Health inspection·April 17, 2025

F689 Code of Federal Regulations, Title 42, Section 483.25 (d) Accidents. The facility must ensure that – §483.25(d)(1) The patient environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each patient receives adequate supervision and assistance devices to prevent accidents. California Code of Regulations, Title 22, Section 72311. Nursing Service - General (a)Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. On 3/4/2025, the California Department of Public Health (CDPH) conducted an unannounced recertification survey at the facility. As a result of the investigation, the CDPH determined the facility failed to provide a safe environment to prevent injuries for Resident 37. The facility failed to: 1. Ensure Licensed Vocational Nurses (LVNs) implemented Resident 37's untitled Care Plan (CP), dated 2/26/2025, to provide interventions such as anticipating Resident 37's needs and providing opportunities for positive interaction/attention to Resident 37 to decrease or eliminate Resident 37's episodes of banging his head on the walls/doors. 2. Ensure Certified Nursing Assistants (CNAs) provided hourly monitoring to Resident 37 who was assessed with aggressive behavior as ordered by Resident 37's physician (MD1) on 2/2/2025. As a result, Resident 37 sustained a self-inflicted laceration on the scalp which measured one centimeter and a head contusion on 3/2/2025. Resident 37 was sent to General Acute Care Hospital 2 (GACH 2) where Resident 37 underwent a repair of laceration by application of skin tissue adhesive glue. In addition, on 3/4/2025 Resident 37 had a physical altercation with Resident 37's roommate (Resident 196) and Resident 37 was sent to GACH 2 for medical evaluation. Resident 37 sustained a displaced nasal septal fracture, a frontal scalp hematoma and complained of severe pain on the face from the altercation with Resident 196. 1. A review of Resident 37's Admission Record indicated the facility initially admitted Resident 37, a 55-year-old male, on 10/11/2024 and readmitted on 2/1/2025 with diagnoses that included Huntington's Disease and dementia. A review of Resident 37's History and Physical dated 2/3/2025 indicated Resident 37 was able to make his needs known but cannot make medical decisions. A review of Resident 37's Minimum Data Set dated 2/7/2025 indicated Resident 37 had moderately impaired cognition. The MDS indicated Resident 37 required supervision for toileting, bathing, sitting to standing, and partial/moderate assistance for walking 10 feet. A review of Resident 37's untitled CP dated 2/26/2025 indicated Resident 37 had a behavior problem of "banging" his head on the wall and punching the wall due to dementia. The CP goal indicated to ensure Resident 37 would not have incidence of behavior problem and fewer episodes of banging head on the wall. The CP interventions indicated for nursing staff to anticipate the needs of Resident 37 and provide opportunities for positive interaction and attention. A review of Resident 37's Progress Notes (PN) dated 3/2/2025 timed at 2:04 PM indicated Resident 37 was walking in the hallway and suddenly threw a remote control from his hand to the floor. The PN indicated Resident 37 turned around and hit the top of his head on the door. The PN indicated Resident 37 had an angry outburst (a sudden violent expression of strong feeling) for no reason. The PN indicated Treatment Nurse 1 assessed Resident 37 and he had minimal bleeding from the top of the center of his head. The PN indicated Resident 37 sustained a laceration on the head which measured 2.5 cm in length by 0.3 cm in width by 0.3 cm in depth. A review of Resident 37's Change of Condition Evaluation (COCE) dated 3/2/2025 timed at 2:34 PM indicated Resident 37 was walking in the hallway and his head on the door causing bleeding on the top of his head. A review of Resident 37's GACH 2 Emergency Department General (EDG) form dated 3/2/2025 at 3:27 PM indicated Resident 37 was brought to the Emergency Department (ED) from the facility by ambulance for evaluation of head injury. The EDG form indicated Resident 37 had a head contusion and one cm laceration to the scalp. The EDG form indicated Resident 37 underwent a repair of the scalp laceration with application of skin tissue adhesive glue. A review of Resident 37's PN dated 3/2/2025 timed at 7:32 PM indicated Resident 37 returned back to the facility from GACH 2. The PN indicated Resident 37's laceration on the head was glued with skin tissue adhesive glue at GACH 2. A review of Resident 37's Order Summary Report (OSR) dated 3/4/2025 indicated for nursing staff to monitor Resident 37's top of the head laceration with surgical glue status post banging head to the wall for any wound dehiscence, bleeding or unusual changes every shift and to report to MD 1 promptly. During an interview with LVN 3 on 3/6/2025 at 1:39 PM, LVN 3 stated on 3/2/2025, Resident 37 hit his head on the shower door in the hallway. LVN 3 stated Resident 37 sustained a laceration on top of Resident 37's head. LVN 3 stated Resident 37 was sent to GACH 2 and received treatment for the laceration. LVN 3 stated she did not know Resident 37 had an order to monitor Resident 37 for episodes of hitting his head on walls/doors. 2. A review of Resident 37's OSR dated 2/2/2025 indicated an order for hourly monitoring of Resident 37 for aggressive behavior every shift. A review of Resident 37's COCE dated 3/4/2025 timed at 7:13 AM indicated Resident 37 had a physical altercation with another resident (Resident 196). The COCE indicated Resident 196 hit Resident 37 on the face and head. The COCE indicated Resident 37 sustained a bloody mouth, a bloody nose, and a small bump on the forehead. A review of Resident 37's Situation, Background, Assessment, Recommendation Communication (SBARC) form dated 3/4/2025, timed at 7:20 AM indicated Resident 37 sustained a bloody mouth, bloody nose, and a small bump on the forehead. The SBARC form indicated Resident 37 was punched by Resident 37's roommate (Resident 196). A review of Resident 37's GACH 2 EDG form dated 3/4/2025 timed at 11:50 AM indicated Resident 37 was brought to the ED from the facility by ambulance due to head and nose pain after a physical altercation at the facility on 3/4/2025 at 7 AM. The EDG form indicated there was no treatment given for Resident 37 at GACH 2. A review of Resident 37's GACH 2 Computer Tomography (CT) scan result of Resident 37's face, dated 3/4/2025, timed at 11:53 AM indicated a mildly displaced nasal septal fracture and a frontal scalp hematoma. During an interview Certified Nursing Assistant (CNA) 8 on 3/4/2025 at 4:15 PM stated Resident 37 returned from GACH 2 on 3/4/2025 with a bump on Resident 37's forehead. During a concurrent observation and interview with Resident 37 in his room on 3/4/2025 at 4:17 PM, Resident 37 was calm and had a small bump on the forehead. Resident 37 stated he had a 10/10 pain on his face as the result of the altercation with Resident 196 on 3/4/2025. During an interview the facility's Director of Staff Development (DSD) on 3/7/2025 at 12:18 PM stated, on 3/4/2025 in the early morning, the DSD entered Resident 37's room and saw blood around Resident 37's nose and mouth. The DSD stated Resident 37 told the DSD that Resident 196 punched Resident 37 in the face. The DSD stated the incident was not witnessed by facility staff. During a concurrent interview and record review with CNA 7 on 3/7/2025 at 12:29 PM, Resident 37's OSR dated 2/2/2025 was reviewed. The OSR indicated an order for hourly monitoring to Resident 37 for aggressive behavior every shift. CNA 7 stated there were no Hourly Behavioral Monitoring Sheet (HBMS) created for Resident 37 on 3/2/2025 and 3/3/2025 and the HBMS on 3/4/2025 was created after the physical altercation incident happened between Resident 37 and Resident 196 on 3/4/2025. CNA 7 stated CNA 7 was not aware or informed that Resident 37 required hourly monitoring. CNA 7 stated Resident 37 needed hourly monitoring when the resident was aggressive and had behavior of hurting himself. CNA 7 stated hourly monitoring was a physician's order and needed to be followed. CNA 7 stated CNAs were responsible for hourly monitoring and documenting the hourly monitoring on the HBMS. CNA 7 stated CNA 7 did not see any HBMS completed for Resident 37 prior to the incidents on 3/2/2025 and 3/4/2025. During a concurrent interview and record review with LVN 3 on 3/7/2025 at 2:21 PM, Resident 37's OSR dated 2/2/2025 was reviewed. The OSR dated 2/2/2025 indicated an order for hourly monitoring of Resident 37 for aggressive behavior every shift. LVN 3 stated hourly monitoring for Resident 37 was not done as ordered by the physician. LVN 3 stated the purpose of monitoring Resident 37 hourly was to ensure Resident 37 was safe. LVN 3 stated prior to the incident on 3/2/2025 and 3/4/2025 nursing staff did not provide hourly monitoring/supervision to Resident 37 as MD 1 ordered. During an interview the facility's Director of Nursing (DON) on 3/7/2025 at 3:15 PM stated hourly monitoring for Resident 37 was not done prior to the incidents on 3/2/2025 and 3/4/2025. The DON stated Resident 37 was not supervised/monitored because the physician's order for hourly monitoring was not implemented. The DON stated, "The incidents on 3/2/2025 and 3/4/2025 could have been prevented if hourly monitoring was done (on Resident 37)." A review of the facility's Policy and Procedure (P&P) titled, "Safety and Supervision of Residents," revised 7/2017 indicated the care team shall target interventions to reduce individual related risks related to hazards in the environment including adequate (enough, acceptable in quality or quantity) supervision and monitoring of residents. The facility failed to provide a safe environment to prevent injuries for Resident 37. The facility failed to: 1. Ensure Licensed Vocational Nurses implemented Resident 37's untitled CP dated 2/26/2025, to provide interventions such as anticipating Resident 37's needs and providing opportunities for positive interaction/attention to Resident 37 to decrease or eliminate Resident 37's episodes of banging his head on the walls/doors. 2. Ensure Certified Nursing Assistants provided hourly monitoring to Resident 37 who was assessed with aggressive behavior as ordered by Resident 37's physician on 2/2/2025. As a result, Resident 37 sustained a self-inflicted laceration on the scalp which measured one centimeter and a head contusion on 3/2/2025. Resident 37 was sent to GACH 2 where Resident 37 underwent a repair of laceration by application of skin tissue adhesive glue. In addition, on 3/4/2025 Resident 37 had a physical altercation with Resident 196 and Resident 37 was sent to GACH 2 for medical evaluation. Resident 37 sustained a displaced nasal septal fracture, a frontal scalp hematoma and complained of severe pain on the face from the altercation with Resident 196. The above violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 37.