Health inspection·July 12, 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 § 72311 Nursing Service—General. (a) Nursing service shall include, but not be limited to, the following: (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: (b) Any sudden and/or marked adverse change in signs, symptoms, or behavior exhibited by a patient. 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 § 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. (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures, and deformities. Such care shall include: (2) Encouraging, assisting, and training in self-care and activities of daily living. (3) Maintaining proper body alignment and joint movement to prevent contractures and deformities. 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 §72543. Patients’ Health Records. (f) Patients' health records shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each patient. 22 CCR §72547 Content of Health Records (a) A facility shall maintain for each patient a health record which shall include: (5) Nurses’ notes which shall be signed and dated. Nurses notes shall include: (A) Records made by nurse assistants, after proper instruction, which shall include: 2. Narrative notes of observation of how the patient looks, feels, eats, drinks, reacts, interacts and the degree of dependency and motivation toward improved health. 3. Notification to the licensed nurse of changes in the patient’s condition. On 5/28/2024, the California Department of Public Health (CDPH) conducted an unannounced visit for an annual recertification survey. The facility failed to: 1. Monitor Resident 53’s range of motion [(ROM) full movement potential of a joint (where two bones meet)] in each joint of both arms and legs upon admission, quarterly, and annually in accordance with the facility’s policies and procedures (P&P) titled, “Resident Mobility and Range of Motion,” which indicated the resident’s comprehensive assessment will identify a resident’s current range of motion of his or her joints. 2. Provide Resident 53 with active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) exercises from 12/23/2022 (admission assessment) to 5/1/2023 (more than four months) in accordance Resident 53’s admission Rehab Screening Form (brief assessment of a resident’s abilities) recommendations, dated 12/23/2022. 3. Provide Resident 53 with passive range of motion ([PROM] movement of joint through the ROM with no effort from the person) of the ankles in accordance with physician orders, dated 3/25/2024. 4. Timely notify the attending licensed healthcare practitioner of Resident 53’s sudden or marked change in range of motion and onset of contractures. 5. Give Resident 53 care to prevent formation and progression of contractures and deformities, including maintaining proper body alignment and joint movement to prevent contractures and deformities. As a result, Resident 53 developed ankle contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness), and required full physical assistance to perform exercises on both arms and legs. A review of Resident 53’s general acute care hospital (GACH) Neurology (branch of medicine concerned with the study and treatment of disorders involving the brain, spinal cord, and nerves) Progress Note, dated 12/18/2022, indicated Resident 53 was fully awake, alert, and followed simple commands. The Neurology Progress Note also included a physical examination, which indicated Resident 53 held the arms and legs against gravity (active movement). A review of Resident 53’s Admission Record indicated Resident 53, was a 47 year-old female, originally admitted to the facility on 12/21/2022 and readmitted on 3/20/2024 with diagnoses including psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), major depressive disorders (depression- a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning), seizures (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness), and gastrostomy (G-tube, tube placed directly into the stomach for feeding and medication administration). A review of Resident 53’s Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 4/2/2024, indicated Resident 53 had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 53 did not have any ROM impairments to both arms and legs. The MDS indicated Resident 53 was dependent (helper does all the effort or the assistance of two or more helpers is required for the resident to complete the activity) for rolling to either side, transferring from sit to lying, chair/bed-to-chair transfers, oral hygiene (cleaning teeth), showering/bathing, and dressing. A review of Resident 53’s Progress Note, dated 12/22/2022 timed at 3:00 p.m., indicated Resident 53 was found in the middle of the bed with both legs dangling outside of the bed. The Progress Note indicated Resident 53 was assisted back to bed and repositioned. The Progress Note indicated Resident 53’s physician was informed, and a physician order was carried out to place the bed in the lowest position and floor mat. A review of Resident 53’s admission Rehab Screening Form, dated 12/23/2022, indicated Resident 53 did not have any contractures or ROM impairments in both arms, but had a ROM impairment in one leg. The Rehabilitation Screening Form indicated Resident 53’s left leg was within functional limits ([WFL] sufficient movement without significant limitation) and the right leg (hip) had tightness into flexion (bending the leg at the hip joint toward the body) and abduction (moving the leg away from the body). The Rehab Screening Form indicated to provide Resident 53 with Restorative Nursing Aide ([RNA] Certified Nursing Aide program that help residents to maintain their function and joint mobility) for AAROM exercises on both arms and legs, three to five times per week (3-5x/week) as tolerated. A review of Resident 53’s Restorative Flow Sheets (record of RNA sessions) for 12/2022, 1/2023, 2/2023, 3/2023, and 4/2023 indicated AAROM exercises on both arms and legs were not included. A review of Resident 53’s quarterly Rehab Screening Form, dated 4/9/2023, indicated Resident 53 did not have any contractures or ROM impairments in both arms. The Screening Form indicated Resident 53 had a ROM impairment in one leg. The Rehab Screening Form indicated Resident 53 had the same level of function without significant decline and to continue the RNA ROM exercise program. A review of Resident 53’s physician orders, dated 5/1/2023, indicated for the RNA to provide Resident 53 with PROM on both arms and legs, 3-5x/week with one person assist as tolerated. A review of Resident 53’s quarterly Rehab Screening Forms, dated 7/9/2023 and 10/10/2023, indicated Resident 53 did not have any contractures or ROM impairments in both arms. The Screening Form indicated Resident 53 had a ROM impairment in one leg. The Rehab Screening Forms indicated Resident 53 had the same level of function without significant decline and to continue the RNA ROM exercise program. A review of Resident 53’s annual Rehab Screening Form, dated 1/9/2024, indicated Resident 53 did not have any contractures and did not have any ROM impairments in both arms. The Screening Form indicated Resident 53 had a ROM impairment in one leg. The Rehab Screening Form indicated Resident 53 had the same level of function without significant decline and to continue the RNA ROM exercise program. A review of Resident 53’s physician orders, dated 3/25/2024, indicated for RNA to provide PROM on both arms and legs, followed by the application of both elbow splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) for four to six hours (4-6 hours), 3-5x/week. A review of Resident 53’s quarterly Rehab Screening Form, dated 4/9/2024, indicated Resident 53 did not have any contractures or ROM impairments in both arms. The Rehab Screening Form indicated Resident 53 had a ROM impairment in one leg. The Rehab Screening Form indicated Resident 53 had the same level of function without significant decline and to continue the RNA ROM exercise program. During a concurrent interview and record review on 5/28/2024 at 10:48 a.m., with the Director of Rehabilitation (DOR), the facility’s Rehab Screening Form was reviewed. The DOR stated the Rehab Screening Form was completed upon a resident’s admission, quarterly, change of condition, and annually. The DOR stated ROM was assessed as either having no impairment, impairment on one side, or impairment on both sides. The DOR stated the Rehab Screening Form did not include a ROM assessment for limitations in each joint of the arms (shoulders, elbows, wrists, and hands) and the legs (hips, knees, ankles). The DOR stated RNA services helped residents maintain their ROM and function. During an observation on 5/29/2024 at 8:13 a.m., in Resident 53’s room, Resident 53 was lying awake in bed with the head-of-bed (HOB) elevated and a bed sheet covering Resident 53’s legs. Resident 53 smiled but did not speak. Resident 53’s body twitched (short, jerky sudden movements) intermittently (did not happen continuously) and both elbows were in a bent position. Resident 53’s hips and knees were visibly rotated away from the body with the knees bent, resembling a frog-like leg position, despite the presence of the bed sheet over both legs. Resident 53’s ankles and feet were not visible. Resident 53 was not wearing any splints on both arms and legs. During an observation on 5/29/2024 at 9:09 a.m., in Resident 53’s room, Resident 53 was observed lying awake in bed with the HOB elevated. Resident 53’s elbows were in a bent position. Restorative Nursing Aide (RNA) 3 performed ROM exercises on Resident 53’s left arm, including shoulder abduction (lifting the arm away from the body) and adduction (returning the arm toward the body), shoulder rotation (circular motion) in clockwise and counterclockwise directions, shoulder flexion (lifting the arm upward) and extension (returning the arm downward), elbow flexion (bending) and extension (straightening), and then applied an elbow extension splint (splint that prevents the resident from bending at the elbow) on the left arm. RNA 3 performed ROM exercises on Resident 53’s right arm, including shoulder abduction and adduction, shoulder rotation in clockwise and counterclockwise directions, shoulder flexion and extension, elbow flexion and extension, and then applied an elbow extension splint on the right arm. Resident 53’s legs were rotated away from the body, both knees were bent, and both ankles were positioned in plantarflexion (ankles bent with toes pointing away from the body). RNA 3 performed ROM exercises on Resident 53’s right leg, including hip abduction (moving the leg away from the body) and adduction (returning the leg toward the body), hip rotation clockwise and counterclockwise while the knee was extended, hip flexion (bending the leg at the hip joint toward the body) with knee flexion (bending the knee), and ankle rotation. RNA 3 did not move Resident 53’s right ankle into dorsiflexion (ankle bent with toes pointing toward the body). RNA 3 performed ROM exercises on Resident 53’s left leg, including hip abduction, hip rotation clockwise and counterclockwise with the knee extended, hip flexion with knee flexion, and ankle rotation. RNA 3 did not move Resident 53’s left ankle into dorsiflexion. RNA 3 then performed exercises to the left-hand fingers into flexion and extension, left wrist rotation, left wrist flexion and extension, right-hand fingers into flexion and extension, right wrist rotation, and right wrist flexion and extension. During an interview on 5/29/2024 at 9:37 a.m., RNA 3 stated she performed PROM on both of Resident 53’s arms and legs and applied both elbow extension splints. During an interview on 5/29/2024 at 11:36 a.m., Physical Therapist (PT, professional trained in the restoration, maintenance, and promotion of optimal physical function) 1, stated the ROM exercises that the RNAs were expected to perform for each resident’s legs included hip flexion and extension, hip abduction and adduction, knee flexion and extension, and ankle dorsiflexion and plantarflexion to prevent contractures. During a concurrent interview and record review on 5/29/2024 at 4:06 p.m., with the DOR, in the presence of the Assistant Director of Nursing (ADON) and the MDS Coordinator (MDS 1), the facility’s Rehabilitation electronic documentation (clinical therapy records) for PT, Occupational Therapy [(OT) profession aimed to increase or maintain a person's capability of participating in everyday life activities (occupations)], and Speech Therapy ([ST or SLP] profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) were reviewed. The DOR stated Resident 53 never received any PT, OT, or SLP services while residing in the facility. During a concurrent interview and record review on 5/29/2024 at 4:23 p.m., with the DOR, Resident 53’s Rehab Screening Form, dated 12/23/2022, was reviewed. The DOR stated Resident 53 had ROM impairments in the right leg due to tightness in the hip. The DOR stated Resident 53 did not have any contractures in both legs upon admission to the facility. During a concurrent observation and interview on 5/29/2024 at 4:38 p.m., with Resident 53, in the presence of the DOR, ADON, and MDS 1, in Resident 53’s room, Resident 53 was observed lying in bed with a bed sheet covering both legs. The DOR lifted the bed sheet to view both legs. Resident 53 did not have any splints on both legs. Resident 53’s ankles were positioned in plantarflexion. The DOR attempted to provide ROM to Resident 53’s ankles into dorsiflexion, but Resident 53’s ankles remained in plantarflexion. During an interview on 5/29/2024