Health inspection·February 21, 2025

§483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR § 72311(a)(1)(C)(2) Nursing Service- General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of Resident care, which shall include at least the following: (C) Reviewing, evaluating, and updating of the Resident care plan as necessary by the nursing staff and other professional personnel involved in the care of the Resident 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. 22 CCR § 72523 Resident Care Policies and Procedures (a) Written Resident care policies and procedures shall be established and implemented to ensure that Resident related goals and facility objectives are achieved. On 1/21/2025, at 7:30 AM, an unannounced visit was conducted at the facility to conduct a Re-certification survey. The facility failed to provide adequate supervision to Resident 1 who was assessed as at risk for falls and was dependent on staff for activities of daily living ([ADL] task such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet and eating) by failing to ensure Resident 1 was left unattended by Certified Nurse Assistant 1 (CNA 1) while Resident 1 was on high back wheelchair. As a result of this deficient practice, Resident 1 fell out of the high back wheelchair on 11/20/2024, landing on the floor and sustaining a left eyebrow laceration (a deep cut or tear in skin or flesh), blunt head injury (an injury to the head caused by a forceful impact), and facial fractures (a partial or complete break in the bone). Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment. Resident 1 was diagnosed with blunt head injury (an injury to the head caused by a forceful impact) and facial fractures (a partial or complete break in the bone). A review of Resident 1’s Admission Record indicated the Resident was admitted to the facility on 8/24/2024 with diagnoses that included dementia ( ), abnormal posture (involuntary and rigid body movements), and schizophrenia (a mental illness that is characterized by disturbances in thought). A review of Resident 1’s Admission Fall Risk Assessment, dated 8/24/2024, indicated Resident 1 was a fall risk. A review of Resident 1’s Care Plan (CP), dated 8/24/2024, indicated Resident 1 has potential for falls related to antihypertensives (drug used to treat high blood pressure) medications, incontinence (a condition where a person experiences involuntary loss of urine or stool), dementia, and impaired mobility (the ability to move or be moved freely and easily). The care plan indicated a goal for the Resident to not have major injuries from fall. The care plan interventions included were to administer medications as ordered, answer call light promptly, assist with transfers and mobility as needed (PRN), to not leave the Resident unattended in shower room, and to keep the environment free from clutter. A review of Resident 1’s Physical Therapy (PT, treatment that helps improve how the body performs physical movements) evaluation and plan of treatment, dated 8/25/2024, indicated Resident 1's functional assessment was done and Resident 1 required total assistance from 1 staff with bed mobility (the ability to move from one position in bed to another), transfers, wheelchair mobility and wheelchair management (teaching a person how to use a wheelchair safely and independently). A review of Resident 1’s Occupational Therapy (OT, treatment that aims to improve the ability to perform daily activities) evaluation and Plan of treatment, dated 8/26/2024, indicated Physical/Cognitive/Psychosocial Performance for Resident 1 presents with impairments in balance and strength resulting in limitations and/or participation restrictions in the areas of mobility and self-care. A review of Resident 1’s History and Physical (H&P), dated 8/26/2024, indicated Resident 1 does not have the capacity to make decisions. A review of Resident 1’s Minimum Data Set (MDS- a resident assessment tool), dated 10/4/2024, indicated Resident 1's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). Resident 1 was dependent with eating, oral hygiene, toileting hygiene, shower/bath, upper and lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1 was dependent with chair/bed to chair transfer (the ability to transfer to and from a bed to chair (or wheelchair). The MDS also indicated Resident 1 was dependent to wheel 50 feet with two turns (once seated in wheelchair, the ability to wheel at least 50 feet and make two turns. The MDS indicated Resident 1 has no history of falls. A review of Resident 1’s PT discharge summary, dated 10/4/2024, indicated discharge functional outcomes included the following: o Static sitting (a position where you sit in a fixed posture for a prolonged period of time) = fair (able to maintain with upper extremities support) o Dynamic sitting (the practice of moving around while seated) = "Poor +" (sits unsupported with minimal assistance) o Static standing (positions where the body is held in a single alignment for a period of time) = poor (requires maximal assistance and upper extremities support) o Bed mobility = total assistance with 1 staff o Rolling = Total assistance with 1 staff o Transfers =Total assistance with 1 staff o Stand = Total assistance with 1 staff o Wheelchair mobility = Total assistance o Wheelchair management = Total assistance with 1 staff A review of Resident 1’s CP, dated 11/16/2024, indicated Resident 1 was dependent on staff for activities, cognitive stimulation, social interaction due to cognitive deficits, immobility, physical limitations. The CP interventions included for staff to provide Resident 1 assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) as required during the activity. A review of Resident 1’s Change of Condition (COC) evaluation, dated 11/20/2024, timed 11:01 AM, by Licensed Vocational Nurse 1 (LVN 1), indicated on 11/20/2024 around 10:35 AM, Certified Nurse Assistant 1 (CNA 1) reported to LVN 1, "CNA 1 put Resident to wheelchair and turned around to get linen from bed. Resident moved quickly and fell forward laying prone on left facing towards the floor." The COC evaluation indicated LVN 1 immediately went to Resident 1's room and found Resident 1 on the floor bleeding from the left eyebrow. Resident 1's left eye was noted with discoloration and mild swelling, laceration on the left eyebrow which measured 0.5 centimeter (cm, unit of measurement) by 0.3 cm. The COC evaluation indicated Resident 1's primary care clinician (Doctor) was notified on 11/20/2024 at 10:38 AM, with an order to transfer Resident 1 to GACH via non-emergent ambulance for further evaluation. A review of Resident 1’s Progress Notes, dated 11/20/2024, timed 10:48 AM, indicated the Director of Nursing (DON) indicated LVN 1 notified the DON regarding Resident 1's witnessed fall. The DON went to Resident 1's room and Resident 1 on the floor on a supine position (lying face upward) with left eyebrow laceration. The DON was unable to assess the left eye due to swelling. Resident 1 was observed with facial grimacing (a facial expression in which your mouth and face are twisted in a way that shows disgust, disapproval, or pain). A review of Resident 1’s GACH Emergency Department (ED) discharge instructions, dated 11/20/2024, indicated diagnoses included were blunt head injury and facial fractures. A review of Resident 1’s GACH radiology report (a medical document that provides a detailed interpretation of the results of an imaging test), indicated a computed tomography (CT, a medical imaging procedure) scan of the head was performed, completed on 11/20/2024 at 1:56 PM. The impression indicated left facial bone fracture and recommendation for CT facial bones. A review of Resident 1’s radiology report, indicated a CT facial was performed, completed on 11/20/2024 at 1:56 PM. The impression indicated the following: " Acute displaced left anterior maxillary (the front teeth located in the upper jaw) wall fracture. " Acute displaced left posterior lateral maxillary (the bones that form the upper part of the jaw) wall fracture. " Acute displaced left zygomatic arch (a bar of bone that runs horizontally along the side of the head, positioned in front of the ear) fracture. " Acute displaced left inferior orbital (the bottom of the left eye) wall fracture. A review of Resident 1’s Progress Notes, dated 11/20/2024, timed 5:49 PM, by Registered Nurse 2 (RN 2), indicated Resident 1 was back to the facility from GACH ED after evaluation status post fall with facial injuries. A review of Resident 1’s Progress Notes, dated 11/21/2024, timed 6:14 AM, indicated Resident 1 was on monitoring for status post fall (after a fall) with multiple facial fractures. It also indicated Resident 1 has left eyebrow laceration with steri-strips (thin, adhesive strips used to close small cuts). During an observation on 1/21/2025 at 10:50 AM, in the nursing station, Resident 1 was sitting in a Broda chair (wheelchair that provides comfort, support, and mobility throughout the day, with ability to tilt and recline), in a reclining position. During an interview on 1/23/2025 at 2:41 PM with LVN 1, LVN 1 stated that on 11/20/2024, morning shift (7 AM -3 PM), CNA 1 reported to her that Resident 1 had a fall. LVN 1 stated CNA 1 witnessed Resident 1 leaning forward and falling face down to the floor. LVN 1 stated CNA 1 informed her that CNA 1 transferred Resident 1 from the bed to the high back wheelchair. LVN 1 stated CNA 1 placed the wheelchair in front of the bed, turned around, walked to the side of the bed to get the linen and when he turned back to attend to Resident 1, CNA 1 witnessed Resident 1 falling. LVN 1 stated CNA 1 stated it happened quickly that CNA 1 did not have the chance to prevent Resident 1 from falling. During an interview on 1/23/2025 at 3:14 PM with RN 1, RN 1 stated Resident 1 is dependent from staff with ADL with transferring, eating, and shower. Resident 1 uses a high back wheelchair and if tilted, could prevent Resident 1 from leaning forward. During a telephone interview on 1/24/2025 at 10:03 AM with CNA 1, CNA 1 stated could not recall if Resident 1’s high back wheelchair was reclined or not before the Resident fell. CNA 5 stated he turned away from Resident 1 and walked a few steps to grab the linen on top of the barrel that was right outside Resident 1’s room, and when he turned back to attend to Resident 1, Resident 1 was already falling. CNA 1 stated Resident 1 fell to the floor with his face down. CNA 1 stated that was all that he remembered. During an interview on 1/25/2025 at 11:02 AM with Occupational Therapist (professional who provides treatment that aims to improve individuals' ability to perform daily activities), Occupational Therapist stated Resident 1 has abnormal posture and required total assistance (a situation where a person is unable to complete an activity without full physical help) for wheelchair management. During an interview on 1/25/2025 at 11:19 AM with Physical Therapist Assistant (PTA), PTA stated Resident 1 was using a high back wheelchair before the fall on 11/20/2024. PTA stated high back wheelchair can be tilted and reclined for comfort, safety, and to help with Resident 1's postural problem. PTA added since Resident 1 has unpredictable movements, Resident 1 should not be left unattended. PTA stated there was a high chance for Resident 1 to fall if he was seated in a high back wheelchair that was not reclined or tilted. During a concurrent record review and interview on 1/24/2025 at 12:27 AM with the DON, Resident 1's medical records were reviewed. The DON stated he was notified by LVN 1 about the fall and went to Resident 1's room. The DON stated he observed Resident 1 on the floor, bleeding from his left eyebrow. The DON stated he does not recall Resident 1's high back wheelchair's set up. The DON stated, to prevent Resident 1 from falling, Resident 1 should not be left unattended. The DON stated Resident 1 has a care plan not to be left unattended in the shower, but it should be applied when Resident 1 is in the wheelchair as well. A review of Facility's Policy and Procedure (P&P) titled, "Managing Falls and Fall Risk," revised in March 2018, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. A review of Facility's P&P titled, "Supporting Activities of Daily Living," revised in March 2018, indicated Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. A review of Facility's P&P titled, "Dementia," revised in November 2018, indicated direct care staff will support the resident in initiating and completing activities and tasks of daily living. Such as bathing dressing, mealtimes, and therapeutic and recreational activities will be supervised and supported throughout the day as needed. The facility failed to provide adequate supervision to Resident 1 who was assessed as at risk for falls and was dependent on staff for activities of daily living ([ADL] task such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet and eating) by failing to ensure Resident 1 was left unattended by Certified Nurse Assistant 1 (CNA 1) while Resident 1 was on high back wheelchair. As a result of this deficient practice, Resident 1 fell out of the high back wheelchair on 11/20/2024, landing on the floor and sustaining a left eyebrow laceration ( ), blunt head injury (an injury to the head caused by a forceful impact), and facial fractures (a partial or complete break in the bone). Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment. Resident 1 was diagnosed with blunt head injury (an injury to the head caused by a forceful impact) and facial fractures (a partial or complete break in the bone). The above violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.