Health inspection·May 15, 2025

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 the admission of the patient and be completed within seven days after admission. (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 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 each patient’s care plan according to the methods indicated. Each patient’s care shall be based on this plan. 22 CCR § 70215 - Planning and Implementing Patient Care (a) A registered nurse shall directly provide: (1) Ongoing patient assessments as defined in the Business and Professions Code, section 2725(b)(4). Such assessments shall be performed, and the findings documented in the patient's medical record, for each shift, and upon receipt of the patient when he/she is transferred to another patient care area. (2) The planning, supervision, implementation, and evaluation of the nursing care provided to each patient. The implementation of nursing care may be delegated by the registered nurse responsible for the patient to other licensed nursing staff, or may be assigned to unlicensed staff, subject to any limitations of their licensure, certification, level of validated competency, and/or regulation. (3) The assessment, planning, implementation, and evaluation of patient education, including ongoing discharge teaching of each patient. Any assignment of specific patient education tasks to patient care personnel shall be made by the registered nurse responsible for the patient. (b) The planning and delivery of patient care shall reflect all elements of the nursing process: assessment, nursing diagnosis, planning, intervention, evaluation and, as circumstances require, patient advocacy, and shall be initiated by a registered nurse at the time of admission. (c) The nursing plan for the patient's care shall be discussed with and developed as a result of coordination with the patient, the patient's family, or other representatives, when appropriate, and staff of other disciplines involved in the care of the patient. (d) Information related to the patient's initial assessment and reassessments, nursing diagnosis, plan, intervention, evaluation, and patient advocacy shall be permanently recorded in the patient's medical record. 22 CCR §72523: §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. F689 42 CFR §483.25(d) Accidents. The facility must ensure that – §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 4/3/2025 the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a revisit for an annual recertification survey to determine the facility’s compliance. During the survey CDPH determined that the facility failed to provide a hazard-free environment and adequate supervision (an intervention and means of mitigating the risk for accidents) to prevent falls and injuries to Resident 1 who was at risk for fall due to poor safety awareness and the history of falls in accordance with the facility's policy and procedure. The facility failed to: 1. Ensure a fall assessment and reassessment was conducted to identify the cause of the falls. 2. Ensure the care plan interventions were revised after each unwitnessed fall by addressing what caused the fall such as answering the call light timely and anticipating the resident's needs for ADL (Activities of Daily Living). 3. Ensure Resident 1’s floor mat (mats use a unique foam that absorbs the impact of a fall and helps to prevent serious injuries) was in place. 4. Ensure the facility follows its policies and procedures in connection with fall management and the call system. As a result of these deficient practices, Resident 1 sustained injuries from three unwitnessed falls at the facility which included a skin tear and swelling to the right elbow on 3/28/25 (one day after admission, first fall), pain to the head and right arm on 3/30/25 (three days after admission to the facility, second fall), and a cut on his right knee and a small hematoma (a solid swelling of clotted blood within the tissues) on the top of his head on 3/31/25 (four days after admission, third fall) that could potentially lead to decline in the resident's wellbeing. During a review of Resident 1’s Admission Record indicated the facility admitted Resident 1 on 3/27/2025 with diagnoses that included urinary tract infection (UTI, an infection in the bladder/urinary tract), injury of the right shoulder and upper arm, and muscle weakness. A review of Resident 1’s Nursing Documentation Evaluation document, dated 3/27/2025, indicated Resident 1 was at risk for fall due to his history of falls in the last six months and unsteady gait (the unable to balance self when walking). The document indicated Resident 1 had a fall at home that resulted in right shoulder pain. A review of Resident 1’s History and Physical (H&P, a comprehensive physician's note regarding the assessment of the resident's health status), dated 3/28/2025 indicated Resident 1 did not have the capacity to understand, make decisions and had a history of multiple falls, with most recent fall was on 3/27/2025 at home. A review of Resident 1’s Clinical Record indicated the resident had the following unwitnessed falls on 3/28/22025, 3/30/2025 and 3/31/2025: A review of the Nursing Progress Note, dated 3/28/2025 at 2 AM, indicated Resident 1 was found on the floor by the CNA (not identified) next to his bed with a skin tear and swelling to the right elbow. A review of a care plan, initiated on 3/28/2025, indicated Resident 1 had an unwitnessed fall. To prevent Resident 1 from another unwitnessed fall the facility will implement care plan interventions that included the nurse would closely monitor the resident and place the call light (a button or a device residents use to signal assistance from the staff) within reach and place floor mat on bilateral sides of the bed. A review of Resident 1’s Physical Therapy (PT, rehabilitative services used to ease pain and help a resident move better or strengthen weakened muscles) evaluation, dated 3/29/2025, indicated Resident 1 had a fear of falling, with fall predictors that included balance and gait (a manner of walking) impairment, history of falls, impaired activities of daily living (ADL, activities such as bathing and toileting), impaired strength, and pain. A review of Resident 1’s Change of Condition Evaluation (CoC, form used to document and report a significant change in a resident's health status), dated 3/30/2025, indicated Resident 1 had an unwitnessed fall on 3/30/2025 at 1:05 AM when the resident was trying to reach and pick up a towel on the floor that resulted in Resident 1’s complaint of head and right arm pain. A review of Resident 1’s care plan, initiated on 3/30/2025, indicated Resident 1 was at risk for injury due to an unwitnessed fall. To prevent further falls, the interventions included the facility to determine and address causative factors of Resident 1’s fall and will provide education for maintaining a safe environment that was free of potential fall hazards. A review of Resident 1’s Nursing Progress note, dated 3/31/2025 at 9:45 AM, the Nursing Progress note indicated Resident 1 was found face down on the floor, covered in stool (bowel movement) with the safety mat on the side and not under where Resident 1 fell. A review of Resident 1’s CoC, dated 3/31/2025, indicated Resident 1 had an unwitnessed fall and was found face down on the floor with a cut on his right knee and a small hematoma (a solid swelling of clotted blood within the tissues) on the top of his head. The CoC indicated Primary Care Physician (PCP) recommended to perform neurological (mental status) checks and monitor Resident 1 for any sudden changes in his level of consciousness. A review of Resident 1’s care plan dated 3/31/2025, indicated the resident had an unwitnessed fall. The plan of care was not revised to include new interventions related to Resident 1’s fall on 3/31/2025 after falling the third time in the facility. A review of Resident 1’s IDT (Interdisciplinary Team-group of facility staff that meet together and develops the plan of care for the residents) meeting report, dated 3/31/2025 timed at 1:03 PM, indicated Resident 1 had an unwitnessed fall on 3/30/2025 at 1:05 AM, and was transferred to the GACH (General Acute Care Hospital) but was re-admitted back to the facility on the same day after a negative computed tomography (CT, diagnostic imaging procedure) scan was completed. The IDT recommendations included providing safety reminders to the resident, place floor mats, Falling Star Program (fall prevention program to alert staff of a high fall risk resident), and medication regimen review. A review of Resident 1’s IDT meeting notes, dated 4/1/2025, indicated Resident 1 fell on 3/31/2025 at 9:45 AM. The IDT meeting indicated Resident 1 was observed on the floor with stool all over Resident 1. The IDT meeting recommendations indicated to place Resident 1’s bed in the lowest position, continue PT/OT (Occupational Therapy- a therapy that uses everyday life activities [occupations] to promote health, well-being, and ability to participate in treatments) and to refer Resident 1 to psychiatry (a branch of medicine that focuses on diagnosis, treatment and prevention of mental, behavioral disorders). A review of Resident 1’s care plan, initiated on 4/1/2025, after resident sustained three falls, the care plan indicated Resident 1 was at risk for falls and injury related to cognitive loss, lack of safety awareness, and impaired mobility. The care plan's interventions indicated to assist Resident 1 with transfers, offer toileting hygiene assistance, and provide verbal cues for safety as needed. During a concurrent observation and interview on 4/3/2025 at 11:08 AM, in Resident 1’s room, Resident 1 had no floor mat on the left side of the bed. Resident 1 stated he would call for the nurses, but nobody came to help him. Resident 1 stated, one time he fell because he wanted to get some towels on the floor, the second time he fell and scratched his knee and hit his head, and the third time he could not recall what he was doing but that facility staff would not assist him and stated "The staff never come to help even though you press the call light button." During an interview on 4/3/2025 at 5PM with the Interim Director of Nursing (DON), stated, Resident 1 needed to be re-assessed and re-evaluated after each fall incident. The Interim DON stated Resident 1 required increased supervision since Resident 1 had fallen three times while in the facility since Resident 1 had poor safety awareness. During a concurrent interview and record review on 4/4/2025 at 8:55 AM with licensed vocational nurse (LVN) 3 stated there was no documentation that Resident 1 was reassessed for the risk of fall and the plan of care was not revised to address the resident's risk for fall after all three incidents of Resident 1’s unwitnessed falls. During an interview on 4/4/2025 at 1:54 PM Certified Nurse Assistant (CNA) 3, stated, she was assigned to care for Resident 1 on 3/31/2025. CNA 3 stated that she delivered Resident 1’s breakfast tray and changed his adult briefs. CNA 3 stated after leaving Resident 1’s room she assisted Resident 2 and Resident 3 with their morning ADL care. Then CNA 3 stated she observed Resident 1’s call light was on, and Resident 1 was yelling. CNA 3 stated, she does not remember what Resident 1 was yelling about. CNA 3 stated when she went to Resident 1’s room, she found Resident 1 on the floor. During a review of the facility's policy and procedures (P&P) titled "Fall Management," dated 5/26/2021, the P&P indicated patients experiencing a fall would receive appropriate care and investigation of the case. The P&P indicated, if a patient falls, perform neurological evaluation for all unwitnessed falls and witnessed falls with injury to the head or face. The P&P indicated to the facility will develop an individualized care plan and will update the care plan to reflect new interventions for the residents at risk for fall or had history of falls. During a review of the facility's P&P titled, "Call system, Resident," dated 10/24/2024, the P&P indicated "calls for assistance are answered as soon as possible, but no later than 5 minutes. Urgent requests for assistance are addressed immediately." During the survey (revisit) CDPH determined that the facility failed to provide a hazard-free environment and adequate supervision (an intervention and means of mitigating the risk for accidents) to prevent falls and injuries to Resident 1 who was at risk for all due to poor safety awareness and history of falls in accordance with the facility's policy and procedure a by failing to: 1. Ensure a fall assessment and reassessment was conducted to identify the cause of the falls. 2. Ensure the care plan interventions were revised after each unwitnessed fall by addressing what caused the fall such as answering the call light timely and anticipating the residents’ needs for ADLs. 3. Ensure Resident 1’s floor mat was in place. 4. Ensure the facility follows its policies and procedures in connection with fall management and the call system. As a result of this deficient practice Resident 1 sustained injuries from three unwitnessed falls at the facility that included a skin tear and swelling to the right elbow on 3/28/25 (one day after admission), pain to the head and right arm on 3/30/25 (three days after admission), and a cut on his right knee and a small hematoma that could potentially lead to decline in the resident's wellbeing. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.