Health inspection·July 11, 2025

§483.25Quality 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.. §483.25(d)(1)(2) 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)(1)Comprehensive Care Plans 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. §72523(a) 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 5/21/2025, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) was neglected when he fell out of bed and passed away on 2/9/2025. On 5/22/2025, CDPH conducted an unannounced visit at the facility to investigate the complaint allegation. Upon investigation, CDPH determined the facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 1 did not turn and reposition Resident 1 during incontinent care without the assistance of an additional staff member, per the Minimum Data Set ([MDS] a resident assessment tool) assessment dated 11/1/2024. 2. Develop a Care Plan related to Resident 1's dependence on the nursing staff for and during incontinent care, turning and repositioning. 3. Follow their Policy and Procedure (P/P), titled, "Turning and Repositioning" dated 12/3/2024, that indicated the protocol for turning and repositioning included use of appropriate number of staff to perform tasks safely. These deficient practices resulted in Resident 1 rolling and falling out of bed when CNA 1 turned the resident during incontinent care without the assistance of additional staff. Resident 1 was transferred to a General Acute Care Hospital (GACH) on 2/2/2025, where he was diagnosed with multiple injuries to his neck and spine, was intubated (when a tube is inserted into the mouth/nose and down into the airway), and placed on a ventilator (a medical device that helps a person breath when they are unable to do so on their own). Resident 1 expired on 2/9/2025 due to a sequelae (any complication or condition that results from a pe-existing illness, injury, or other trauma to the body) of blunt traumatic injuries from a ground level fall. A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1, an 89 year-old male, was admitted to the facility on 7/28/2024 with a diagnosis including a fracture of the left humerus (the upper arm bone), congestive heart failure (a heart disorder which causes the heart to not pump the blood efficiently), generalized muscle weakness, and myasthenia gravis (an autoimmune disorder that causes muscle weakness and fatigue due to a breakdown in communication between nerves and muscles). A review of Resident 1's MDS dated 11/1/2024, indicated Resident 1 had mild cognitive impairment (memory and thinking problems). The MDS indicated Resident 1 was dependent on nursing staff for toileting hygiene, rolling to the left and right side while in bed and required two-person assistance for incontinent (loss of control of bowel and/or bladder) care, turning and repositioning. The MDS indicated Resident 1 was incontinent of both bowel and bladder function. A review of Resident 1's clinical record indicated there was no documentation that a care plan was developed related to Resident 1's dependence on nursing staff for incontinent care or turning and reposition with two-person physical assistance. A review of Resident 1's SBAR ([situation, background, assessment, recommendation] a communication tool used by healthcare workers when there is a change of condition among the residents) Fall Report of Incident, dated 2/2/2025 and timed at 7:25 a.m., indicated on 2/2/2025 at 6:35 a.m., Resident 1 was alert, oriented, and verbally responsive when CNA 1 adjusted his bed to her waist level and repositioned Resident 1 to his right side. The SBAR indicated Resident 1 slid out of bed and landed on a floor mat in a prone (lying face down) position. The SBAR indicated CNA 1 called for help, Licensed Vocational Nurse (LVN) 1 responded and found Resident 1 awake and alert but unresponsive (unable to react to stimuli like touch, sound, or pain). The SBAR indicated Resident 1 was placed back in bed while LVN 1 called 911. The SBAR indicated Resident 1 was transferred to a GACH via 911. A review of Resident 1's Emergency Medical Services (EMS) form, dated 2/2/2025, indicated EMS was dispatched to the facility on 2/2/2025 at 6:35 a.m., and arrived at the facility at 6:46 a.m. The EMS form indicated Resident 1 had a Glasgow Coma Score ([GCS] a method used to determine a patient's conscious state ranging from 3-15, a score of 3-8=coma) of 4. The EMS form indicated that Resident 1 was lying in bed supine (on his back), was drowsy, but able to open his eyes and that he (Resident 1) hit the occipital (the back region) area of his head. The EMS form indicated Resident 1 had left side facial droop and a low oxygen saturation ([O2 sat] a measurement of how much oxygen is carried by the blood, normal range is 95% to 100%) level of 84% on room air (without the use of oxygen supplement). A review of the GACH's Admission Record, dated 5/2/2025, indicated Resident 1 arrived at the GACH at 7:03 a.m., with a primary diagnosis of respiratory insufficiency (a condition that causes problems with breathing, specifically at rest) and a hospital problem (Resident 1's status identified by the GACH) of lung failure (respiratory failure). A review of the GACH's Emergency Department (ED) Notes, dated 2/2/2025 and timed at 10:32 a.m., indicated Resident 1 was intubated and placed on a ventilator at 7:11 a.m. A review of the ED Provider Note dated 2/2/2025 and timed at 7:07 a.m., indicated Resident 1 presented to the ED with a GCS of 6 and had pinpoint pupils (pupils that are abnormally small, and an indication of a severe head injury) upon initial evaluation. A review of the GACH's Imaging Note, dated 2/5/2025, and timed at 4:25 p.m., indicated an MRI ([Magnetic Resonance Imaging] a medical technique that uses strong magnetic field and radio waves to create detailed images of the body's internal structures) of Resident 1's brain resulted in the following: 1. Acute traumatic ligamentous (tough bands of tissue that connect bones and help stabilize the spine) injuries with slight anterior translation (movement or displacement of a body part forward from its normal position relative to another bone or joint) of the dens (a bony projection of the second neck bone that acts as a pivotal point enabling head rotation), and C1 vertebra (a ring shaped bone that begins at the base of the skull that holds the head upright). 2. Superimposed hematoma (a collection of blood outside of the blood vessel occurring on top of an existing hematoma, either in the same area or in a different locations) vs an inflammatory mass (a clump of tissue that has become swollen or irritated) with secondary compression of the cervical cord (a condition where the spinal cord in the neck region is squeezed) A review of the GACH's Imaging Note, dated 2/5/2025, and timed at 4:52 p.m., indicated an MRI of Resident 1's C-spine ([cervical spine] the upper portion of the spinal column located in the neck region) resulted in the following: 1. Brain stem (the lowest part of the brain responsible for functions such as breathing) and cervical cord edema over seven centimeters ([cm] a unit of measurement) in length. 2. Cervical cord hemorrhage (bleeding) at C1. 3. Suspected ligamentous tears from the skull base (the bony floor of the skull that separates the brain from the upper neck) and C2 (second vertebra of the neck) region to the C6 through C7 (sixth and seventh vertebra of the neck) vertebra. 4. Likely disc (involves the cushion-like discs in the spine that allow movement, provide shock absorption, ad maintain spinal stability) injury at C3 through C7. 5. Indications of interspinous (located between spines, specifically between the bone projections of the adjacent vertebrae in the spine) ligamentous tears from C2 through C5. 6. Suspected acute fracture on C4 vertebral body (the main component of each vertebra in the spine, providing support and structure)/osteophyte ([bone spur] an abnormal bony projection that forms on the edges of the bones which can develop due to injury) and C3 vertebrae. 7. Multi-level cervical spinal stenosis (narrowing of the space within the neck bones where the spina cord and nerve roots run, causing compression of these delicate structures) including mild stenosis at C5 through C6, moderate stenosis at C4 through C5, and moderate stenosis at C3 through C4. A review of the GACH's Medicine Discharge Summary, dated 2/16/2025, indicated Resident 1 was still on a ventilator on 2/6/2025 and neurosurgery (a medical specialty concerned with diagnosis and treatment of patients with injury of the brain, spine, spinal cord, and other nerve related body parts) consulted with Resident 1's family, and decided on comfort care (care that focuses on an end of life approach such as managing pain symptoms, and spiritual/emotional needs of both patient and family). The Medicine Discharge Summary indicated Resident 1's family was aware of Resident 1's poor prognosis (a low likelihood of recovery) and was ready to withdraw care (a discontinuation of life-prolonging treatments such as ventilators). Resident 1 was taken off the ventilator on 2/9/2025. The Medicine Discharge Summary indicated Resident 1 passed away on 2/9/2025. A review of Resident 1's Certificate of Death dated 2/8/2025 and timed at 6:05 p.m., indicated Resident 1's immediate cause of death was sequelae of blunt traumatic injuries from a ground level fall. During an interview on 5/22/2025 at 2:47 p.m., Family Member (FM) 1 stated Resident 1 passed away on 2/9/2025 at the GACH due to breaking his neck with a spinal cord injury from his fall on 2/2/2025 at the facility. FM 1 stated she last talked to Resident 1 on 2/1/2025 over the phone, and he was alert, oriented, and able to speak to her normally. FM 1 stated she visited Resident 1 at the GACH from 2/2/2025 through 2/9/2025, and Resident 1 was not able to move, talk, or breath without the use of a ventilator. During an interview on 5/23/2025 at 5:10 a.m., LVN 1 stated on 2/2/2025 at 6:30 a.m., CNA 1 called for help, and he (LVN 1) rushed into Resident 1's room and observed Resident 1 lying on the floor face down on the right side of his bed on a floor mat. LVN 1 stated Resident 1's bed was without side rails and was approximately three feet high from the floor. LVN 1 stated when they (LVN 1 and CNA 2) turned Resident 1 over onto his back he had no visible injuries, his eyes were open, but he did not blink, and he was not able speak. LVN 1 stated when he asked CNA 1 what happened she informed him Resident 1 fell when she was changing him by herself. During an interview on 5/23/2025 at 8:05 a.m., CNA 1 stated on 2/2/2025, sometime in the early morning (exact time unknown) she went into Resident 1's room to provide care to him. CNA 1 stated she raised Resident 1's bed to the level of her waist (exact height was unknown) and pulled Resident 1 to the left side of his bed using a draw sheet (a small bed sheet placed crosswise over the middle of the bottom sheet of a mattress to cover the area between the person's upper back and thighs, often used by medical professionals to move patients). CNA 1 stated Resident 1 was facing the window with his back to the front of her body and as she pulled him towards her, he suddenly slipped out of the bed. CNA 1 stated she worked with Resident 1 two to three times in the past and she was never informed that he required two-person assistance, and she did not think she needed help turning him because he was able to assist in turning himself. During an interview on 5/23/2025 at 9:01 a.m., the Director of Staff Development (DSD) stated he found out about Resident 1's fall on 2/2/2025 at 8:15 a.m., during morning huddle (a meeting where nurses discuss resident updates). The DSD stated if Resident 1 was totally dependent for his care needs, for safety purposes and to prevent falls there should have been two people assisting during his care. During an interview on 5/23/2025 at 9:38 a.m., the MDS Nurse stated she completed the activities of daily living ([ADL] activities such as bathing, dressing and toileting a person performs daily) section of the MDS and determined Resident 1 was dependent on staff when rolling from left to right, which meant he was not able to turn himself at all and required two-person assistance for turning and repositioning to prevent him from falling. A review of the facility's P/P titled "Turning and Repositioning" dated 12/3/2024, indicated the protocol for turning and repositioning included use of appropriate number of staff to perform tasks safely. The facility failed to: 1. Ensure CNA 1 did not turn and reposition Resident 1 during incontinent care without the assistance of an additional staff member, per the MDS assessment. 2. Develop a Care Plan related to Resident 1's dependence on the nursing staff for incontinent care, rolling from left to right and a two person physical assist during incontinent care and turning and repositioning. 3. Follow their P/P titled "Turning and Repositioning" dated 12/3/2024, that indicated the protocol for turning and repositioning included use of appropriate number of staff to perform tasks safely. These deficient practices resulted in Resident 1 rolling and falling out of bed when CNA 1 turned the resident during incontinent care without the assistance of an additional staff. Resident 1 was transferred to a GACH on 2/2/2025 where he was diagnosed with multiple injuries to his neck and spine, was intubated, and placed on a ventilator. Resident 1 expired on 2/9/2025 due to a sequelae of blunt traumatic injuries from a ground level fall. The above violations either jointly, separately, or in any combination presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and were a substantial factor in the death of Resident 1.