and able to follow commands. The EDN indicated Resident 1 was provided wound care to Resident 1's right forearm wound. The EDN notes indicated a right arm sling was applied. A review of Resident 1's right shoulder Xray (a procedure that uses radiation to create images of inside of the body) report dated 1/29/2025, indicated nondisplaced fracture (a broken bone where pieces remained in place and aligned) of distal (away from the center) clavicle. A review of Resident 1's Medication Administration Record (MAR), for the month of January 2025, indicated pain rating of 0 = (equals) no pain, 1 to 4= mild pain, 5 to 7=moderate pain, 8 to 10=severe pain. The MAR indicated Resident 1 had pain level of 8 (severe pain) on 1/29/2025 at 10:31 am and received two tablets of acetaminophen (medication to treat pain and reduces fever) 500 milligrams (mg, a unit of measurement) for severe pain. A review of Resident's History and Physical (H & P) dated 2/4/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. A review of the IDT (Inter Disciplinary Team, a team of professionals from various fields who work together toward the goals of the resident Care Plan Summary notes) notes, dated 2/11/2025, indicated Resident 1 was readmitted on 2/4/2025 from GACH and had right clavicle fracture from a fall at the facility on 1/29/2025. Resident 1's FM 2 wanted Resident 1 to be encouraged to ambulate using assistive device especially during appointment. The IDT notes indicated Resident 1 will use wheelchair with two persons assist. The IDT notes indicated the facility will implement preventive measures of siderails, grab bars and visual checks. During a concurrent observation and interview on 2/12/2025 at 10:15 am with Resident 1 in her room, Resident 1 was observed with blue sling (a device that holds a broken arm or shoulder while it heals) on her right arm and guarding (the body's ways of protecting an injury) her right arm. Resident 1 stated her right shoulder hurts. Resident 1 stated her pain level was four on a scale of 0 to 10 on a numeric pain scale (zero meaning "no pain" and 10 meaning "the worst pain imaginable." A pain level of four meant mild pain). Resident 1 stated her pain level was eight (severe pain) when touched. Resident 1 stated the pain was from the right side of her neck down to her right shoulder. Resident 1 stated she was told (unable to recall who informed her) she got fractured from a fall (did not specify exact location) but does not remember the fall incident. During an interview on 2/12/2025 at 10:38 am., CNA 2 stated on 1/29/2025, LVN 1 was pushing Resident 1 in a wheelchair and asked her (CNA 2) to wheel Resident 1 from the basement to the front of facility to meet FM 1 for dental appointment. CNA 2 stated LVN 1 instructed her to take the route that uses multiple ramps closer to the street parking lot to transport Resident 1 but did not provide safety precaution instructions. CNA 2 stated she had taken care of Resident 1 before at least more than ten times. CNA 2 stated Resident 1 usually ambulated (walked) with a walker and did not use a wheelchair on daily basis. CNA 2 stated that day (on 1/29/2025) was the first time she transported Resident 1 in a wheelchair. CNA 2 stated she did not give any instructions to Resident 1 before and during the transport or before approaching the ramp because Resident 1 was calm during transport. CNA 2 stated she did not see a reason to explain the procedure (the transport) to Resident 1, remind the resident to avoid any sudden movements or provide reassurance regarding safety, as the resident was calm prior to transport. During a concurrent observation and interview on 2/12/2025 at 10:58 am, at the facility basement, CNA 2 demonstrated how she transported Resident 1 on 1/29/2025. CNA 2 stated, when she received the resident in the basement from LVN 1, she transported Resident 1 alone using the wheelchair. CNA 2 demonstrated how she maneuvered the resident backwards down Ramp 1 (ramp by the basement). CNA 2 stated and demonstrated that she then used her back to push the double door open (leading to Ramp 2 in the basement) CNA 2 stated she wheeled Resident 1 facing forward while going up the Ramp 2. During the concurrent observation and interview on 2/12/2025 at 10:58 am, CNA 2 stated Resident 1 suddenly appeared nervous, made a sudden movement halfway up the incline of Ramp 2, and caused the wheelchair to tilt to the right side. CNA 2 stated she released the wheelchair and attempted to catch Resident 1 from behind, grabbing the resident by both shoulders, but was unable to s