Health inspection·October 2, 2024

42 CFR §483.25(c) Mobility (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 (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. (3) A resident with limited mobility receives appropriate services, equipment, and to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. 22 CCR §22 72315 Nursing Services - 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. 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 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: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: . . . (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies, or services as prescribed under conditions which present a risk to the health, safety, or security of the patient. On 8/23/2024, the California Department of Public Health (CDPH) conducted a standard annual Recertification Survey of the facility. The facility failed to: 1. Provide appropriate monitoring of Resident 60's ROM on a quarterly basis to determine any changes in ROM in accordance with the facility's policy titled "Joint Mobility Assessment, ([JMS] a brief assessment of a resident's ROM in both arms and both legs)" which indicated, "all residents shall be assessed for joint mobility limitations upon admission and reviewed every three months thereafter." 2. Ensure Restorative Nursing Assistant ([RNA 1] certified nursing aide program that helps residents to maintain their function and joint mobility) reported Resident 60's decline in ROM during restorative program ( nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible ) sessions to the charge nurse (a licensed nurses in charge) in accordance with the facility's job description titled, "Restorative Nursing Assistant." 3. Provide Resident 60 with passive range of motion ([PROM] a movement of a joint through the ROM with no effort from resident) exercises to both arms daily from March 2023 to October 2023 per physician's order and in accordance with the Occupational Therapy ([OT], profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) discharge recommendation made on 3/3/2023. 4. Ensure RNA 1 did not modify Resident 60's splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) to both hands without notifying OT. As a result, Resident 60 developed contractures to both hands and both wrists, causing pain and placing Resident 60 at risk for physical, emotional, and psychosocial decline. Resident 60 was placed at risk to have a decline in ROM, improper fitting splints, ineffective interventions to maintain ROM, pain, and skin breakdown. A review of Resident 60's Admission Record, indicated Resident 60 a 57 year old female was initially admitted to the facility on 1/4/2023 and readmitted to the facility on 7/24/2024 with diagnoses including chronic respiratory failure (any condition that affects breathing function and result in lungs not functioning properly) and traumatic brain injury (damage to the brain from an external force that can cause temporary or permanent changes in brain function). A review of Resident 60's OT's Joint Mobility Screening ([OT JMS, a brief joint mobility assessment of a resident's ROM in both arms and both legs completed by an OT), dated 1/5/2023, indicated Resident 60 had full PROM in both wrists, hands, fingers, and elbows and had moderate (26-50 percent [%] ROM loss) ROM limitations in both shoulders. A review of Resident 60's OT's Evaluation and Plan of Treatment (OT Eval), dated 1/8/2023, indicated Resident 60's ROM in both elbows, forearms, wrists, and hands were within functional limits ([WFL]a sufficient movement without limitation). The OT Eval indicated Resident 60 had no contractures in both arms and was at risk for contracture development. A review of OT's Discharge Summary dated 3/3/2023, indicated the OT recommended for Resident 60 to have RNA to provide PROM exercises to both arms and apply splints to both elbows, four to six hours daily or as tolerated. A review of Resident 60's Order Summary Report, indicated a physician's order, dated 3/3/2023, for RNA to provide PROM exercises to Resident 60's both arms and both legs and apply splints to both elbows, four to six hours daily or as tolerated. A review of Resident 60's RNA Survey Report (record of nursing assistant tasks) for March 2023, indicated for the RNA to provide the resident with PROM exercises to both arms and both legs and apply splints to both elbows for four to six hours, daily or as tolerated. The squares on the RNA Survey Report had the letter "X" (X stands for resident was not seen for RNA treatment that day) on the following days: 3/4/2023, 3/5/2023, 3/11/2023, 3/12/2023, 3/18/2023, 3/19/2023, 3/25/2023, and 3/26/2023. A review of Resident 60's RNA Survey Report for April 2023, indicated for the RNA to provide the resident with PROM exercises to both arms and both legs and apply splints to both elbows for four to six hours, daily or as tolerated. The squares on the RNA Survey Report had the letter "X" on the following days: 4/1/2023, 4/2/2023, 4/8/2023, 4/9/2023, 4/15/2023, 4/16/2023, 4/22/2023, 4/23/2023, 4/29/2023, and 4/30/2023. A review of Resident 60's RNA Survey Report for May 2023, indicated for the RNA to provide the resident with PROM exercises to both arms and both legs and apply splints to both elbows for four to six hours, daily or as tolerated. The squares on the RNA Survey Report had the letter "X" on the following days: 5/6/2023, 5/7/2023, 5/13/2023, 5/14/2023, 5/20/2023, 5/21/2023, 5/27/2023, 5/28/2023. A review of Resident 60's RNA Survey Report for June 2023, indicated for the RNA to provide the resident with PROM exercises to both arms and both legs and apply splints to both elbows for four to six hours, daily or as tolerated. The squares on the RNA Survey Report had the letter "X" on the following days: 6/3/2023, 6/4/2023, 6/10/2023, 6/11/2023, 6/17/2023, 6/18/2023, 6/24/2023, and 6/25/2023. A review of Resident 60's RNA Documentation Survey Report for July 2023, indicated for the RNA to provide the resident with PROM exercises to both arms and both legs and apply splints to both elbows for four to six hours, daily or as tolerated. The squares on the RNA Survey Report had the letter "X" on the following days: 7/1/2023, 7/2/2023, 7/8/2023, 7/9/2023, 7/15/2023, 7/16/2023, 7/22/2023, 7/23/2023, 7/29/2023, and 7/30/2023. A review of Resident 60's RNA Survey Report for August 2023, indicated for the RNA to provide the resident with PROM exercises to both arms and both legs and apply splints to both elbows for four to six hours, daily or as tolerated. The squares on the RNA Survey Report had the letter "X" on the following days: 8/5/2023, 8/6/2023, 8/12/2023, 8/13/2023, 8/19/2023, 8/20/2023, 8/26/2023, and 8/27/2023. A review of Resident 60's RNA Survey Report for September 2023, indicated for the RNA to provide the resident with PROM exercises to both arms and both legs and apply splints to both elbows for four to six hours, daily or as tolerated. The squares on the RNA Survey Report had the letter "X" on the following days: 9/2/2023, 9/3/2023, 9/9/2023, 9/10/2023, 9/16/2023, 9/17/2023, 9/23/2023, 9/24/2023, and 9/30/2023. A review of Resident 60's RNA Survey Report for October 2023, indicated for the RNA to provide the resident with PROM exercises to both arms and both legs and apply splints to both elbows for four to six hours, daily or as tolerated. The square on the RNA Survey Report was blank on 10/2/2023. The squares on the RNA Survey Report had the letter "X" on the following days: 10/1/2023, 10/7/2023, 10/8/2023, 10/14/2023, 10/15/2023, 10/21/2023, 10/22/2023, 10/28/2023, and 10/29/2023. A review of Resident 60's Minimum Data Set ([MDS], a standardized assessment and care-screening tool), dated 7/11/2024, indicated Resident 60 had moderately impaired cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 60 was dependent (full staff performance) on staff with eating, oral hygiene, toilet hygiene, bathing, dressing, rolling to both sides, and transfers (moving from one surface to another). The MDS indicated Resident 60 had functional ROM limitations (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and both legs. A review of Resident 60's Annual OT JMS, dated 1/28/2024, indicated Resident 60 had severe (greater than 50 % ROM loss) ROM limitations in both wrists, both hands, both fingers, and both shoulders. The OT JMS indicated Resident 60 had minimal (less than 25% ROM loss) ROM limitations in both elbows. The OT JMS indicated Resident 60 had a minimal to severe loss of PROM to both arms and recommended a skilled OT evaluation. A review of Resident 60's OT Eval, dated 1/30/2024, indicated Resident 60 was referred to OT services due to a decline in ROM and strength of both arms. The OT Eval indicated Resident 60 had contractures in both arms which affected Resident 60's functional skills (basic or everyday skills necessary for daily living) and required skilled therapy (services that require specialized training and experience of a licensed therapist or therapy assistant) to address the contractures. The OT Eval indicated Resident 60's ROM in the right arm was impaired at the shoulder, elbow, forearm, wrist, and hand. The OT Eval indicated Resident 60 had a right "claw hand" contracture (condition of the hand where the fingers of the hand are in a hyperextended position [the extension of a body part beyond it's normal limits] at the knuckle joints and bent at the fingertips) and had zero degrees of PROM (normal is 70 to 90 degrees ROM) at the right wrist in an upward position. The OT Eval indicated Resident 60's ROM in the left arm was impaired at the shoulder, wrist, and hand. The OT Eval indicated Resident 60 was unable to straighten the fingers of the left hand and indicated a two-inch gap between the fingertips of the left hand and crease in the palm of the hand. The OT Eval indicated Resident 60 had zero degrees of PROM at the left wrist into an upward position. The OT Eval indicated OT recommended Resident 60 wear splints to both hands. During a concurrent observation and interview on 8/20/2024 at 10:43 a.m., in Resident 60's room, Resident 60 was in bed. Resident 60's right arm was held out in front of her body at shoulder level with the elbow bent, wrist fully bent in a downward position, and fingers of the hand in a hyperextended (the extension of a body part beyond it's normal limits) position at the knuckles with the fingertips bent. Resident 60's left arm moved upwards to shoulder height, the elbow was slightly bent, and the hand was partially closed with the fingers bent at the knuckles and the fingertips. Resident 60 was observed shouting and asking for staff to assist in wrapping her right arm in a towel. Resident 60 stated she wanted her right arm wrapped in a towel because her arm was in pain, liked the warmth the towel provided to help with the pain, and needed the towel wrapped around the right forearm so she could use it to wipe her mouth since her both hands does not work. Licensed Vocational Nurse (LVN 5) was observed entering the room and wrapping Resident 60's right arm with a towel. LVN 5 stated Resident 60 constantly asked for her right arm to be wrapped in a towel and was unsure why. LVN 5 stated she thought Resident 60 liked her arm wrapped because the right arm was painful, and it helped her wipe her mouth since she could not bring her forearm to her mouth. LVN 5 stated Resident 60 was unable to use both hands for activities of daily living (ADLs, basic activities such as eating, bathing, and dressing) because they were contracted and required total care for mobility and ADLs. During an interview on 8/20/2024 at 12:59 p.m., RNA 1 stated the Director of Nursing (DON), all available RNAs, and the Director of Rehabilitation (DOR) met monthly to discuss any concerns with residents receiving RNA services, including if any resident experienced a decline in ROM or mobility. RNA 1 stated any concerns or declines observed during RNA sessions should be immediately reported to charge nurse and the Rehabilitation Department (Rehab) for re-assessment. During an interview on 8/20/2024 at 1:49 p.m., the DOR , who was an OT, stated the facility monitored residents for changes and declines in ROM by JMS conducted upon admission and quarterly by the rehab department and quarterly by the MDS nurses along with report from staff of any observed changes or declines. The DOR stated the DOR, RNAs, Director of Staff Development (DSD), and the DON met monthly to discuss any concerns (in general) with residents receiving RNA services, including any declines, changes, or problems requiring re-assessment or intervention. During an observation of RNA session with Resident 60 in Resident 60's room on 8/21/2024 at 10:53 a.m., the resident was in bed with her right arm wrapped in a towel covering the hand, wrist, forearm, elbow, and lower half of the upper arm. Resident 60's right arm was held out in front of her body with the right elbow bent and the wrist bent downwards. Resident 60's left arm was resting at the side of her body with the elbow slightly bent, the wrist straight, and the fingers of the hand bent into a fist position. RNA 1 was observed attempted to assist Resident 60 with PROM exercises to the right arm, but Resident 60 reported increased pain and refused exercises. RNA 1 moved to the left side of the bed and provided PROM exercises to Resident 60's left shoulder, elbow, wrist, and hand. RNA 1 was unable to straighten all of Resident 60's fingers on the left hand and moved the left wrist in small motions side to side. Resident 60 stated she had pain with PROM exercises to the left wrist and hand with exercises. RNA 1 was observed attempted to place a hand splint (splint secured from the hand to the forearm to position the hand and wrist in a functional position) onto Resident 60's left arm but Resident 60 refused and stated the splint hurt. RNA 1 observed to bend the left-hand splint at the wrist and removed a cylindrical portion of the splint that supported the fingers of the hand. Resident 60 agreed to w