Health inspection·May 16, 2025

F689 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. §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 resident 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 22 CCR § 72311. Nursing Service--General. (a) Nursing service shall include, but not be limited to, the following: (1) (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. On 4/1/2025 California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding quality of care. The facility failed to ensure Resident 1, who was assessed as a risk for falls, did not fall and sustained an injury. The facility failed to: 1. Ensure Resident 1 was supervised and monitored to prevent repeated falls and injuries from 9/13/2024 to 3/15/2025 per care plan titled; "Falling Star Program" dated 9/13/2024. 2. Revise and evaluate the effectiveness of interventions of Resident 1's care plan titled, "Falling Star Program," dated 9/13/2024 after Resident 1 was found on floor 11/14/2024, to prevent Resident 1 from future falling. 3. Ensure staff followed the facility's policy and procedures (P&P) titled, "Falls and Fall Risk, managing" dated 11/21/2024, which indicated, "staff will identify interventions related to the resident's specific risk and causes to prevent the resident from falling and to minimize complications from falling." 4. Ensure an accident-free environment as much as possible, including removing paddle of urine on the floor by Resident 1's bedside that, according to facility's Director of Nursing, led Resident 1 to slip and fall on 3/15/2025. 5. Ensure Resident 1's call light remained within the resident's reach. As a result of these failures, Resident 1 had three falls: -On 9/13/2024 Resident 1 fell and sustained a 1 (one) millimeter (mm-unit of measurement) anterior subluxation (a partial dislocation or displacement of a joint where the bones remain in contact, but not fully aligned and is the most unstable form of cervical spine injury) of C2 (second cervical vertebra (bone) onto C3..." -On 11/14/2024, Resident 1 fell with no injuries. -On 3/15/2025. Resident 1 fell again and suffered severe pain and left sub-capital (below) left femoral (thigh bone) neck fracture requiring hospitalization to undergo hemiarthroplasty (a surgical procedure where half of a joint is replaced with an artificial implant) of the left hip. During a record review, Resident 1's admission record indicated Resident 1 was originally admitted to the facility on 6/14/2014 and was re-admitted on 3/22/2025, with diagnoses that included Osteoarthritis (degenerative joint disease, in which the tissues in the joint break down over time), repeated falls, protein malnutrition (deficiency or imbalance of protein and energy), atherosclerosis (disease characterized by the buildup of plaque in the inner walls of the arteries), major depressive disorder (persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities, significantly impacting daily functioning) and epilepsy (disorder of the brain characterized by sudden alteration of behavior due to a temporary change in the electrical functioning of the brain) During a record review, Resident 1's Change of Condition (COC - a deviation from a patient's baseline state of health, often involving a sudden or clinically significant worsening) 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 9/13/2024, at 6:45 AM indicated a certified nurse assistant (CNA) found Resident 1 "sitting on the floor at foot of her bed" and had blood on the hair and on the left hand. The COC-SBAR indicated that upon assessment, Resident 1 sustained a cut to the left side of the head and a cut underneath the left eye. The COC-SBAR indicated Resident 1 did not respond to verbal stimuli. The resident's blood pressure, heart rate, respirations, temperature and oxygen saturation were taken and 911 (emergency response telephone number) was called. Resident 1 was transferred to an acute care hospital for a higher level of care. During a record review, Resident 1's care plan titled, "Falling Star Program," dated 9/13/2024, indicated Resident 1 initially fell on 9/13/2025 and that Resident was at risk for falls related to history of falls, dementia, muscle wasting. The care plan goal indicated to reduce risk of falls and/or injury through appropriate intervention(s) daily until the next assessment. The care plan interventions include bed in lowest position, wheelchair's wheels locked, call light within reach, environment-maintained clutter free, non-skid shoes/slipper when out of bed, room organization, safety round checks, and may apply pad alarm on the bed to alert staff to assist resident to prevent falls. During a record review, Resident 1's care plan titled, "Resident has had an actual fall" created on 9/13/2024, indicated that: -On 9/13/2024, Resident 1 with cut of left side of the head and underneath left eye. Resident 1 was found sitting on the foot of her bed. Resident 1 was transferred to GACH via 911. - On 11/14/2024, Resident 1 was found on floor sitting on buttocks against bed sitting in upright position. -On 3/15/2025, Resident 1 had an actual fall. Resident 1 was found lying at the foot of her bed, positioned on the left side. Patient's muscles are tensed and shaking continuously. Risk factors include poor balance, poor communication, unsteady gait and dementia. During a record review, Resident 1's Fall Risk Assessment dated 9/13/2024 at 9:25 AM, indicated Resident 1 had an "unwitnessed fall inside her room obtained left forehead skin tear s/p (status post-after) seizure." The Fall Risk Assessment - fall interventions included skilled rehab (rehabilitation) services for Physical Therapy (PT - is a healthcare specialty that focuses on improving physical function and movement using exercises, manual therapy, and other modalities), Occupational Therapy (OT - The practice of helping individuals with disabilities or health conditions improve their ability to participate in daily activities and maintain independence), and Safety awareness. During a record review, Resident 1's Computerized Tomography (CT - is a medical imaging technique that uses x-rays to create detailed, cross-sectional images of the body's internal structures, such as bones, organs, and blood vessels) of the cervical spine ... dated 9/13/2025, indicated, "There is no acute (of sudden onset) fracture... There is 1 mm-unit anterior subluxation of C2 (second cervical vertebra onto C3..." During a record review, Resident 1's GACH Vascular Neurology (a specialized field within neurology that focuses on diagnosing, treating, and managing diseases and conditions related to the blood vessels of the brain and spinal cord) Progress Note dated 9/15/2024, indicated Resident 1 was brought to the emergency room on 9/13/2024 after unwitnessed fall. The GACH Vascular Neurology Progress Note indicted Resident 1's CT scan was "unremarkable (a test or examination reveals nothing abnormal or concerning)," and Resident 1 was discharged from ED. During a record review, Resident 1's GACH Hospitalist (a Physician whose primary focus is caring for hospitalized patients only) Progress Notes signed by GACH medical doctor (MD) dated 9/15/2024 at 1:05 PM, indicated that on 9/13/2024 at 1:05 PM, Resident 1 presented to the GACH from the skilled nursing facility (SNF) due to unwitnessed fall. The GACH hospitalist progress notes assessment and plan included ... Staples (fasteners used to close wounds or surgical incisions) to be removed in 7-10 days from head laceration after fall at SNF. During a record review, Resident 1 Interdisciplinary Team (IDT- group of healthcare professionals from various disciplines who work together to provide comprehensive and coordinated care for patients) Review-Fall dated 9/16/2024 at 11:40 AM, indicated that on 9/13/2025, Resident 1 had "unwitnessed fall inside her room obtained left forehead skin tear s/p seizure ... was transferred to hospital via 911." The IDT Review- Fall interventions include skilled rehab services for PT and OT and safety awareness. The IDT Review-Fall did not address interventions to prevent future falls. During a record review, Resident 1's Rehab Admission Rehabilitation Screening notes dated 9/18/2024, indicated Resident 1 was totally dependent on staff and required two persons assistance for bed mobility and transfer. The Rehab Admission Rehabilitation Screening notes indicated Resident 1 was not evaluated for ambulation (the act of walking or moving about). The Rehab Admission Rehabilitation Screening notes indicated Resident 1 used a wheelchair for locomotion (movement), and that the resident was totally dependent and required two persons assistance with sitting balance. The Rehab Admission Rehabilitation Screening notes indicated Resident 1 was unsteady, and had mild difficulty with cognition, decision making due to a memory problem. During a record review, Resident 1's COC-SBAR dated 11/14/2024 at 11:50 AM, indicated Resident 1 was "found on floor sitting on buttocks back against bed sitting in upright position, increased confusion noted, complaining of dizziness and unsteady gait." The COC-SBAR indicated Resident 1 was not sent to GACH after the fall. During a record review, Resident 1's IDT Review-Fall dated 11/24/2024 at 12 AM, indicated "[Resident 1] found on floor sitting on buttocks back against bed sitting in upright position. Bed in lowest level, call light within reach (during the fall)." The IDT Review- Fall assessment/root cause analysis indicated" (Resident 1) was demented, periods of not calling for assistance due to forgetfulness. Intervention was to leave the bed to lowest level for prevention of injury." The IDT Review- Fall interventions include bilateral (both) upper rails for enabler and mobility use due to generalized muscle weakness. Monitor side effects from antidepressant medication, Zoloft. On skilled PT to promote gait and safe functional transfer and mobility." The IDT Review-Fall did not address interventions to prevent future falls. During a record review, Resident 1s Minimum Data Set (MDS - a standardized resident assessment tool) dated 1/13/2025, indicated Resident 1 had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS indicated Resident 1 required supervision or touching assistance with personal hygiene, upper body dressing and ambulating up to 10 feet, Resident 1 required partial moderate assistance with personal hygiene and lower body dressing. The MDS indicated Resident 1 is continent (ability to voluntary release of urine or feces). During a record review, Resident 1's Fall Risk Assessment dated 3/15/2025, indicated Resident 1 had decreased muscular coordination, and an unsteady gait/balance while standing and walking, placing the resident at a moderate risk (a situation where a person is considered to have a higher likelihood of falling) for falls. During a record review, Resident 1's COC-SBAR dated 3/15/2025 at 1:15 AM, indicated that on 3/15/2025 at 1:15 AM, the charge nurse (unidentified) notified the writer (a registered Nurse -RN) that Resident 1 was found lying on the left side on the floor at the foot of the bed. The COC-SBAR indicated Resident 1 was experiencing significant discomfort and pain evidenced by the resident guarding of the left hip. The COC-SBAR indicated Resident 1's left hip muscle was tensed, and the muscle was shaking continuously. The COC-SBAR indicated Resident 1 refused the charge nurse to take the vital signs (measurable physiological indicators that reflect a person's overall health and well-being including blood pressure - BP 129/68 millimeters of mercury [mmHg- unit of measurement -normal is less than 120/80 mmHg], temperature [Temp] 97.5 degrees Fahrenheit [F - normal range 97-99], Pulse [heart rate-HR] 72 beats per minute [normal 60-100], respirations [RR] 18 breaths per minute [normal 12-18], and Oxygen saturation [O2 Sat - percentage of oxygen present in the blood] . The COC-SBAR indicated Resident 1 stated that she was trying to go the bathroom. The COC-SBAR indicated Paramedics (healthcare professionals, who provides advanced emergency medical care and transportation) were contacted immediately, came to the facility, assessed Resident 1 and determined that Resident 1 needed to be transferred to the emergency room (ER-a specialized hospital area equipped to handle and treat patients with sudden, serious illnesses or injuries requiring immediate medical attention). During a record review, Resident 1's x-ray dated 3/15/2025 at 10:42 AM, indicated an impression of Redemonstrated (a finding or condition has been observed again on a follow-up examination) sub-capital left femoral neck fracture (a fracture of the neck of the femur specifically in the sub-capital region (the area just below the head of the femur) on the left side. During a record review, Resident 1's GACH History and Physical dated 3/15/2025 at 11:34 AM, indicated Resident 1 presenting from Skilled Nursing facility (SNF) with unwitnessed fall with left hip pain (pain level not indicated). During a record review, Resident 1's GACH Operative Report dated 3/16/2025 at 3:11 PM, indicated Resident 1 had a pre-operative (before surgery) diagnosis of displaced left femoral neck fracture and that on 3/16/2025 at 3:11 PM, Resident 1 had left hip hemiarthroplasty. During a record review, Resident 1's GACH Orthopedic (medical specialty focused on the diagnosis, treatment, and prevention of conditions related to the musculoskeletal system (bones, joints, muscles, tendons, ligaments, and nerves) Consult Notes dated 3/15/2025 at 1:21 PM indicated Resident 1, with a history of dementia, who presented with severe pain in the left hip which began after an unwitnessed fall yesterday at the skilled nursing facility (SNF) where she was found in a puddle of urine. ... has continued severe pain in the left hip that is worse with movement and improved with rest..." During a record review, Resident 1's COC-SBAR dated 3/18/2025 at 4:53 PM and documented by RN Consultant, indicated that on 3/15/2025 at 1:15 AM, indicated that Resident 1 was transferred to hospital via 911 due to unwitnessed fall... 2 CNAs heard the loud noise from Resident 1's room then rushed to the resident. The 2 CNAs called the Charge Nurse (unidentified), and RN (unidentified) assessed Resident 1. The COC-SBAR indicated that 1 (one) transferred the resident back to bed and paramedics called because Resident 1 was in pain. During a concurrent observation and interview on 4/1/2025 at 12:37 PM, in Resident 1's room, with licensed vocational nurse (LVN) 1, Resident 1's call light was observed on the resident's dresser drawer and not within reach. LVN 1 stated Resident 1's call light was probably moved away from the resident by a Certified Nurse Assistant (CNA) 1, who cleaned Resident 1 in the morning (4/1/2025). LVN