Health inspection·December 24, 2025

483.25(c) Mobility. 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. 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. 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. (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. 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 10/16/2025 at 12 PM, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to investigate a complaint regarding quality of care. The facility failed to ensure Resident 1 received appropriate treatment to prevent further decrease in Resident 1’s mobility when the facility failed to implement the physician order to have Resident 1 walk five times a week. As a result, Resident 1 experienced a decrease in the ability to walk. A review of Resident 1's Admission Record (AR) indicated the facility admitted Resident 1, a 53-year-old male, on 1/6/2025 and readmitted Resident 1 on 7/1/2025 with diagnoses including cerebral infarction, difficulty in walking, and personal history of traumatic brain disorder. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 8/28/2025, indicated Resident 1 was moderately impaired in cognitive skills. The MDS indicated Resident 1 needed supervision or touch assistance from staff for dressing, bathing, and toileting, oral, and personal hygiene. The MDS also indicated Resident 1 had impaired movement of both upper and lower extremities and required substantial/maximal assistance (helper lifts or holds trunk or limbs and performs more than half the effort) to walk 10 feet. A review of Resident 1’s Order Summary Report (OSR), dated 10/16/2025, indicated Resident 1 had a physician order for Restorative Nursing Assistant (RNA) to ambulate (walk) Resident 1 five times a week with a front wheel walker (FWW). The physician order was dated 8/28/2025. A review of Resident 1’s Nursing Note (NN) indicated Resident 1 was discharged home from the facility on 10/7/2025. During a concurrent interview and record review on 10/16/2025 at 1:26 PM with the Director of Rehabilitation (DOR), Resident 1’s PT (Physical Therapy) Discharge Summary (DS), dated 8/28/2025, was reviewed. The DS indicated, “Patient (Resident 1) is currently able to walk in corridor, and walk in room…patient (Resident 1) will be able to walk in corridor with assist of one, and balance will require the physical support of one, by performing the following Restorative Nursing interventions: provide assistance of one, use gait belt, use walker, encourage participation and allow patient to take his or her time.” The DOR stated Resident 1 was discharged from rehab services on 8/28/2025. The DOR stated Resident 1 needed RNA services to include an RNA would walk with Resident 1 in the hallway 5 days out of each week. During a concurrent interview and record review on 10/16/2025 at 2:04 PM with RNA 1, Resident 1’s Restorative Nursing Orders (RNO) for August, September, and October 2025, were reviewed. The RNO failed to indicate Resident 1 received the treatment order of ambulating in the hallway 5 times a week. RNA 1 confirmed RNA 1 did not ambulate with Resident 1, 5 times a week. During an interview with Certified Nursing Assistant (CNA) 2 on 10/16/2025 at 2:26 PM, CNA 2 stated CNA 2 took care of Resident 1 a week before Resident 1 was discharged home. CNA 2 stated Resident 1 could grab on the bar in the bathroom and could stand up a little bit to go to the bathroom while CNA 2 held on to Resident 1’s right arm. CNA 2 stated Resident 1 was unsteady when Resident 1 stood. During a concurrent interview and record review with the MDS Coordinator (MDSC) on 10/20/2025 at 11:20 AM, the MDSC stated Resident 1’s MDS discharge MDS was not filled out yet. The MDSC reviewed Resident 1’s medical record. The MDSC stated the discharge score for Resident 1’s activity performance level would be based on the CNA notes for the last three days prior to Resident 1’s discharge. The MDSC stated based on the CNA notes Resident 1 was dependent on others to transfer to and from a bed to a chair or wheelchair or the toilet upon discharge. The MDSC stated based on the CNA notes Resident 1 was dependent on others to walk 10 feet upon discharge. A review of the facility's policy and procedure (P&P) titled, "Restorative Nursing Programs," dated 2024, the P&P indicated, “It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level.” The facility failed to ensure Resident 1 received appropriate treatment to prevent further decrease in Resident 1’s mobility when the facility failed to implement the physician order to have Resident 1 walk five times a week. As a result, Resident 1 experienced a decrease in the ability to walk. The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.