Health inspection·July 3, 2025

California Code, Health and Safety Code - HSC § 1424 (f)(1) A willful material falsification or willful material omission in the health record of a resident of a long-term health care facility is a violation. On 5/20/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding quality of care/treatment of Resident 5. As a result of the investigation, the facility failed to ensure accurate documentation of restorative nursing services (RNS- specialized nursing interventions provided by a restorative nursing aide [RNA] focused on helping to maintain or regain functional abilities to achieve the highest level of well-being, often after rehabilitation or to prevent decline) on the Restorative Nursing Record (RNR) for Resident 5, in accordance with the facility’s policy and procedure (P&P) titled, “Documentation- Nursing Manual- Restorative Nursing Program,” by failing to ensure Restorative Nursing Assistant 3 (RNA- a specialized Certified Nursing Assistant [CNA] with additional training in rehabilitation techniques) did not willfully falsify in Resident 5’s RNR that RNA 3 had provided ambulation (walking) RNS as ordered by the physician for the month of 4/2025. This failure resulted in Resident 5 not receiving any RNS for the month of 4/2025 and had the potential to result in Resident 5 developing further physical decline, loss of function and mobility, and the inability to walk. A review of Resident 5’s Admission Record (AR), indicated the facility admitted Resident 5, an 81-year-old female, on 9/10/2022 with diagnoses that included other abnormalities of gait and mobility (inability to walk normally due to injuries or underlying conditions) and unspecified dementia (progressive states of decline in mental abilities). A review of Resident 5’s Minimum Data Set (MDS- a resident assessment tool) dated 3/18/2025, indicated Resident 5 had intact cognition. The MDS indicated Resident 5 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity and may be provided throughout the activity or intermittently) with walking 50 feet (ft- unit of measurement). A review of Resident 5’s Order Summary Report (OSR), indicated Resident 5 had an order for (the) RNA to assist with ambulation (the act of walking) using a front wheel walker (FWW- mobility aid designed to assist with walking) three times per week, up to 100 feet (ft- unit of measurement) or up to the patient’s limits to maintain functional mobility skills, active as of 3/31/2025. A review of Resident 5’s untitled Care Plan (CP) initiated 3/31/2025, indicated Resident 5 was receiving ambulation using a FWW three times per week, up to 100 feet or up to Resident 5’s limit to maintain functional mobility skills. The CP goals indicated Resident 5 would maintain functional abilities through the RNA program as ordered through the next review period. The CP goals indicated to monitor and observe Resident 5 for tolerance, pain, and skin integrity, and to notify the licensed nurses (LN), rehabilitation (services) and physician if Resident 5 showed a decline in function. A review of Resident 5’s Restorative Nursing Record (RNR- record kept indicating when RNS is provided) for 4/2025, indicated Resident 5 received RNS on 4/1/2025, 4/3/2025, 4/5/2025, 4/7/2025, 4/9/2025, 4/11/2025, 4/14/2025, 4/16/2025, 4/18/2025, 4/21/2025, 4/23/2025, 4/25/2025, 4/28/2025, and 4/29/2025. During an interview on 5/21/2025, at 12:21 pm, RNA 3 stated on 4/30/2025 in the afternoon, MR printed out the RNR for residents receiving RNS for the month of 5/2025 (Record for RNAs to sign/initial as treatment is given for 5/2025). RNA 3 stated in the morning on 5/1/2025, RNA 3 realized Resident 5 had RNS orders for the month of 4/2025, but did not receive any RNS for 4/2025. RNA 3 stated RNA 3 realized Resident 5’s RNS orders were placed on 3/31/2025. RNA 3 stated RNA 3 informed the Assistant Director of Nursing (ADON), who informed the DON. RNA 3 stated the DON informed RNA 3 to start Resident 5’s RNS orders on 5/2/2025. RNA 3 stated Resident 5 was first ambulated on 5/2/2025 since the RNS orders were placed on 3/31/2025. RNA 3 stated on 5/5/2025, while the California Department of Public Health (CDPH) was onsite investigating Resident 5’s RNS, CDPH asked for Resident 5’s RNR for 4/2025 and the facility needed to provide it. RNA 3 stated the DON asked RNA 3 to sign Resident 5’s treatment record for 4/2025 because the facility had to, “Correct and do something about Resident 5’s RNR.” RNA 3 stated the DON asked RNA 3 to sign Resident 5’s RNR for 4/2025, “So I did.” RNA 3 stated, “The DON didn’t tell me I was falsifying Resident 5’s record, the DON just told me I needed to fix the mistake for Resident 5.” RNA 3 stated, “Because the DON is my boss, I felt like I had to listen to the DON.” During an interview on 5/21/2025 at 1:33 pm, the ADON stated the ADON did know what dates in April Resident 5 did not receive RNS. The ADON stated the ADON did not know why Resident 5’s RNR for 4/2025 was signed and initialed, indicating RNS was provided to Resident 5. The ADON stated the ADON did not remember when the missed RNS was brought to the DON’s attention, and did not remember what the DON instructed the ADON to do about Resident 5’s missed RNS dates. The ADON stated Resident 5 could develop a decline in activities of daily living (ADL- the tasks of everyday life fundamental to caring for oneself), loss of muscle mass (amount of muscle in the body) and the ability to walk from not receiving RNS. The ADON stated Resident 5 could become weaker and put Resident 5 at risk for complications from not receiving the ordered RNS. During a concurrent interview and record review on 5/21/2025 at 1:46 pm, Resident 5’s RNR for 4/2025 was reviewed with the Director of Nursing (DON). The DON stated (in general) Physical Therapist put in RNS orders for residents and it was the rehabilitation staffs’ responsibility to communicate with RNAs when a RNS order was placed for residents. The DON stated MR will print out the RNR for each resident for the month ahead so RNAs can fill out the RNR as RNS is provided. The DON stated, regarding Resident 5’s RNS, there was a miscommunication between nursing, RNA, and rehabilitation staff. The DON stated on 5/1/2025 or 5/2/2025 (exact date unknown), the ADON informed the DON that Resident 5’s RNR for 4/2025 was missing. The DON stated the DON informed the unidentified RNAs to continue Resident 5’s RNS orders. The DON stated the first week of 5/2025 (exact date unknown) RNA 3 informed the DON that Resident 5 had not been ambulated (as ordered) for 4/2025. The DON stated the DON did not know how many dates Resident 5 was not ambulated. The DON stated on 5/5/2025, while CDPH was onsite, the DON asked RNA 3 to find Resident 5’s RNR for 4/2025 but RNA 3 could not find it. The DON stated the DON did not know why Resident 5’s RNR for 4/2025 was provided to CDPH because the RNR was never printed. During an interview on 5/21/2025 at 3:33 pm, the Rehabilitation Program Manager (RPM), stated on 5/1/2025, the DON informed the RPM there was a “Discrepancy,” with Resident 5’s RNS order but did not go into detail because the RPM was not working on 5/1/2025. The RPM stated the RPM returned to work on 5/9/2025 and was not updated on Resident 5’s RNS order from the ADON, DON, or rehabilitation staff, “So I assumed everything was fine.” The RPM stated the RPM was not informed Resident 5 did not receive any RNS for 4/2025. During an interview on 5/21/2025 at 4:05 pm, Resident 5 stated they (exact staff unknown) had been walking Resident 5 for about a month, but did not remember when facility staff began walking Resident 5. During an interview on 5/22/2025 at 3:19 pm, the DON stated on 5/1/2025 the DON informed the RPM there was a “Discrepancy,” with Resident 5’s RNS orders for 4/2025. The DON stated the DON “Looked into it,” and discovered that Resident 5’s RNS orders were not communicated to the RNAs. The DON stated the DON asked an unidentified rehabilitation staff what happened with Resident 5’s RNS orders for 4/2025, but “Did not get an answer so I let it go.” The DON stated when CDPH was onsite on 5/5/2025 and provided Resident 5’s RNR for 4/2025 the DON did not check the RNR. The DON stated Resident 5’s RNR for 4/2025 was missing and should not have been provided to CDPH. The DON stated Resident 5 was supposed to receive 14 RNS treatments for 4/2025. The DON stated by not receiving RNS as ordered, Resident 5 could have a decline in health and ability to ambulate, and a decline in function and suffer muscle wasting that could lead to a negative effect on Resident 5’s quality of life. During a review of the facility’s P&P titled, “Documentation- Nursing Manual- Restorative Nursing Program (RNP)” revised 11/1/2017, the P&P indicated the purpose was to ensure that resident progress in the RNP was documented accurately and timely. The P&P indicated that each resident would be given the appropriate treatment and services to maintain or improve his or her abilities, as indicated by the resident’s comprehensive assessment, to achieve and maintain the highest practicable outcome. The P&P indicated the RNA will document and communicate any significant resident problems or changes to the charge nurse promptly. The facility failed to ensure accurate documentation of RNS on the RNR for Resident 5, in accordance with the facility’s P&P titled, “Documentation- Nursing Manual- Restorative Nursing Program,” by failing to ensure RNA 3 did not willfully falsify in Resident 5’s RNR that RNA 3 had provided ambulation RNS as ordered by the physician for the month of 4/2025. This failure resulted in Resident 5 not receiving any RNS for the month of 4/2025 and had the potential to result in Resident 5 developing further physical decline, loss of function and mobility, and the inability to walk. This violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 2.