Health inspection·April 4, 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 2/20/2024, the California Department of Public Health (CDPH) conducted an unannounced visit for an annual recertification survey. The facility failed to: 1. Perform a Joint Mobility Assessment ([JMA] a brief assessment of a resident's range of motion in both arms and both legs) on both of Resident 86's arms and legs upon admission to the facility on 10/27/2022 and quarterly in accordance with the facility's policies titled, "Functional Impairment - Clinical Protocol" and "Resident Mobility and Range of Motion." 2. Provide Resident 86 with passive range of motion ([PROM] movement of joint through the ROM with no effort from the person) exercises to the left arm and the left leg from 10/27/2022 (admission) to 6/12/2023 (approximately 8 months) in accordance with the hospice physician’s recommendations, dated 10/27/2022. These failures resulted in Resident 86 developing left a shoulder moderate joint mobility limitation (50 to 75 % ROM limitation), left wrist moderate joint mobility limitation, left hand minimal joint mobility limitation (25 to 50% ROM limitation), left hip minimal joint mobility limitation, left knee moderate joint mobility limitation, and left ankle minimal joint mobility limitation as indicated in the Resident 86's JMA, dated 6/12/2023. These failures also resulted in the development of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) on Resident 86's left hip, left knee, and left wrist, causing Resident 86 to have increased pain in the left arm. A review of Resident 86's Admission Record indicated Resident 86 was a 56 year-old female admitted to the facility on 10/27/2022 with diagnoses including traumatic hemorrhage of the cerebrum (bleeding in the brain caused by a severe injury or trauma to the head) and alcohol abuse with alcohol-induced psychotic disorder (a serious condition where drinking alcohol causes someone to experience mental health problems). A review of Resident 86's History and Physical (H&P), dated 10/27/2022, indicated to initiate Resident 86's hospice care plan and monitor for any signs or symptoms of decline. The H&P indicated Resident 86 did not have the capacity to understand and make decisions. A review of Resident 86's physician orders, dated 10/27/2022, at 7:00 PM, indicated to admit Resident 86 under hospice care with the primary diagnosis of intracranial hemorrhage (severe bleeding inside the brain). A review of Resident 86's Physician's Certification for Hospice Benefit (physician confirmation a resident is terminally ill with a life expectancy of six months or less), dated 10/27/2022, included a Prognosis Summary which indicated Resident 86 was weak to four extremities with left arm paralysis and left leg contracture (unspecified joints). Resident 86's Prognosis Summary indicated a recommendation for PROM exercises as tolerated to prevent further contractures. A review of Resident 86's Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 11/7/2022, indicated Resident 86 had functional limitations in ROM to one arm and one leg. A review of Resident 86's MDS quarterly assessments, dated 2/6/2023 and 5/4/2023, indicated Resident 86 had functional limitations in ROM to one arm and one leg. A review of Resident 86's JMA, dated 6/12/2023, indicated Resident 86 had left a shoulder moderate joint mobility limitation, left wrist moderate joint mobility limitation, left hand minimal joint mobility limitation, left hip minimal joint mobility limitation, left knee moderate joint mobility limitation, and left ankle minimal joint mobility limitation. A review of Resident 86's quarterly Rehabilitation Screening (brief assessment to determine whether a person would benefit from therapy services), dated 6/12/2023, indicated recommendations for a Restorative Nursing Aide ([RNA] a certified nursing aide program that helps residents to maintain their function and joint mobility) program to maintain Resident 86's joint mobility. The Rehabilitation Screening recommendation indicated splints were not indicated due to Resident 86's pain and discomfort. A review of Resident 86's Restorative Nursing Program (RNP) Referral/Care Plan, dated, 6/12/2023, indicated Resident 86 was at risk for decline in ROM to the left arm and left leg. The RNP goal indicated to maintain Resident 86's current ROM to the left arm and left leg. The RNP approach (intervention) included RNA to perform PROM exercises to Resident 86's left arm and left leg, three times per week as tolerated. A review of Resident 86's physician orders, dated 6/12/2023 timed at 4:10 PM, indicated for the RNA to provide PROM exercises on Resident 86's left arm and left leg, three times per week as tolerated. A review of Resident 86's Documentation Survey Report (record of nursing assistant tasks) for RNA services, dated 6/2023, indicated Resident 86 received PROM exercises to the left arm and the left leg, three times per week, starting on 6/14/2023. A review of Resident 86's physician orders, dated 8/23/2023 at 3:26 PM, indicated to discharge Resident 86 from hospice services. Resident 86 remained in the facility as a long-term care patient. A review of Resident 86's physician orders, dated 8/23/2023 (untimed), indicated for RNA to provide PROM exercises on Resident 86's left arm and left leg, three times per week as tolerated. A review of Resident 86's H&P, dated 8/24/2023, indicated Resident 86 was admitted under hospice care but doing better. The H&P indicated Resident 86's diagnoses included intracranial bleeding, history of alcohol abuse, and weakness with Physical Therapy (PT) and Occupational Therapy (OT). The H&P indicated Resident 86 had capacity to understand and make decisions. A review of Resident 86's MDS, dated 8/31/2023, indicated Resident 86 had functional limitations in ROM to one arm and one leg. A review of Resident 86's MDS, dated 11/30/2023, indicated Resident 86 had clear speech, expressed ideas, and wants, clearly understood others, and had intact cognition. The MDS indicated Resident 86 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying assistance as resident completes the activity) for eating, partial/moderate assistance (helper does less than half the effort) for upper body dressing, and dependent (helper does all the effort) for oral hygiene, toileting hygiene, and lower body dressing. The MDS indicated Resident 86 had functional limitations in ROM to one arm and one leg. During an interview on 2/20/2024 at 9:37 AM in the bedroom, Resident 86 stated she was unable to move her left arm and left leg. During a follow-up observation and interview on 2/20/2024, at 10:03 AM in the bedroom, Resident 86 was lying in bed with the head-of-bed (HOB) elevated. Resident 86's left elbow was slightly bent, the left forearm was turned with the palm facing upward, and the left wrist was bent to 90 degrees. Resident 86's left hip was rotated away from the body and the left knee was bent. Resident 86 stated the facility staff (unspecified) provided Resident 86 with exercises, but Resident 86 stated she felt pain during the exercises. During an interview on 2/20/2024 at 12:06 PM with the Rehabilitation Coordinator (RC), the RC stated the PT and OT perform screens on the residents (in general) for mobility and ROM upon admission and quarterly. During a concurrent observation and interview on 2/21/2024 at 10:21 AM with Restorative Nursing Aide 1 (RNA 1) in the bedroom, Resident 86 was awake and alert while lying in bed fully dressed, wearing a shirt and pants. Resident 86 stated, "I can only handle so much (of the exercises)." RNA 1 performed PROM exercises to Resident 86's left shoulder, elbow, wrist, and hand. Resident 86 complained of pain during PROM of the left elbow. RNA 1 lifted the left wrist from a bent position but did not bend the left wrist upward (wrist extension). RNA 1 bent the large knuckles of Resident 86's left-hand fingers but did not bend the fingertip joints. Resident 86's left knee was bent, and the left hip was bent upward and rotated away from Resident 86's body at rest. RNA 1 provided PROM exercises to the left hip, left knee, and left ankle. RNA 1 placed one pillow under Resident 86's left arm and another pillow under Resident 86's left knee to turn the left hip toward the body at the end of the RNA session. During an interview on 2/21/2024 at 10:32 AM with RNA 1, RNA 1 stated she provided PROM to the left arm and left leg to Resident 86's pain tolerance. RNA 1 stated she did not bend Resident 86's left-hand fingertip joints into a fist because Resident 86 cannot tolerate PROM at the fingertips due to pain. RNA 1 stated Resident 86's left knee was bent and unable to fully straighten. During a concurrent interview and record review on 2/21/2024 at 3:04 PM with the RC, the RC reviewed the therapy documentation system and stated Resident 86 never received therapy services, including PT and OT from 10/27/2022 (admission) to 6/12/2023 (approximately 8 months). During a review of Resident 86's JMA, dated 2/21/24, completed by Physical Therapist 1 (PT 1), the JMA indicated Resident 86 had left hip minimal joint mobility limitation, left knee moderate joint mobility limitation, and left ankle minimal joint mobility limitation. During an interview on 2/22/2024, at 8:53 AM in the bedroom, Resident 86 stated the facility admitted Resident 86 approximately two years ago after she hit her head on a wooden bus stop while drunk. Resident 86 stated both the left arm and left leg were straight upon admission to the facility. Resident 86 stated the facility provided exercises, but she sometimes refused the exercises because Resident 86 cannot take the pain. During a concurrent interview and record review on 2/22/2024, at 9:38 AM with the RC, the RC reviewed Resident 86's Census List (record of hospitalizations, room changes, and payer source changes) and stated Resident 86 was never hospitalized since admission to the facility on 10/27/2022. The RC stated Resident 86 should have received a JMA and Rehabilitation Screen upon admission to the facility under hospice services on 10/27/2022. The RC reviewed Resident 86's JMA and Rehabilitation Screen records and was unable to locate any JMA or Rehabilitation Screens for Resident 86 prior to 6/12/2023 (approximately 8 months after admission). The RC stated Resident 86's JMA, dated 6/12/2023, indicated Resident 86 had left shoulder moderate ROM limitations, left wrist moderate ROM limitations, left hand minimal ROM limitations, left hip minimal ROM limitations, left knee moderate ROM limitations, and left ankle minimal ROM limitations. During an interview on 2/22/2024, at 10:55 AM with the Director of Staff Development (DSD), the DSD stated RNA services included providing ROM exercises and assisting with ambulation or sit to stand transfers to maintain residents’ function and prevent the development of contractures. During an interview on 2/22/2024, at 11:07 AM with the DSD and the Director of Nursing (DON), the DON stated hospice residents received the same services as all the facility's residents, including the screening assessments and RNA services. During a concurrent interview and record review on 2/22/2024, at 11:13 AM., with the DSD and DON, the DSD and DON stated Resident 86 was admitted to the facility on 10/27/2022 with hospice services. The DON and DSD reviewed Resident 86's MDS upon admission, dated 11/7/2022. The DON stated Resident 86 had functional limitations in ROM to one arm and one leg due to Resident 86's hemiplegia (weakness to one side of the body) on the left side of the body. The DON stated Resident 86's MDS did not include ROM measurements of both arms and both legs. The DON stated the therapists completed ROM measurements of the residents (in general) using the JMA. The DON was unable to locate Resident 86's JMA upon admission on 10/27/2022 and stated the facility did not have any documented evidence of Resident 86's ROM in both arms and both legs upon admission. The DON and DSD stated Resident 86 started to receive RNA services for PROM exercises to the left arm and left leg in accordance with the physician orders, dated 6/12/2024. The DON and DSD stated there was no evidence Resident 86 received any RNA services for PROM exercises to the left arm and the left leg for 8 months from 10/27/2022 (admission) to 6/12/2023. The DON and DSD stated contractures developed over time and could be prevented with ROM exercises. The DON and DSD stated Resident 86's left arm and left leg contractures were preventable. During a concurrent observation and interview on 2/22/2024 at 4:18 PM with Occupational Therapist 1 (OT 1) in the bedroom, Resident 86 was lying in bed with the HOB elevated. Resident 86 moved the right arm without any ROM limitations, and OT 1 stated Resident 86's right arm was strong. OT 1 moved Resident 86's left arm at the shoulder, elbow, wrist, and hand joints. OT 1 lifted Resident 86's left arm to shoulder height and stopped due to Resident 86's complaint of pain. Resident 86 stated the intensity of the left shoulder pain was an 8 out of 10 (0 to 10 pain scale with 0 indicating no pain and 10 indicating severe pain). OT 1 bent Resident 86's left elbow past 90 degrees and stopped due to Resident 86 's complaint of 7 out of 10 pain. OT 1 moved Resident 86 ' s left wrist up from a bent position and stopped when Resident 86 complained of 8 out of 10 pain. Resident 86 had a slightly bent position of the left wrist. OT 1 observed having difficulty bending the fingertips of Resident 86's left hand. During an interview over the telephone on 2/22/2024 at 4:45 PM with Physical Therapist 1 (PT 1), PT 1 stated Resident 86 had a flexion (bending) contracture of the left hip and the left knee. During a review of Resident 86 ' s JMA, dated 2/22/2024 completed by OT 1, the JMA indicated Resident 86 had left shoulder minimal joint mobility limitations, left wrist moderate joint mobility limitations, and left hand moderate joint mobility limitations. During an interview on 2/22/2024 at 5:05 PM with OT 1, OT 1 stated Resident 86 had a flexion contracture of the left wrist since Resident 86 had a slight bend in the wrist, and OT 1 was unable to move the left wrist into extension. During a concurrent interview and record review on 2/23/2024 at 9:04 AM with the RC, the RC stated the purpose of the JMA was to monitor a resident's ROM. The RC stated the facility missed three opportunities to measure Resident 86's ROM in both arms and both legs, including upon admission (10/27/2022) and two quar