Health inspection·April 14, 2025

The following reflects the findings of the California Department of Public Health (CDPH) during an abbreviated standard survey. Facility Reported Incident Number: CA00945994 The inspection was limited to the specific Facility Reported Incident investigated and does not represent the findings of a full inspection of the facility. A Class A Citation was issued for the Facility Reported Incident: CA00945994. §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:(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: 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 2/24/2025 CDPH made an unannounced visit to the facility to investigate a complaint regarding quality of care. The facility failed to: 1) Ensure Resident 1's bed alarm (a physical or electronic device that monitors resident movement and alerts the staff when movement is detected while the resident is in bed) was in place and functional as ordered by a physician. 2) A care plan for reducing the risk of falls was initiated/created for Resident 1. As a result, on 2/07/2025 Resident 1 fell and sustained a small cut on the forehead and a fracture (break in a bone) to the right hip bone near hip prosthesis (a device that replaces or enhances a missing or impaired body part) and needed to be transferred to a higher level of care for further evaluation. A record review of Resident 1's Admission Record (a document containing demographic and diagnostic information) indicated Resident 1 was admitted to the facility on 11/09/2024 with diagnoses including: metabolic encephalopathy (a general term that describes a brain disease, damage or malfunction; brain function is disturbed), muscle weakness (when muscles are weak causing difficulty performing normal activities that require strength), unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems interfering with the person's daily life and activities), unspecified glaucoma (a condition in which there is a build-up of fluid in the eye, causing vision loss and blindness), unsteadiness on feet, abnormalities of gait (a person's manner of walking) and mobility (ability to move freely and easily), history of falling, and presence of right artificial hip joint (a surgical implant that replaces a damaged hip joint). During a record review, Resident 1's Admission Summary Progress Note, dated 11/09/2024, indicated, Resident 1 had the following diagnoses: metabolic encephalopathy, glaucoma, history of falls, clinical bilateral blindness (a complete loss of vision in both eyes), was hard of hearing, and had a surgical scar to the right hip. During a record review, Resident 1's Physician Order Summary Report (a list of all types of physician orders) dated 11/09/2024, indicated, Resident 1 had orders for a bed alarm (a device that detects when someone leaves their bed and alerts caregivers so they can prevent falls) and bilateral (both sides) floor mats applied as fall precaution devices. During a record review of Resident 1's Fall Risk Assessment (a tool to assess a patient's likelihood of falling) dated 11/09/2024, indicated, Resident 1 was at risk for falls. During a record review, Resident 1's History and Physical (H&P - a physician's complete patient examination), dated 11/11/2024, indicated, Resident 1 was on fall precaution, confused, and had episodes of mania (mental state of an extreme highs or depressive lows). The H&P indicated Resident 1 was not able to understand and make decisions due to altered mental status (AMS - a group of clinical symptoms rather than a specific diagnosis, and includes cognitive disorders, attention disorders, arousal disorders, and decreased level of consciousness). During a record review, Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 11/15/2024, indicated, Resident 1 had moderately impaired cognition (make poor decisions, cues and supervisions required). The MDS indicated Resident 1 used a wheelchair for mobility. During record review, Resident 1's care plan (CP - a guideline for nurses to help staff create and achieve a solid plan of action in the treatment of a patient) on behavior problem dated 11/16/2024, indicated, Resident 1 had a behavior problem (restlessness) related to dementia with psychotic (a mental health condition characterized by a loss of touch with reality) behavior. The CP goal indicated that Resident 1 will have fewer episodes of restlessness by 12/26/2024. The CP interventions included to monitor Resident 1's behavior episodes while attempts are made to determine underlying cause. During a record review, Resident 1's Physician Order Summary Report dated 2/04/2025, indicated, to monitor Resident 1 for persistent episodes of aggressive behavior every shift. During an interview on 2/24/2025 at 1:57 PM, Resident 3 (Resident 1's roommate in room A Resident 3 stated that Resident 1 "pulled the curtain between us many, many times, almost daily." Resident 3 stated Resident 1 had to get out of bed to do this because Resident 1 cannot reach the curtain. Resident 3 stated Resident 1 gets out of bed frequently. During an interview with RNS 1 on 2/24/2025 at 2:56 PM, RNS 1 stated Resident 1 had a bed alarm on the bed in Room A, but the bed alarm was not moved with Resident 1 during the room transfer "because there was already a bed" in Room B. However, RN 1 stated the bed alarm was not transferred with Resident 1 from Room A. During a concurrent observation and interview, in the Compliance Office with CNA 1 on 2/24/2025 at 5:15 PM, CNA 1 stated that on 2/07/2025, Resident 1 was agitated and was throwing things on Resident 8's bedside table onto the floor. CNA 1 stated that on 2/07/2025, Resident 1 was transferred in a wheelchair to Room B because there's already a bed in Room B. CNA 1 stated that on 2/07/2025 at 6 PM, he went to Resident 1's room because, "I heard someone screaming for help." CNA 1 stated CNA 1 found Resident 1 on the floor. CNA 1 demonstrated how CNA 1 found Resident 1 on the floor. CNA 1's legs were stretched out with the back leaning against a chair. CNA 1 stated CNA 1 did not hear Resident 1's bed alarm go-off to alert staff that the resident was getting out of bed. CNA 1 stated another nurse (unable to identify nurse's name) helped CNA 1 return Resident 1 back to bed. During a record review, the facility report titled "Final Investigation" for Resident 1, dated 2/14/2025, indicated that on 2/7/2025, Resident 1 had an episode of altercation (heated argument) with resident's roommates. Resident 1 grabbed the roommate's (unidentified) arm. Resident 1 was confused, agitated, and sustained a skin tear on the forehead. Resident 1 was not able to verbalize the detail of the incident because of the dementia. First aid was provided to Resident 1 and Resident 1's physician ordered to transfer the resident to general acute care hospital (GACH) for further evaluation. The final investigation report indicated that per ED (Emergency Department) assessment (no date), indicated Resident 1 presented with a "small wound to the mid forehead," and a CT showed that Resident 1 had nondisplaced oblique (a fracture at an angle) fracture lucency (dark area on x-ray image that indicates a bone fracture) within R (right) subtrochanteric (below the bony part of the thigh bone) region concern of periprosthetic fracture (a fracture occurring near a hip replacement implant) ... Resident 1 had right hip tenderness." During a record review, the facility Interview Statement document dated 2/11/2025 documented by Social Services Director (SSD), indicated SSD interviewed Resident 2. The facility Interview Statement indicated Resident 2 (Resident 1's roommate in Room B) said he [Resident 2] did not hear a bed alarm. During a record review of Resident 1's GACH hospitalization from 2/07/2025 through 2/11/2025, Resident 1 was in the GACH emergency room (ER) on 2/07/2025 for a mid-forehead wound and a closed fracture of the right hip (a break in the hip joint that does not break the skin). During a record review, GACH x-ray of the right femur (thigh bone) taken on 2/07/2025, indicated Resident 1 sustained a "new fractured line (visible line or crack where a bone has broken)" inside the right hip arthroplasty (a surgical procedure to replace parts of the right hip joint with artificial parts). During a record review, GACH Computed Tomography (CT - a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce images of the inside of the body) scan taken on 2/08/2025, indicated Resident 1 sustained a fracture (a break in a bone) within the right hip. During a record review of Resident 1's orthopedic consult noted dated 2/07/2025, indicated Resident 1 "Is admitted status post ground level fall to the right side yesterday (2/06/2025) evening. Is unable to ambulate after the fall. He reported right hip pain. He was brought to the ED where X-rays revealed a right periprosthetic proximal femur fracture. Ortho (orthopedic) was consulted for further management." During a record review, GACH H&P dated 2/08/2025, indicated, Resident 1 was admitted to the medical surgical unit (a specialized area that provides care for patients who need medical and surgical care) of the hospital on 2/08/2025 for periprosthetic fracture (a bone fracture that occurs around or near an orthopedic [bone or muscle] implant). During a telephone interview with Resident 1's family member (FMR1) on 2/25/2025 at 2:48 PM, FMR1 stated that on 2/07/2025 around 9:15 PM and 9:30 PM Licensed Vocational Nurse (LVN) 1 told FMR1 that the facility sent Resident 1 to GACH Emergency Room (ER) because the resident was confused. FMR1 stated LVN 1 told FMR1 that Resident 1 was "going room to room, walking." FMR1 stated to LVN 1 that Resident 1 was "not supposed to walk because [Resident 1] will fall." FMR1 stated that RNS 1 told FMR1 that Resident 1 was sent to GACH ER because the resident was confused and agitated. FMR1 stated FMR1 contacted the GACH and an ER Nurse informed FMR1 that Resident 1 had a fresh laceration on the forehead and that Resident 1 was complaining of extreme pain to the right hip and leg. During a telephone interview on 2/25/2025 at 4:14 PM, LVN 1 stated that Resident 1 was identified as a fall risk. LVN 1 stated that on 2/07/2025, CNA 1 transferred Resident 1 in a wheelchair from Room A to Room B. LVN 1 stated Resident 1 had a "small little cut on the bridge of his nose ..., seemed agitated, didn't want to sit in the wheelchair, didn't want to be touched, and was confused." LVN 1 stated LVN 1 performed a visual assessment of the Resident 1 because Resident 1, "didn't want to be touched ...when I touched him, he would just jerk away." When LVN 1 was asked what Resident 1 was trying to "jerk away" from, LVN 1 stated "I don't know ...I think he was very agitated." During a record review, Resident 2's Admission Record indicated Resident 2 was admitted to the facility on 12/10/2024. During a record review, Resident 2's MDS dated 12/23/2024 indicated Resident 2 was cognitively intact (mental ability to make decisions on activities of daily living). During a record review, Resident 3's Admission Record indicated Resident 3 was admitted to the facility on 6/01/2021 and re-admitted on 6/06/2024. During a record review, Resident 3's MDS dated 12/02/2024 indicated Resident 3 was cognitively intact. During a record review, the facility Policy and Procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled 'Tab Alarms (Bed Alarms), Bed Alarms, Wanderguard System (a bracelet with sensors that trigger alerts when a resident attempts to leave a designated area),' reviewed on 11/21/2024, indicated, 'the bed alarms may be used on a resident who is deemed unsafe ... The bed alarm will be utilized on the resident while they are in bed. When bed alarms are in place, a safety check to ensure bed alarm is in proper working condition before leaving the resident." During a record review, the facility P&P titled "Safety and Supervision of Residents," reviewed on 11/21/2024, indicated, "the care team shall ... reduce individual risks related to hazards ...including adequate supervision ..." During a record review, the facility P&P titled Assessing Falls and Their Causes, reviewed on 11/21/2024, indicated, residents are to be evaluated "for possible injuries to the head, neck, spine, and extremities (arms, legs, fingers and toes)" and "if an assessment rules out significant injury ..." The facility failed to ensure: 1) The facility failed to ensure Resident 1's bed alarm was in place and functional as ordered by a physician. 2) A care plan for reducing the risk of falls was initiated/created for Resident 1. As a result, on 2/07/2025 Resident 1 fell and sustained a small cut on the forehead and a fracture to the right hip bone near hip prosthesis and needed to be transferred to a higher level of care for further evaluation. The above violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result for Resident 1.