Health inspection·May 16, 2025

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. 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. The comprehensive care plan must describe the following - 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 4/3/2025 California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a facility reported incident disclosed on 4/2/2025 regarding a resident (Resident 1) who had forehead laceration and left eye discoloration, prompting additional investigation into the history of her injury. The facility failed to: 1. Ensure a Certified Nursing Assistant (CNA) 1, who was assigned to provide Resident 1 with 1:1 (a constant observation provided by a care giver/sitter) supervision for safety, prevented Resident 1 from walking towards the wall and banging her head on the wall. 2. Implement a comprehensive person-centered care plan by ensuring CNA 1 was informed and had knowledge of Resident 1's behavior of banging her head on the wall. 3. Ensure the facility's policy and procedure (P&P) titled, "Resident Safety," dated 4/15/21, which indicated, "the purpose is to provide a safe and hazard free environment" was followed. As result Resident 1 bang her head on the wall and fell on the floor sustaining laceration on the left forehead (the left corner of the front head) requiring six sutures. On 3/26/25 at 2:47 p.m. Resident 1 was transferred to the General Acute Care Hospital (GACH) for evaluation and treatment. A review of Resident 1's Admission Record indicated Resident 1 was originally admitted to the facility on 11/8/2024 and readmitted on 03/7/25 with diagnoses including paranoid schizophrenia, anxiety disorders , and chronic obstructive pulmonary disease (COPD). A review of Resident 1's Minimum Data Set (MDS-resident assessment tool) dated 2/15/2025, indicated Resident 1 had severe impairment in cognitive skills for daily decision-making. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs) from staff for activities of daily living (ADL- routine tasks/activities such as bathing, dressing and toileting) and with transfers between surfaces. A review of Resident 1's Physician's Order Summary dated, 3/11/25, indicated a physician's order dated 3/11/25 for Resident 1 to have a care companion in the room (unknown duration) and in line of sight, in the hallway/outside of room, for safety. A review of Resident 1's care plan titled, "Resident 1 bangs head on the wall" initiated on 03/12/25 and revised on 03/27/25, indicated the goal for Resident 1 was to minimize injury related to hitting head on the wall. The care plan interventions included for Resident 1 to wear helmet (used to protect resident from head injuries), as necessary when banging head on the wall for safety, installing pads on walls, and continuing to monitor Resident 1's behavior (banging head on the walls) causing harm to self. A review of Resident 1's care plan titled, "Resident 1 is non-compliant with wearing a helmet" initiated on 03/13/2025, indicated the goal for Resident 1 was to minimize injury related to hitting the head. The care plan interventions included having a care companion in the room (unknown duration) and line of sight for safety. A review of Resident 1's Transfer Form dated 3/26/2025, the Transfer Form indicated Resident 1 was transferred to the GACH for evaluation and treatment related to a fall on 3/26/2025 at 2:47 pm. A review of Resident 1's GACH's Trauma Flow Sheet dated 3/26/25, indicated Resident 1 was brought to the ER from the facility with four-centimeter (cm) long laceration to the left forehead. The GACH's Trauma Flow Sheet indicated Resident 1 received six sutures to the left forehead. A review of Resident 1's Nursing Progress Notes dated 03/26/25 and timed at 8:16 pm, Resident 1 return to facility from the GACH's emergency room (ER) with sutures on the left forehead open to air with lump in the middle of forehead. The Nursing Progress Notes indicated to continue with 1:1 supervision at bedside for safety. A review of Resident 1's Interdisciplinary Team (IDT) Note dated 03/27/25 and timed at 5:25 pm, indicated Resident 1 had a history of hitting her head on the wall. The IDT Note indicated interventions included for Resident 1 to wear a padded helmet to prevent injury, but "the resident was non-compliant with wearing a helmet." The IDT Note indicated "due to Resident 1's noncompliance in wearing the padded helmet, Resident 1 to have a care companion in the room and within line of sight in the hallway for safety." The IDT Note indicated the new safety measures implemented included to remove Resident 1's side table and television and pad the wall to prevent further injury. There were no supportive documents provided by the facility that an IDT meeting was held prior to the incident on 3/26/2025. A review of Change of Condition Evaluation (COC) dated 3/31/25, indicated Resident 1 had the left forehead laceration, with lump/hematoma on the center of Resident 1's forehead. The COC indicated Resident 1 remained on continuous frequent monitoring, and 1:1 supervision with a sitter. During a concurrent observation and interview with CNA 2 on 04/03/25 at 3:06 pm with Resident 1, in Resident's 1 room, Resident 1 was observed sitting on a bed and CNA 2 (1:1 sitter) sitting on a chair by the resident's bed side. During the observation it was noted that the wall was padded only in front of the resident bed and on its right side. Resident 1 was observed to have six sutures on her left forehead with no dressing over it. Resident 1 was observed to have a purple discoloration around the left eye with swelling. CNA 2 stated her responsibilities as 1:1 sitter included keeping close supervision on Resident 1 for safety and preventing Resident 1 from falling or banging her head on the walls. CNA 2 stated she was not working on the day Resident 1 bang her head on the wall and fell on the floor (3/26/25). CNA 2 stated to prevent Resident 1 from banging her head on the wall, she will sit closer to Resident 1 and will get up anytime Resident 1 gets out of bed or chair to provide safety. During a phone interview on 4/03/25 at 3:47 pm CNA 1 stated she was the 1:1 sitter for Resident 1 on 3/26/25 from 7 am to 3 pm shift. CNA 1 stated she was sitting beside Resident 1 in the resident's room, when Resident 1 suddenly got up and walked towards the wall near the door. CNA 1 stated Resident 1 started to hit and bang her head on the wall. CNA 1 stated she could not catch Resident 1 in time because Resident 1 got up too quickly. CNA 1 stated she was able to grab Resident 1 partway down as she was falling to the floor. CNA 1 stated she yelled for help because Resident 1 was bleeding from the forehead. CNA 1 stated she felt bad over Resident 1's injury as it could have been prevented. CNA 1 stated that she was not informed about Resident 1 banging her head against the walls until after the incident on 3/26/25. CNA 1 stated that she was told that the reason why Resident 1 required 1:1 sitter was because the resident was losing her balance and wandering (moving from place to place without a fixed plan) in the hallway. CNA 1 stated that if she had been aware of Resident 1's behavior of banging her head against the walls, she could have been more vigilant and sat closer to Resident 1 to help prevent injuries and falls. During a phone interview on 04/3/25 at 4:01 pm Licensed Vocational Nurse l (LVN 1) stated she was the charge nurse on 3/26/25. LVN 1 stated she was passing medication when she heard CNA 1 yelling for help. LVN 1 stated when she entered Resident 1's room, Resident 1 was sitting on the floor and blood was coming out of Resident 1's forehead. LVN 1 stated Resident 1 was sent to the GACH via 911 due to laceration on the forehead. During a phone interview on 3/4/25 at 4:13 pm Resident 1's Family member (FM 1) stated Resident 1's injury could have been prevented if the facility staff (CNA 1), who was watching Resident 1, paid close attention to Resident 1. FM 1 stated she was surprised when she saw Resident 1' s face with bruises and laceration on the left side of her forehead. During an interview on 4/4/25 at 4:03 pm the Director of Nursing, (DON) stated Resident 1 has a history of wandering and throwing herself on the floor. The DON stated the incident happened so fast, in spite CNA 1 sitting close to Resident 1, as Resident 1's behavior was unpredictable. During a concurrent observation and interview on 04/04/25 at 4:26 pm with the Administrator (ADM) and the DON, in Resident 1's room, the ADM demonstrated how the incident happened on 3/26/25 based on CNA 1's interview. The ADM demonstrated that CNA 1 was seated at the foot of Resident 1's bed facing the resident, who was sitting on the side of the bed. Resident 1 quickly crossed in front of CNA 1 and bang her head against the wall near the cabinet, which was located at the foot of the bed. During the observation, the distance from where Resident 1 was seated on the side of the bed to the wall near the cabinet where Resident 1 bangs her head was approximately eleven steps from Resident 1's bedside to the wall near the cabinet. The DON stated the incident could have been prevented if CNA 1 was fast enough to stop Resident 1. A review of the facility's P&P titled, "Resident Safety," dated 4/15/21, indicated "the purpose of this policy is to provide a safe and hazard free environment. Residents will be evaluated on admission, quarterly and whenever there is a change in condition to identify circumstances that pose a risk for the safety and wellbeing of the resident." A review of the facility's P&P titled, "Sitters" dated 1/25/24, indicated, "to assist residents who need additional observation and/or companionship in obtaining sitters or companion care." The facility failed to: 1. Ensure a CNA 1, who was assigned to provide Resident 1 with 1:1 supervision for safety, prevented Resident 1 from walking towards the wall and banging her head on the wall. 2. Implement a comprehensive person-centered care plan by ensuring CNA 1 was informed and had knowledge of Resident 1's behavior of banging her head on the wall. 3. Ensure the facility's P&P titled, "Resident Safety," dated 4/15/21, which indicated, "the purpose is to provide a safe and hazard free environment" was followed. As result Resident 1 bang her head on the wall and fell on the floor sustaining laceration on the left forehead requiring six sutures. On 3/26/25 at 2:47 p.m. Resident 1 was transferred to the General Acute Care Hospital (GACH) for evaluation and treatment. These violations jointly, separately or in any combination, presented either imminent danger that death or serious harm would result, or a substantial probability of death or serious physical harm would result to Resident 1.