Health inspection·July 20, 2023

42 CFR § 483.25(d) Accidents The facility must ensure that – (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 42 CFR § 483.21(b) Comprehensive Care Plans (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. 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; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv) In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. §483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (iii) Be culturally competent and trauma-informed. 22 CCR § 72311 Nursing Services - 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: (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. 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 6/1/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about quality of care. The facility failed to prevent a fall and injury for Resident 4 who was identified as a high fall risk, with unsteady standing and walking balance, and poor safety awareness. The facility failed to: 1. Ensure Resident 4 was provided with contact guard assistance (CGA, the contact is made to help steady the body and help with balance) and hand-held assistance (HHA) while walking, as assessed by the physical therapist (PT, a health professional trained to evaluate and treat people who have conditions or injuries that limit their ability to move and do physical activities). 2. Identify the fall risk posed by Resident 4’s use of the post-op shoe (also called post-surgical shoe, or hard sole shoe - medical shoe used to protect the foot and toes when there is an injury, a wound, or after surgery) to the right foot for wound management ordered on 4/27/2023. 3. Identify and make recommendations to address Resident 4’s posture due to a hunched back (abnormal rounding of the upper back) that affected the resident’s balance and caused the resident to look down while walking. 4. Develop a comprehensive care plan and failed to review and revise care plan interventions that were individualized based on Resident 4’s risk of falls, behavior problems, hunchback posture, and open wound on the right foot requiring the use of a special shoe. The facility did not review and revise the care plan to include the CGA and HHA needed, the interventions related to the use of the special shoe, and the hunchback posture affecting the balance. 5. Implement the facility’s policies and procedures titled, “Accident/Incident Prevention,” “Managing Falls and Fall Risk,” “The Resident Care Plan,” “Falling Star Program,” and “Promoting Safety, Reducing Falls.” As a result, on 5/25/2023 at 9:45 a.m., Resident 4 fell onto the floor while walking unassisted in the hallway and sustained a right shoulder fracture (broken bone). The resident was transferred to General Acute Care Hospital 1 (GACH 1) for treatment with immobilization and returned to the facility on 5/25/2023 with right arm sling and aftercare instructions. On 6/1/2023 at 10:10 a.m., during an observation and interview, it was noted Resident 4 had a hunched back and was sitting on a wheelchair in the activity room. Resident 4 was wearing a right shoulder sling (used to both support the weight of the arm and limits arm movement). Resident 4 stated she had a sling because of a fall but she did not remember the details and she did not answer further questions. The resident also had a black post-op shoe with a thick sole on the right foot and had a non-slip non-skid sock (improves the grip to help preventing slip and fall) on the left foot. A review of Resident 4’s Admission Record indicated the facility initially admitted the resident on 11/2/2020 and readmitted the resident on 12/22/2020. Resident 4’s diagnoses included type 2 diabetes mellitus (a disease that occurs when the blood sugar levels were too high) with diabetic foot ulcers (open sores or wounds of patients with diabetes) on the right foot, muscle weakness, and osteoarthritis (occurs when the cartilage that cushions the ends of the bones or joints gradually deteriorates). A review of Resident 4’s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 5/2/2023, indicated the resident had severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). Resident 4 required limited assistance (staff provided guided maneuvering of limbs) with one-person physical assist with walking in-room (how resident walks between locations in the room) and walking in-corridor (how resident walks in corridor on unit). Resident 4’s balance during transition and walking were not steady (only able to stabilize with staff assistance). Resident 4 used a wheelchair as a mobility device. A review of Resident 4’s Care Plan developed for the resident’s self-care deficit and needing assistance with activities of daily living (ADLs, including walking, transfers, toilet use, bathing, dressing, and personal hygiene), initiated on 11/2/2020 and last revised on 5/13/2023, had a goal for the resident to be clean and dry daily and another goal to minimize decline. The Care Plan interventions included to assist with ADLs and provide a safe environment. The type of assistance was not addressed. The use of the post-op shoe ordered on 4/27/2023 was not addressed. A review of Resident 4’s Care Plan for risk for fracture, initiated on 11/2/2020 and revised on 11/17/2021, indicated the goal of reducing the risk of injury. The interventions included assisting with all transfers and ambulation as needed. The type of assistance was not included. A review of Resident 4’s Care Plan on the Falling Star Program (program that includes interventions for residents identified as fall risk), initiated on 11/2/2020 and last revised on 5/13/2023, indicated the resident was at risk for falls secondary to balance deficit, cognitive impairment, poor safety awareness, difficulty in walking, and muscle weakness. The goal was to reduce Resident 4’s risk of falls through appropriate interventions. The interventions included to respect the resident’s wishes for independence and dignity, to conduct frequent visual monitoring, and to place the resident close to the activity designee station for close observation. The use of the post-op shoe ordered on 4/27/2023 was not addressed as an increased risk for falls due to the thick sole. The resident’s need for CGA and HHA was not included. A review of Resident 4’s Care Plan addressing secured unit placement, initiated on 11/2/2020 and last revised on 11/17/2021, indicated the resident was at risk for purposeless wandering (a common behavior in dementia [decline in mental ability severe enough to interfere with daily functioning/life] causing people to become lost or confused about their location) and potential for self-injury. The goals indicated were for the resident to have safe wandering and directed activities with no self-injury. The interventions included managing behavioral and psychological symptoms of dementia (BPSD). A review of Resident 4’s Interdisciplinary Wound Management Care Plan form dated 4/27/2023, indicated the wound on the right mid-foot metatarsal (the ball of the foot) had reopened. A review of Resident 4’s Physician’s Orders, dated 4/27/2023, indicated to apply the post-op shoe on the right lower extremity during functional mobility (while standing and walking). A review of Resident 4’s Fall Risk Assessment, dated 5/2/2023, indicated the resident had a total score of 20. A total score above 18 represents high risk for falls. The level of consciousness/mental status section indicated Resident 4 had intermittent confusion, poor safety awareness, and noncompliance. The gait (manner of walking) and balance section indicated Resident 4 had unsteady gait (when a person is having trouble with their balance or the way they walk) with poor sitting or standing balance. A review of Resident 4’s Interdisciplinary Team (IDT, a group of healthcare professionals from different disciplines who participate in the care of the resident) notes, dated 5/2/2023, indicated an IDT meeting was conducted due to Resident 4’s reopening of the right foot diabetic ulcer. The IDT meeting note indicated Resident was typically pacing (walking or moving repeatedly, often back and forth) around, even wandering around, was fully ambulatory, wearing proper footwear with non-skid socks but sometimes preferred only the non-skid socks. A review of Resident 4’s Licensed Nurse Record from 5/21/2023 to 5/24/2023, indicated the resident required extensive assistance with one-person assist with gait and ambulation. A review of Resident 4’s Physical Therapy (PT) Treatment Encounter Notes, dated 5/22/2023, 5/23/2023, and 5/24/2023, indicated the resident required CGA and HHA with walking on level surfaces. The PT notes did not address the post-op shoe Resident 4 was using or that the thick sole would cause imbalance during standing and walking. A review of Resident 4’s Change of Condition (COC) Assessment Form, dated 5/25/2023, indicated that at 9:15 a.m., the resident was seen multiple times walking in the hallways. At 9:45 a.m., Certified Nursing Assistant 2 (CNA 2) saw the resident lying on the floor across the kitchen hallway. Upon checking Resident 4’s right arm, the resident had facial grimace and complained of pain on the right shoulder. At 10:10 a.m., staff notified the physician and the physician ordered x-rays (a procedure that creates pictures of the inside of the body in different shades of black and white). At 2:34 p.m. the x-ray result showed an acute fracture of the right shoulder. At 3:22 p.m., the physician ordered transfer to GACH 1. A review of Resident 4’s IDT Narrative Notes, dated 5/25/2023 at 5:51 p.m., indicated the resident had confusion, disorientation, poor safety awareness, and impulsiveness. Resident 4 was ambulatory and required physical assist with ADLs. The IDT Narrative Notes indicated Resident 4’s fall was not prevented because of the distance between the witness and the resident. A review of Resident 4’s GACH 1 right shoulder x-ray report, dated 5/25/2023 timed at 7:46 p.m., indicated the resident sustained a mildly comminuted fracture (the breaking of a bone into several small pieces) and impacted fracture (happens when a bone is compressed causing parts of the bone to crumble) of the right proximal (at the shoulder level) humerus (the long bone of the upper arm). Resident 4 was sent back to the facility the same day with the sling and with instructions to have a follow-up appointment with orthopedic surgery (the branch of surgery concerned with conditions involving the musculoskeletal [muscles and bones] system) in the next three months. On 6/1/2023 at 10:36 a.m., during an interview, CNA 2 stated Resident 4 walks while looking down on the floor. CNA 2 stated Resident 4 was standing at the hallway across the kitchen door, with no wheelchair, and falling forward tilting towards the right side. CNA 2 stated he was not able to reach Resident 4 to prevent the fall because of the distance between them. CNA 2 stated there was no other staff in the hallway at the time of Resident 4’s fall. CNA 2 could not remember what footwear Resident 4 was wearing at the time of the fall. On 6/1/2023 at 11:02 a.m., during an interview, Registered Nurse 2 (RN 2) stated Resident 4 walks slowly while looking down on the floor. RN 2 demonstrated Resident 4’s posture (hunched back) during ambulation. RN 2 could not remember what footwear Resident 4 had at the time of the fall. On 6/1/2023 at 12:03 p.m. during an interview, CNA 3 stated Resident 4 could walk but needed assistance. CNA 3 stated Resident 4 stated that before the fall, Resident 4 was wearing the post-op shoe on the right foot and was sitting on the wheelchair in front of Nursing Station 2. CNA 3 stated Resident 4 constantly attempts to get out of the wheelchair. CNA 3 stated the resident was not safe walking with the post-op shoe because of the uneven footing from the sole thickness of the post-op shoe. On 6/1/2023 at 1:13 p.m., during a concurrent interview and record review, RN 3 stated Resident 4 was stable in ambulating before the right foot ulcer reopened. RN 3 stated Resident 4 walked wearing the post-op shoe during the MDS assessment. RN 3 defined limited assistance as the resident’s ability to perform 75% of the task with minimal staff assistance. Resident 4’s MDS functional status section was reviewed with RN 3 who confirmed the resident was not steady and needed staff to be beside the resident while ambulating. RN 3 further stated Resident 4’s use of the post-op shoes should have been evaluated as a fall risk and should have been included in the care plan. On 6/1/2023 at 1:58 p.m., during a concurrent interview and record review, the Director of Rehab (DOR) stated Resident 4 had an unsteady gait and needed close supervision for redirecting. The DOR stated Resident 4 had a right diabetic foot wound and had been walking up to 125 feet with the post-op shoes during PT sessions. The DOR stated Resident 4 could walk more than 125 feet but required frequent rest periods. The DOR defined Resident 4’s kyphotic (hunchback) posture as rounded spinal curvature which changed the resident’s center of balance. The DOR stated a kyphotic posture was a contributing factor for Resident 4’s unsteady gait. The DOR confirmed not addressing in the PT notes Resident 4’s hunched back and the use of the post-op shoes as fall risk. The DOR confirmed Resident 4 required CGA and HHA during ambulation. The DOR acknowledged the care plans were not reviewed and revised to address the resident’s need for CGA and HHA, the need for increased awareness on the use of the special post-op shoe, and the hunched back affecting the resident’s balance. On 6/1/2023 at 2:32 p.m., during a concurrent interview and record review, RN 2 stated Resident 4’s MDS indicated the resident required limited assistance with one-person assist and the resident had an unsteady gait. RN 2 stated Resident 4 should be closely supervised while walking. On 6/5/2023 at 10:15 a.m., during an inter