Health inspection·February 14, 2025

F 689 CFR §483.25 (d)(2) Accidents. The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. §483.25(d) Accidents. The facility must ensure that – §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. § 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 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 of 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 of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. § 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. An unannounced visit was conducted by California Department of Public Health on 1/29/2025 at 7:30 AM to investigate a complaint regarding an allegation of patient safety-falls. The facility failed to ensure Patient 1 who was assessed as a high risk for falls and with diagnoses of dementia (a progressive state of decline in mental abilities), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), lack of coordination and repeated falls was free from falls and injury. On 1/18/2025, the Director of Activities (DOA) wheeled Patient 1 outside of the activity room to take care of other patients and left Patient 1 unattended while sitting in a wheelchair (WC) at the hallway (outside the activity room). As a result of this deficient practice, Patient 1 fell in the hallway outside the activity room on 1/18/2025 around 11:13 AM. Patient 1 sustained redness on the right side of resident’s forehead. On 1/24/2025 (6 days after the fall), Patient 1 complained of pain on the patient’s right ribs (slender curved bones protecting the lungs). Patient 1 underwent a Xray (a quick, painless test that captures images of the inside of the body) on 1/25/2025 and the result showed that Patient 1 had a fracture (a break in a bone) on the resident’s right eighth (8th) and ninth (9th) ribs. A review of Patient 1’s Admission Record, it indicated Patient 1 was an 80- year- old male who was admitted to the facility on 1/17/2025 with diagnoses that included: dementia, cerebral infarction, lack of coordination and repeated falls. A review of Patient 1’s Admission Fall Risk Assessment (AFRA) dated 1/17/2025, it indicated, Patient 1 is chair bound (unable to walk and dependent on a chair/ wheelchair to move around) and has a high risk for potential falls. A review of Patient 1’s Care Plan (CP) dated 1/17/2025, it indicated Patient 1 was at risk for falls due to history of falls. The CP did not indicate interventions such as facility staff actions or strategies to prevent resident from falling while the patient is in the wheelchair, such as monitoring and/ or supervising the patient while in wheelchair. A review of Patient 1’s Change of Condition (CoC) dated 1/18/2025 at 11:13 AM, it indicated Patient 1 fell outside the activity room while trying to turn his WC and the resident’s right hand slipped causing the resident to fall on the floor. The COC also indicated the patient was observed having redness to the right side of the forehead. A review of Patient 1’s CoC dated 1/24/2025 at 7:44 PM, it indicated the patient has hemiparesis (weakness to one side of body) and complained of pain on the right side of his ribs. A review of Patient 1’s physician’s order, dated 1/24/2025, it indicated Patient 1 may have Xray of the right ribs due to pain. A review of Patient 1’s Radiology Report (Xray of ribs) dated 1/25/2025, it indicated Patient 1 had right 8th and 9th rib fractures. A review of Patient 1’s CoC dated 1/25/2025 at 11:09 PM, it indicated the patient’s Xray result indicated the patient sustained fractures to the 8th and 9th rib and Tylenol (acetaminophen – medicine for mild pain) and ice were ordered for pain. A review of Patient 1’s Medication Administration Record (MAR) dated 1/1/2025 to 1/31/2025, it indicated Patient 1 received acetaminophen on 1/18/2025 at 11:28 AM for a pain (location of pain not indicated) level of two (2) out of 10 (mild pain). The MAR also indicated Patient 1 received acetaminophen on 1/26/2025 at 5:56 AM for a pain (location of pain not indicated) level of four (4) out of 10 (moderate pain). During an interview on 1/29/2025 at 8:04 AM with the DOA, the DOA stated on 1/18/2025, DOA wheeled Patient 1 outside of the activity room and left Patient 1 at the hallway unattended to take care of other residents that were inside of the activity room. The DOA also stated, DOA heard a sound coming from the hallway outside of the activity room and turned finding Patient 1 on the floor. DOA stated, Patient 1 is at high risk for falling and that means the patient must be constantly monitored, and the patient needs someone with him at all times especially when the resident is in the wheelchair. DOA stated on 1/18/2025, DOA did not tell another staff member to watch Patient 1 while DOA attends to other patients. DOA stated, Patient 1 should not have been left unattended by facility staff on 1/18/2025 and the fall could have been prevented. During an interview on 1/29/2025 at 8:26 AM with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 1/18/2025, CNA 1 saw Patient 1 being wheeled out of the activity room by the DOA and left unattended in the hallway outside of the activity room. CNA 1 also stated, CNA 1 walked past Patient 1, then heard a thump, turned around and saw Patient 1 on the floor of the hallway outside of the activity room. During an interview on 1/29/2025 at 10:24 AM with RN 1, RN 1 stated Patient 1 is confused, has right sided weakness and is unable to use the WC by himself. RN 1 stated, on 1/18/2025 RN 1 was called to assess Patient 1 after the resident fell in the hallway outside of the activity room and saw redness on Patient 1’s forehead. RN 1 also stated, Patient 1 had multiple falls before being admitted at the facility and was assessed to be at high risk for falling. RN 1 stated Patient 1 needs to always be monitored/ supervised because the resident is at risk for falling. RN 1 stated, Patient 1’s fall and injury could have been prevented if the patient was monitored/ supervised by facility staff last 1/18/2025 while in the activity room. During a record review on 1/29/2025 at 11:46 AM with the Director of Nursing (DON), the facility’s P&P titled, Fall Risk Assessment updated 1/27/2025 was reviewed. The P&P indicated: 1. The nursing staff, in conjunction with others will seek to identify and document resident risk factors for falls and establish a resident centered falls prevention plan based on relevant assessment information. 2. Upon admission the nursing staff and physician will review a resident’s record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. The facility failed to ensure Patient 1 who was assessed as a high risk for falls and with diagnoses of dementia, lack of coordination and repeated falls was free from falls and injury. On 1/18/2025, the DOA wheeled Patient 1 outside of the activity room to take care of other residents and left Patient 1 unattended while sitting in a WC at the hallway (outside the activity room). The above violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 1.