Health inspection·March 26, 2025

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 §483.65 Specialized rehabilitative services. §483.65(a) Provision of services. If specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity as set forth at §483.120(c), are required in the resident’s comprehensive plan of care, the facility must— §483.65(a)(1) Provide the required services; or §483.65(a)(2) In accordance with §483.70(f), obtain the required services from an outside resource that is a provider of specialized rehabilitative services and is not excluded from participating in any federal or state health care programs pursuant to section 1128 and 1156 of the Act. 42 CFR §483.20(c) Quarterly Review Assessment A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months. 42 CFR §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident’s status. 22 CCR § 72311. Nursing Service--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: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (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 § 72315. Nursing Service--Patient Care. (e) Each patient shall be encouraged and/or assisted to achieve and maintain the highest level of self-care and independence. Every effort shall be made to keep patients active, and out of bed for reasonable periods of time, except when contraindicated by orders of a licensed health care practitioner acting within the scope of his or her professional licensure. (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (3) Maintaining proper body alignment and joint movement to prevent contractures and deformities. 22 CCR § 72403. Physical Therapy Service Unit--Services. (a) “Physical therapy service” means those services ordered by a physician for a patient or upon a physician's referral and provided to a patient by or under the supervision of a physical therapist. (b) Physical therapy services shall include but are not limited to: (1) Assisting the physician in an evaluation of the patient's rehabilitation potential. (2) Applying muscle, nerve, joint and functional ability tests. (3) Treating patients to relieve pain and to develop or restore function. (4) Assisting patients to achieve and maintain maximum performance using physical means such as exercise, massage, heat, sound, water, light or electricity. (5) Establishing and modifying a treatment program by the physical therapist, as needed, based upon initial and continuing assessment of the patient. 22 CCR § 72413. Occupational Therapy Service Unit--Services. a) “Occupational therapy service” means those services ordered by the licensed healthcare practitioner acting within the scope of his or professional licensure in which selected purposeful activity is used as treatment in the rehabilitation of persons with a physical or mental disability. (b) Occupational therapy services shall include but not be limited to: (1) Assisting the licensed healthcare practitioner acting within the scope of his or her professional licensure in an evaluation of a patient's level of function by applying diagnostic and prognostic tests. (2) Conducting and preparing written initial and continuing assessment of the patient's condition and modifying treatment goals under the order of a licensed healthcare practitioner acting within the scope of his or her professional licensure, consistent with identified needs of the patient. (3) Decreasing or eliminating disability during patient's initial phase of recovery following injury or illness. (5) Enhancing a patient's physical, emotional and social well-being. (6) Developing function to a maximum level. (c) An occupational therapy service unit shall meet the following requirements: (3) Initial and continuing assessment, development of a treatment plan and discharge summary shall be written and entered in each patient's health record. 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 2/4/2025, during an annual recertification survey, the California Department of Public Health (CDPH) determined the facility failed to provide services to prevent Resident 76’s decline in range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move). The faciity failed to: 1. Provide Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities) services upon identification of Resident 76’s ROM impairments (unspecified) in both arms as indicated in Resident 76’s OT Evaluation dated 8/7/2024. 2. Provide Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) services upon identification a decline in Resident 76’s ROM in both ankles and as indicated in PT’s Evaluation, dated 8/7/2024. 3. Provide PT services upon r identification of further Resident 76’s ROM decline in the right knee and both ankles as indicated Resident 76’s PT Evaluation, dated 9/9/2024. 4. Perform an accurate quarterly Joint Mobility Screening ([JMS] brief assessment of a resident's range of motion in both arms and both legs) of Resident 76’s ROM in both arms and legs on 10/31/2024, and 1/27/2025. 5. Implement the facility’s policy and procedure (P&P) titled, “Resident Mobility and Range of Motion,” revised 7/2017, which indicated “residents would not experience an avoidable reduction in ROM.” As a result, Resident 76 developed limited ROM in the left hand, right knee, and plantarflexion (ankle bent with toes pointing away from the body) contractures in both ankles, which increased Resident 76’s risk for developing pressure injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony area), bone fractures (break in bone), and pain. A review of Resident 76’s General Acute Care Hospital (GACH) Documents Review Report indicated Resident 76, a 36-year-old-female, was admitted to the GACH on 3/27/2024 where she underwent surgical removal of the meningioma on 4/2/2024, partial removal of the skull on 4/3/2024, and had a tracheostomy tube (hole made through the front of the neck and into the windpipe [trachea] to enable the resident to breath) placement on 4/13/2024. On 4/25/2024, Resident 76’s was discharge to the facility’s sub-acute (level of care that does not require hospitalization but requires more intensive skilled nursing care including medical equipment, supplies, and treatments such as ventilators [medical device to help support or replace breathing) unit. A review of the GACH Discharge Medication Orders dated 4/25/2024 indicated Resident 76 had both ankle foot orthosis ([AFO] brace to position the foot and ankle) boots. A review of Resident 76’s Admission Record, indicated the the resident was admitted to the facility on 4/25/2024 with diagnoses including severe hypoxic ischemic encephalopathy (brain injury that occurs when the brain does not receive enough oxygen [hypoxia] and blood flow [ischemia]), cerebral infarction (brain damage due to loss of oxygen to the area) of the right posterior cerebral artery ([PCA] blood vessel that supplies blood and oxygen to a portion of the brain), cerebral edema (swelling of brain tissue due to excessive fluid), and attention to the G-tube. A review of Resident 76’s History and Physical (H&P), dated 4/26/2024, indicated Resident 76’s diagnoses included a surgical removal of the meningioma and cerebral infarct with left sided weakness. The H&P indicated Resident 76 did not have the capacity to understand and make decisions. A review of Resident 76’s JMS, dated 4/26/2024, indicated Resident 76 had full/functional ROM in all joints of both arms and legs, including both shoulders, elbows, wrists, hands, hips, knees, and ankles. Resident 76’s JMS indicated skilled rehabilitation services were not indicated (reason not indicated) and Resident 76 would benefit from the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) program. A review of Resident 76’s physician’s orders, dated 4/26/2024, indicated for the RNA to assist Resident 76 with passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) exercises to both arms and legs, five times per week for three months or as tolerated. A review of Resident 76’s Rehab Progress Notes, dated 5/8/2024 written by the Director of Rehabilitation (DOR), indicated Resident 76’s family requested both AFOs for Resident 76 (date of family’s request not documented). The Rehab Progress Notes indicated the DOR assessed Resident 76’s ROM and muscle tone to determine if Resident 76 could benefit from the AFOs. The Rehab Progress Notes indicated Resident 76 had normal tone and did not have any signs of foot drop (difficulty lifting the front part of the foot). The Rehab Progress Notes indicated the DOR did not recommend both AFOs since Resident 76’s ankle ROM was within normal limits ([WNL] normal joint movement) and application of both AFOs might affect Resident 76’s skin integrity. A review of Resident 76’s Situation, Background, Assessment, and Recommendation ([SBAR] communication tool used by healthcare workers when a resident has a change of condition) and Initial Change of Condition (COC) Alert Charting and Skilled Documentation, dated 5/20/2024, indicated Resident 76’s family was at bedside with concerns of redness and discoloration above the resident’s right eye. The SBAR indicated Resident 76’s physician was contacted, and the physician recommended Resident 76 be transferred to the GACH for further evaluation. A review of Resident 76’s Nurses Notes, dated 5/20/2024, indicated Resident 76 was transferred to the GACH in stable condition A review of Resident 76’s Census (record of hospitalizations, room changes, and payor source changes), indicated the facility re-admitted Resident 76 on 5/25/2024. A review of Resident 76’s JMS, dated 5/29/2024, indicated Resident 76 had full/functional ROM in all joints in both arms and legs, including both shoulders, elbows, wrists, hands, hips, knees, and ankles. The JMS indicated Resident 76’s skilled rehabilitation services were not indicated (reason not indicated) and Resident 76 would benefit from the RNA program. A review of Resident 76’s physician’s orders, dated 5/29/2024, indicated for the RNA to assist Resident 76 with PROM exercises to both arms and legs, five times per week for three months or as tolerated. A review of Resident 76’s Documentation Survey Report (report of nursing assistant tasks) for RNA, dated 5/2024, 6/2024, and 7/2024, indicated Resident 76 received RNA for PROM exercises to both arm and legs, five times per week. A review of Resident 76’s Personal Inventory Update, dated 7/10/2024, included three foam baseballs. A review of Resident 76’s Documentation Survey Report (report of nursing assistant tasks) for RNA, dated 8/2024, indicated Resident 76 received RNA for PROM exercises to both arm and legs, five times per week. A review of Resident 76’s JMS, dated 8/2/2024, indicated Resident 76 had full/functional ROM in all joints in both arms and legs, including both shoulders, elbows, wrists, hands, hips, knees, and ankles. The JMS indicated Resident 76 had an RNA ROM program. A review of Resident 76’s OT Evaluation and Plan of Treatment, dated 8/7/2024 (five days after the JMS on 8/2/2024) written by Occupational Therapist 1 (OT 1), indicated Resident 76 had an independent level of function prior to admission to the facility. The OT Evaluation indicated Resident 76 had impaired ROM (unspecified) in both shoulders, elbows/forearms, wrists, and hands. The OT Evaluation indicated Resident 76 had rigidity (muscle stiffness), hypertonicity (muscle with abnormally increased muscle tone, resulting in stiffness and difficulty moving), and swelling in both arms. The OT Evaluation indicated Resident 76’s skin was intact without any observable issues. The OT Evaluation indicated Resident 76 could benefit from continued skilled services for neuromuscular retraining (technique used to restore movement patterns through repetitive motion to retrain the brain), cognitive (relating to the ability to think, understand, learn, and remember) and visual retraining, and contracture prevention management. The OT Evaluation indicated Resident 76 was at risk for further decline in function, immobility, and muscle atrophy (loss of muscle mass) without skilled therapy intervention. A review of Resident 76’s PT Evaluation and Plan of Treatment, dated 8/7/2024 (five days after the JMS on 8/2/2024) written by Physical Therapist 2 (PT 2), indicated Resident 76’s prior level of function was independent with all functional mobility and the resident walked without an assistive device. The PT Evaluation indicated Resident 76 was referred to PT for assessment of mobility and function. The PT Evaluation indicated Resident 76’s ROM in both hips and knees were within functional limits. The PT Evaluation indicated both of Resident 76’s ankles had impaired ROM with the right ankle measuring negative 20 degrees (-20 degrees) of dorsiflexion (bending the ankle toward the body, normal 0 to 20 degrees) and the left ankle measuring negative -15 degrees of dorsiflexion. The PT Evaluation indicated Resident 76 was alert, non-verbal, had left-sided neglect (condition after a brain injury where a person is not aware of the indicated side of the body), had left-sided hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and left leg hypertonicity. The PT Evaluation indicated Resident 76 had been bed bound since 3/2024, had limitations in both ankles into dorsiflexion, and both ankles exhibited foot drop while lying in bed. The PT Evaluation indicated Resident 76 would benefit from continued skilled PT services to address limitations in ankle dorsiflexion, improve muscle strength, and provide education on positioning and bed mobility. The PT Evaluation indicated Resident 76 was at risk for immobility, further decline in function, pressure injuries, decreased skin integrity, muscle atrophy, and increased muscle tone without skilled therapy intervention. A review of Resident 76’s Census, indicated Resident 76 moved from the facility’s sub-acute area (Nursing Station 2) to skilled-nursing (lower level of care) Nursing Station 1 on 8/17/2024. A review of Resident 76’s PT Evaluation an