Health inspection·June 13, 2025

Code of Federal Regulations, Title 42, Section 483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each Patient, consistent with the Patient rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a Patient's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following — (i) The services that are to be furnished to attain or maintain the Patient's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40 Code of Federal Regulations, Title 42, Section 483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be— (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. California Code of Regulation, Title 22, Section 72311. Nursing Services – General (a) Nursing services 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 Regulation, Title 22, Section 72311. Nursing Services – General (a) Nursing services 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 (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professionals personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient’s condition 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. On 4/25/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding quality of care and nursing services for Resident 1. As a result of the investigation, the CDPH determined the facility failed to follow its policies and procedures (P&P) titled, “Care Planning,” and “Fall Management Program,” by failing to: 1. Implement Resident 1’s care plan for falls dated 10/16/2023 to keep personal items within reach. 2. Complete Resident 1’s quarterly fall risk assessment on 3/5/2025. 3. Revise Resident 1’s care plan for falls after Resident 1 sustained a fall on 3/20/2025. These failures resulted in Resident 1 not receiving the appropriate care and services and sustaining a recurrent fall on 4/9/2025. Resident 1 sustained skin discoloration to Resident 1’s right forehead, right eye, right hand, and swelling to Resident 1’s right eye and right hand from the fall on 4/9/2025. These failures placed Resident 1 at risk for further falls. A review of Resident 1's Admission Records (AR), indicated the facility admitted Resident 1, a 76-year-old female on 11/14/2021, and readmitted Resident 1 on 2/24/2025, with diagnoses which included bullous pemphigoid (an autoimmune disease that causes large fluid-filled blisters on the Patient's skin), dementia (a progressive state of decline in mental abilities), and hemiplegia (total paralysis of the arm, leg, and trunk of the same slight of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease (stroke, damage to the brain from interruption of its blood supply) affecting right dominant side. A review of Resident 1's Care Plan (CP) titled, "Care Plan Report," revised on 10/16/2023, indicated Resident 1 was at risk for falls related to confusion, gait/balance problems, incontinence, poor communication/comprehension, and lack of awareness of Resident 1's safety needs. The CP's goal indicated Resident 1 will be free of falls through 5/22/2025. The CP interventions included for the staff to anticipate and meet Resident 1's needs, review information on past falls to determine the cause of Resident 1's falls, follow the facility's fall protocol, and ensure Resident 1's personal items were within reach. A review of Resident 1's Fall Risk Assessment (FRA) dated 1/11/2025, indicated Resident 1 was at high risk for falls due to impaired gait, more than one diagnosis, and overestimating or forgetting limits. A review of Resident 1's History and Physical (H&P), dated 2/25/2025, indicated Resident 1 did not have the capacity to understand and make decisions. The H&P indicated Resident 1 was able to make decisions for Resident 1's activities of daily living (ADLs, activities such as bathing, dressing, and toileting a person performs daily). A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 3/3/2025, indicated Resident 1's cognitive skills were severely impaired. The MDS indicated Resident 1 required moderate assistance with eating. The MDS indicated Resident 1 was dependent on staff for transferring from bed to chair and rolling from lying on her back to left or right side. The MDS indicated Resident 1 used a wheelchair for transportation within the facility. The MDS indicated Resident 1 did not have a history of falls in the last six months of the assessment. A review of Resident 1's Change in Condition Evaluation (COC), dated 3/20/2025, timed at 2:31 AM, the COC indicated Resident 1 had an unwitnessed fall (on 3/20/2025). The COC indicated Resident 1 was found "laying on the floor in horizontal position" between Bed A and Bed B. The COC indicated Resident 1 had no change to Resident 1's level of consciousness (LOC) and did not sustain any skin injuries. A review of Resident 1's Skin Observation Checks (SOC), dated 3/20/2025, timed at 8:03 AM, indicated Resident 1 had redness noted on the cheek (specific side not indicated). A review of Resident 1's COC, dated 4/9/2025, timed at 4:06 PM, indicated Resident 1 had an unwitnessed fall (on 4/9/2025). The COC indicated Resident 1 sustained skin discoloration to Resident 1's right forehead, right eye, and right hand. The COC indicated Resident 1 sustained swelling to Resident 1's right eye and right hand. The COC indicated Resident 1's Primary Care Physician (PCP 1) was notified and recommended an X-ray of Resident 1's right facial bone and right hand STAT (immediately). A review of Resident 1's Nursing Progress Notes (NPN), dated 4/9/2025, timed at 4:20 PM, indicated Resident 1 was found sitting on the floor with Resident 1's right head leaning towards the plastic bedside dresser by Resident 1's head of bed. The COC indicated Resident 1 attempted to stand up from (Resident 1's) bed to reach Resident 1's glasses from the drawer and lost balance. A review of Resident 1's Radiology Results Report (X-ray Report) of Resident 1's facial bones, dated 4/9/2025, timed at 6:44 PM, the X-ray Report indicated no acute findings. A review of Resident 1's X-ray Report of Resident 1's right hand, dated 4/9/2025, timed at 6:44 PM, the X-ray Report indicated Resident 1's right hand had mild soft tissue swelling. During an observation on 4/25/2025 at 12:46 PM in Resident 1's room, Resident 1 was observed attempting to transfer from lying to sitting position without assistance. Resident 1's plastic three (3) drawer storage container was against the wall, on the right side of Resident 1's bed, by Resident 1's headboard. There was a water pitcher, a cup, a pair of glasses, a tissue box, and personal items on top of Resident 1's storage container. Resident 1's wheelchair was in front of the three-drawer storage container. Resident 1's overbed table was in front of the wheelchair by Resident 1's padded footboard. Resident 1's overbed table did not have anything on top of it. During a concurrent observation of Resident 1, in Resident 1’s room, and interview on 4/25/2025 at 12:55 PM, with Registered Nurse (RN) 1, Resident 1 was observed with discoloration on the left and right side of Resident 1's face. RN 1 stated Resident 1 had an old bruise on the left and right side of the face. RN 1 stated RN 1 was unaware if Resident 1 had any falls in 2025. RN 1 stated Resident 1 was at risk for falls. During an interview on 4/25/2025 at 1:30 PM, Certified Nurse Assistant (CNA) 2 stated Resident 1's overbed table did not have any items on top of it because Resident 1 "knocks it down." CNA 2 stated when Resident 1 was sitting up in bed, Resident 1 "will start knocking things off the table." During an interview on 5/1/2025 at 12:28 PM, the MDS Nurse stated a resident’s (in general) fall risk assessment was completed upon admission, quarterly, and post-fall incident. During a concurrent interview and record review on 5/1/2025 at 12:35 PM, the MDS Nurse reviewed Resident 1's fall risk assessments from 1/2025 to 4/2025. The MDS Nurse stated there was no documented evidence Resident 1 had a quarterly fall risk assessment completed in 3/2025. The MDS Nurse stated Resident 1's quarterly fall risk assessment should have been completed on 3/5/2025. The MDS Nurse stated a quarterly fall risk assessment was important to identify if there were any new changes in Resident 1's mobility and to reevaluate Resident 1's specific person-centered interventions. During an interview on 5/1/2025 at 12:38 PM, the MDS Nurse stated the MDS Nurse was unaware of any care plans related to placing Patient's 1 daily items within reach. The MDS Nurse stated Resident 1's daily items should be within reach to prevent any further falls. During a concurrent interview and record review on 5/1/2025 at 12:40 PM, the MDS Nurse reviewed Resident 1's CP related to Resident 1's actual fall on 3/20/2025 was reviewed. The MDS nurse stated there was a CP created for Resident 1's actual fall, but Resident 1's CP was not revised in a timely manner. The MDS nurse stated Resident 1’s CP should have been revised after the fall on 3/20/2025. The MDS nurse stated CP should be revised quarterly and if there are any significant changes. During a concurrent interview and record review on 5/1/2025 at 4 PM, the Director of Nursing (DON) reviewed Resident 1's fall risk assessments from 1/2025 to 4/2025. The DON stated there was no documented evidence Resident 1 had a quarterly fall risk assessment completed in 3/2025. The DON stated a quarterly fall risk assessment was important to assess and identify if Resident 1 was still at high risk for falls and to identify new interventions to implement to ensure Resident 1's safety. During an interview on 5/1/2025 at 4:20 PM, the DON stated Resident 1 wanted Resident 1's personal items in a particular place and would get agitated if Resident 1's items were not where Resident 1 wanted the items. The DON stated Resident 1's personal items on top of Resident 1's three-drawer plastic storage container were not within Resident 1's reach. The DON stated Resident 1 could continue to fall if Resident 1's daily items were not within reach as indicated in Resident 1’s fall risk care plan. During the same interview on 5/1/2025 at 4:20 PM, the DON reviewed Resident 1's CPs related to falls. The DON stated Resident 1's CP should have been revised after the fall on 3/20/2025 and after any COC. The DON stated a CP should be created or revised the day of the fall incident to 72 hours later. The DON stated CP revisions were important to indicate the patient's goals and intervention as an indicator of the facility' s CP for Resident 1. A review of the facility's P&P titled, "Care Planning," dated 10/1/2023, indicated, "Each Patient's comprehensive care plan will describe ... "services that are furnished to attain or maintain the Patient's highest practicable physical, mental, and psychosocial well-being." A review of the facility's P&P titled, "Fall Management Program," dated 10/1/2023, indicated, "The Licensed Nurse will assess each Patient for their risk of falling upon admission, quarterly, and with significant change of condition." The P&P indicated, "The Nursing Staff and interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their patient) ... will identify and implement interventions to reduce the risk of falls. The P&P indicated, "The Nursing Staff will develop a plan of care specific to the Patient's needs with interventions to reduce the risk of falls ... interventions will be implemented ..." A review of the facility's P&P titled "Fall Management Program," dated 10/2023, the P&P indicated the "licensed nurse will review the circumstances of the fall, review the plan of are, implement new interventions as appropriate, and revise the plan as indicated." The P&P indicated, "Interdisciplinary Team (IDT, a collaborative approach from multiple medical disciplines who work together towards the goal of the patient) will routinely review the plan of care at a minimum of quarterly, with significant change of condition, and post fall. Interventions will be implemented or changed based on the patient' s condition and response." The P&P indicated the committee will meet within 72 hours of the fall incident and review the "summary of event following a fall, root cause analysis, referrals, as necessary, and interventions to prevent future falls." The P&P indicated the "nursing staff will develop a plan of care specific to the patient' s needs with interventions to reduce the risk of falls." As a result of the investigation, the CDPH determined the facility failed to follow its P&P titled, “Care Planning,” and “Fall Management Program,” by failing to: 1. Implement Resident 1’s care plan for falls dated 10/16/2023 to keep personal items within reach. 2. Complete Resident 1’s quarterly fall risk assessment on 3/5/2025. 3. Revise Resident 1’s care plan for falls after Resident 1 sustained a fall on 3/20/2025. These failures resulted in Resident 1 not receiving the appropriate care and services and sustaining a recurrent fall on 4/9/2025. Resident 1 sustained skin discoloration to Resident 1’s right forehead, right eye, right hand, and swelling to Resident 1’s right eye and right hand from the fall on 4/9/2025. These failures placed Resident 1 at risk for further falls. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.