Health inspection·May 31, 2024

42 CFR §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. 42 CFR § 483.25 Quality 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 resident's choices, including but not limited to the following. 22 CCR § 72313 Nursing Service--Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. 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 4/15/2024, the California Department of Public Health (CDPH) conducted an unannounced visit for an annual recertification survey. The facility failed to: 1. Monitor Resident 91’s range of motion ([ROM] full movement potential of a joint [where two bones meet] ) in both arms and legs quarterly (every three months) in accordance with Resident 91’s care plan between 4/21/2021 and 3/27/2024 (approximately 3 years). 2. Provide Resident 91 with Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) services for ambulation (the act of walking) using a front-wheeled walker ([FWW] an assistive device with two front wheels used for stability when walking) in accordance with the physician orders, dated 5/5/2020, for multiple dates during the months of 3/2022, 4/2022, 5/2022, 7/2022, and 8/2022. 3. Provide Resident 91 with intervention to prevent a decline in ROM of both legs and a decline in the ability to walk prior to changing Resident 91’s RNA program from walking using a FWW to sit to stand transfers (ability to come to a standing position from sitting) on 9/15/2022. 4. Provide Resident 91 with intervention to prevent a decline in ROM of both arms and a decline in the ability to use both hands prior to applying hand rolls (soft fabric and positioned in the palm of the hand to protect from skin irritation) on 9/28/2022. 5. Provide Resident 91 with RNA services in accordance with physician orders for sit to stand transfers, dated 9/15/2022, and application of both hand rolls, dated 9/28/2022, for multiple dates during the months of 12/2022, 2/2023, 3/2023, 9/2023, and 1/2024. 6. Provide Resident 91 with interventions to prevent further ROM loss in both arms and both legs when a decline was identified on Resident 91’s Joint Mobility Assessment ([JMA] brief assessment of a resident's range of motion in both arms and both legs), dated 3/27/2024, in accordance with the facility’s policy. These failures caused Resident 91 to develop moderate joint mobility limitations (50 to 75 percent [%] available ROM; 25-50% ROM loss) in both elbows, both wrists, and the right hand and minimal joint mobility limitations (75-100% available ROM; 0-25% ROM loss) in both hips, both knees, and both ankles, which limited Resident 91’s ability to participate in activities of daily living ([ADLs] tasks related to personal care including bathing, dressing, hygiene, eating, transfers, and walking) and prevented Resident 91 from being able to stand upright. A review of Resident 91’s Resident Status History List (record of hospitalizations and room changes) indicated the facility originally admitted Resident 91 on 11/14/2014, re-admitted Resident 91 on 4/21/2020, and discharged Resident 91 on 1/1/2023. A review of Resident 91’s Face Sheet (admission record) indicated Resident 91, was a 71 year-old female, readmitted to the facility on 1/1/2023 with diagnoses including chronic obstructive pulmonary disease ([COPD] lung disease that causes constriction of the airways making it difficult or uncomfortable to breathe), intracranial injury (brain injury), and epilepsy (abnormal electrical activity in the brain marked by sudden, recurrent episodes of loss of consciousness or uncontrolled body shaking). A review of Resident 91’s physician orders, dated 5/5/2020, included RNA for ambulation with front-wheeled walker ([FWW] an assistive device with two front wheels used for stability when walking) five times per week as tolerated. A review of Resident 91’s JMA, dated 4/21/2021, indicated both of Resident 91’s shoulders, elbows, wrists, hips, knees, and ankles were within functional limits ([WFL] sufficient movement without significant limitation). The JMA indicated Resident 91 had minimal to moderate joint mobility limitations to the left hand and had minimal joint mobility limitations in the right hand. A review of Resident 91’s Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 2/15/2022, indicated Resident 91 had intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 91 had a ROM limitation in one arm and no ROM limitations in both legs. The MDS indicated Resident 91 used a walker and wheelchair for mobility and required extensive assistance (resident involved in activity while staff provide weight-bearing support) for transfers between surfaces, walking in room, walking in the corridor, and eating. A review of Resident 91’s Restorative Record ([RNA Record] record of RNA treatment sessions) for 2/2022 indicated the RNA Record included a weekly summary, dated 2/17/2022, which indicated Resident 91 required moderate assistance (requires 25-50% physical assistance) to maximum assistance (requires 50-75% physical assistance to perform the task) to stand up from the wheelchair and walked 30 to 40 (30-40) steps with rest breaks. A review of Resident 91’s RNA Record for 3/2022 indicated the RNA Record had a slash (/) and did not have RNA initials to indicate a treatment was provided to Resident 91 for ambulation with a FWW on 3/1/2022, 3/4/2022, 3/14/2022, 3/16/2022, 3/25/2022, and 3/28/2022. A review of Resident 91’s RNA Record for 4/2022 indicated the RNA Record had a slash (/) and did not have RNA initials to indicate treatment was provided to Resident 91 for ambulation with a FWW on 4/1/2022, 4/11/2022, 4/19/2022, and 4/25/2022. A review of Resident 91’s RNA Record for 5/2022 indicated the RNA Record had a slash (/) and did not have RNA initials to indicate treatment was provided to Resident 91 for ambulation with a FWW on 5/2/2022, 5/4/2022, 5/5/2022, 5/10/2022, 5/11/2022, 5/12/2022, and 5/30/2022. A review of Resident 91’s RNA Record for 7/2022 indicated the RNA Record had a slash (/) and did not have RNA initials to indicate treatment was provided to Resident 91 for ambulation with a FWW on 7/1/2022, 7/4/2022, 7/5/2022, 7/6/2022, 7/7/2022, 7/8/2022, 7/28/2022, and 7/29/2022. A review of Resident 91’s RNA Record for 8/2022 indicated the RNA Record had a slash (/) and did not have RNA initials to indicate treatment was provided to Resident 91 for ambulation with a FWW on 8/1/2022, 8/11/2022, 8/25/2022, 8/26/2022, and 8/29/2022. A review of Resident 91’s RNA Record for 9/2022 indicated the RNA Record included a weekly summary, dated 9/12/2022, indicating Resident 91 required maximum assistance to stand with two RNAs (unknown) and moderate to maximum assistance to maintain balance while walking with the FWW. The weekly summary also indicated Resident 91 dragged both feet while walking 10-20 short, slow steps with rest breaks. A review of Resident 91’s Nurses Notes, dated 9/15/2022 timed at 9:30 a.m., indicated to discontinue the current RNA program and begin RNA to assist with a sit to stand program, every day, five times per week as tolerated. A review of Resident 91’s physician orders, dated 9/15/2022 (untimed), indicated to discontinue current RNA program and begin RNA to assist with a sit to stand program, every day, five times per week as tolerated. A review of Resident 91’s Nurses Notes, dated 9/28/2022 timed at 12:00 p.m., indicated the Occupational Therapist [[OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities (occupations)] evaluated Resident 91 who had contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) in both hands. The Nurses Notes indicated for RNA to apply hand rolls, every day, five times per week for four to six (4-6) hours or as tolerated. A review of Resident 91’s physician orders, dated 9/28/2022 timed at 12:00 p.m., indicated the RNA will apply both hand rolls, every day for 4-6 hours, five times per week or as tolerated. A review of Resident 91’s RNA Record for 10/2022 included a weekly summary, dated 10/24/2022, indicating the RNA (unspecified) assisted Resident 91 to place her hands on the hallway handrail and required moderate to maximum assistance to perform 5-10 repetitions of sit to stand exercises. The RNA weekly summary also indicated Resident 91 tolerated both hand rolls for 4-6 hours with checks every 2 hours as Resident 91 removed the hand rolls. A review of Resident 91’s care plan for RNA, dated 11/15/2022, indicated Resident 91 required a RNA program to maintain and/or improve joint mobility. The goal for Resident 91 was to maintain maximum joint capacity (greatest possible amount) for the next three months. The care plan’s approach (treatment) plan included to provide RNA program as ordered, position the resident to prevent further contractures with pillow or splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) as needed, and quarterly assessments of joint mobility or as needed. A review of Resident 91’s RNA Record for 12/2022 indicated a slash (/) but did not have RNA’s initials to indicate treatment was provided for sit to stand exercises and application of both hand rolls on 12/1/2022, 12/2/2022, 12/5/2022, 12/26/2022, 12/28/2022, and 12/30/2022. A review of Resident 91’s RNA Record for 2/2023 indicated a slash but did not have a RNA initials to indicate treatment was provided for sit to stand exercises and application of both hand rolls on 2/1/2023, 2/2/2023, 2/6/2023, 2/8/2023, 2/9/2023, 2/17/2023, 2/20/2023, 2/21/2023, 2/22/2023, 2/23/2023, 2/27/2023, and 2/28/2023. A review of Resident 91’s RNA Record for 3/2023 indicated a slash but did not have a RNA’s initials to indicate treatment was provided for sit to stand exercises and application of both hand rolls on 3/1/2023, 3/9/2023, 3/16/2023, 3/17/2023, 3/20/2023, 3/21/2023, 3/22/2023, 3/23/2023, and 3/28/2023. A review of Resident 91’s RNA Record for 4/2023 indicated a weekly summary, dated 4/24/2023, indicating Resident 91 required moderate to maximum assistance from two RNAs (unspecified) to perform 4-6 repetitions of sit to stand exercises, take breaks during exercises due to tiring easily, and required RNA encouragement to maintain an upright posture. The weekly summary also indicated Resident 91 tolerated both hand rolls for 4-6 hours with checks every 2 hours. A review of Resident 91’s RNA Record for 9/2023 indicated a slash but did not have a RNA’s initials to indicate treatment was provided for sit to stand exercises and application of hand rolls on 9/14/2023, 9/18/2023, 9/19/2023, 9/20/2023, 9/21/2023, 9/22/2023, and 9/27/2023. A review of Resident 91’s RNA Record for 1/2024 indicated a slash but did not have a RNA’s initials to indicate treatment was provided for sit to stand exercises and application of both hand rolls on 1/1/2024, 1/2/2024, 1/4/2024, 1/11/2024, 1/22/2024, 1/24/2024, 1/25/2024, 1/29/2024, and 1/31/2024. A review of Resident 91’s MDS, dated 1/11/2024 indicated Resident 91 had clear speech, expressed ideas, and wants, had clear understanding of verbal content, and had moderately impaired cognition. The MDS indicated Resident 91 used a wheelchair for mobility, required substantial/maximal assistance (helper does more than half the effort) for sit to stand and chair/bed-to-chair transfers (ability to transfer to and from a bed to a chair or wheelchair), and walking 10 feet was not attempted due to medical condition or safety concerns. A review of Resident 91’s Joint Mobility Assessment ([JMA] brief assessment of a resident's range of motion in both arms and both legs), dated 3/27/2024, indicated Resident 91 had moderate joint mobility limitations in both elbows, both wrists, both hands and minimal joint mobility limitations in both hips, both knees, and both ankles. The JMA indicated Resident 91 maintained assessed mobility and to continue the RNA program. A review of Resident 91’s RNA Record for 4/2024 indicated a weekly summary, dated 4/15/2024, indicating Resident 91 required maximum assistance from two RNAs (unspecified) to perform 2-3 repetitions of sit to stand exercises with both knees bent and required encouragement to straighten posture. The weekly summary also indicated Resident 91 tolerated both hand rolls for 4-6 hours. During an interview on 4/15/2024 at 11:36 a.m., with the Director of Rehabilitation (DOR), the DOR stated the OT or Physical Therapist (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) performed the JMA for each resident (in general) upon admission, annually (every year), and during a change of condition to monitor for ROM and mobility. The DOR also stated the JMA form also included a quarterly screening (on the back of the JMA form) of each resident for ROM and mobility. During a concurrent observation and interview on 4/16/2024 at 8:31 a.m., with Restorative Nursing Aide 2 (RNA 2) and RNA 3, in Resident 91’s room, Resident 91’s hands were in a closed fist position and Resident 91 was unable to open either hand. RNA 2 and RNA 3 applied hand rolls into Resident 91’s palms. Resident 91 stated, “This is the first time I remember these” hand rolls. Resident 91 stated the RNAs usually applied terry cloth rags in his hands. RNA 2 and RNA 3 stated towel rolls were applied to Resident 91’s hands when the hand rolls were washed. During observation on 4/16/2024 at 8:40 a.m., RNA 2 and RNA 3 wheeled Resident 91 into the hallway facing the hallway handrails. RNA 2 placed a cloth gait belt (assistive device placed around a person’s waist to assist with safe transferring between surfaces or while walking) around Resident 91’s waist and removed both hand rolls. RNA 2 was positioned on Resident 91’s left side, and RNA 3 was positioned on Resident 91’s right side. Each RNA placed Resident 91’s hand onto the handrail and assisted the resident to stand from the wheelchair. Both of Resident 91’s knees remained bent. Both of Resident 91’s ankles were bent downward, causing Resident 91 to stand on the toes of both feet. Resident 91 performed two repetitions of sit to stand exercises. RNA 2 removed the cloth gait belt, and RNA 3 wheeled Resident 91 back to the room. During an interview on 4/16/2024 at 9:22 a.m., with RNA 2 and RNA 3, RNA 2 and RNA 3 stated Resident 91 used to walk years ago (unknown length of time). RNA 2 and RNA 3 stated Resident 91 required two people to perform sit to stand transfers because Resident 91 cannot stand without assistance and cannot stand all the way upright. During an interview on 4/16/2024 at 9:50 a.m., with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated Resident 91 required assistance with fee