Health inspection·April 23, 2024

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. On 3/11/2024, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding quality of care, resident safety, and falls. As a result of the investigation, CDPH determined the facility failed to provide care and services to prevent a fall for Residents 2 and 3 by failing to: 1. Ensure Certified Nurse Assistant (CNA) 5 kept Resident 2's bedside tray, water pitcher, and cup within reach of Resident 2 while in bed. 2. Ensure Licensed Vocational Nurse (LVN) 1 and CNA 4 provided Resident 3 with adequate supervision while Resident 3 was in the restroom unassisted. 3. Ensure Residents 2 and 3 had a "red star" emblem placed on and/or located at Resident 2 and Resident 3’s head of bed, Resident 2 and Resident 3’s assistive devices such as wheelchairs, and outside Residents 2 and 3's room on the name sign, and a wrist band indicating Residents 2 and 3 were fall risks, based on the facility's policy and procedure (P&P) titled, "Fall Prevention Program." These violations resulted in Resident 2’s fall while reaching for the water pitcher that was not within reach on 2/24/2024 at 2:05 pm. Resident 2 suffered a head laceration to the occiput. Resident 2 was transferred to General Acute Care Hospital (GACH) 1 on 2/24/2024 and required two staples to close the laceration. On 3/10/2024 at 10:00 am, Resident 3 fell in the bathroom and suffered a head laceration to the right eyebrow. Resident 3 was transferred to GACH 1 on 3/10/2024 at 12:43 pm and required 4 sutures to close the laceration. A review of Resident 2’s Admission Record, indicated Resident 2 was an 84-year-old male admitted to the facility on 2/16/2024, with diagnoses that included muscle weakness, history of falling, and other abnormalities of gait and mobility. A review of Resident 2's Nursing Admission Assessment (NAA), dated 2/16/2024, indicated Resident 2 required one-person assistance with bed mobility, transfers, and walking in the room. The NAA indicated Resident 2 had a weak gait. The NAA indicated Resident 2 forgot limits or overestimated Resident 2's own ability to ambulate. The NAA indicated Resident 2 was at a high risk for falls and had a history of previous falls. A review of Resident 2's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 2/21/2024, indicated Resident 2 had moderately impaired cognition. The MDS indicated Resident 2 required substantial/maximal assistance with eating, oral hygiene, upper and lower body dressing, personal hygiene, sitting to lying, sitting to stand, and chair/bed-to-chair transfers. The MDS indicated Resident 2 was dependent with toileting hygiene, showering/bathing self, and putting on/taking off footwear. A review of Resident 2's Care Plan (CP), dated 2/21/2024, indicated Resident 2 was at risk for injuries related to falls. The CP goal indicated Resident 2 would have a decrease in significant injury because of falls in the next three months. The CP interventions included to maintain call light within reach, and answer promptly, monitor, anticipate and intervene for factors causing prior falls such as bowel/bladder urgency and mobility problems such as standing, transferring, and walking. A review of Resident 2's Situation-Background-Assessment-Recommendation (SBAR), dated 2/24/2024, timed at 2:05 pm, indicated Resident 2 had an incident of falling. The SBAR indicated Resident 2 had a small amount of blood to the occiput from "a tear that was noted." A review of Resident 2's Progress Notes (PN), dated 2/24/2024, timed at 6:07 pm, indicated Resident 2 was transferred to GACH 1 for further evaluation. A review of Resident 2’s GACH 1 Emergency Department (ED) report dated 2/24/2024, timed at 6:22 pm, indicated Resident 2 was brought in from the nursing home status post fall with a laceration to the back of the head. A review of Resident 2’s GACH 1 Computed Tomography (CT) Scan of the Head Report dated 2/24/2024, indicated Resident 2 had a small right occipital laceration with overlying cutaneous staples with no intracranial hemorrhage, midline shift or mass effect. A review of Resident 2's PN, dated 2/25/2024, timed at 8:50 am, indicated Resident 2 was received in bed and reassessed with one (1) centimeter (cm) by 1.5 cm wound to the back of the head with two staples. A review of Resident 2's Post Fall Assessment (PFA), dated 2/26/2024, timed at 3:30 pm, indicated Resident 2 was found on Resident 2's back with the head towards the foot of the bed. The PFA indicated Resident 2 had been by Resident 2's self at the time of the fall. The PFA indicated Resident 2 had attempted to reach for the water pitcher and cup on the other side of the bed when Resident 2 lost Resident 2's balance and fell. A review of the Interdisciplinary Team (IDT) Post Event Review, dated 2/26/24, untimed, indicated "Resident 2 was found on the floor lying down in a supine position near the floor mat with the head positioned toward the foot part of the bed. The IDT Post Event Review indicated Resident 2 stood up unassisted while trying to reach Resident 2's water and lost balance." During a concurrent observation and interview on 3/11/2024 at 1:05 pm, inside of Resident 2's room, CNA 3 stated Resident 2's water pitcher was not on the bedside tray. CNA 3 stated Resident 2's water pitcher and cup were on Resident 2's bedside table, on the back left corner, where the left side of the head of the bed was. CNA 3 stated Resident 2 could not reach the water pitcher and cup while it was on the bedside table. CNA 3 stated Resident 2's bedside tray was pushed away from the bed to the left wall, parallel with the bed. CNA 3 stated Resident 2's bedside tray was not within reach of Resident 2. CNA 3 stated Resident 2's water pitcher and cup needed to be on the bedside tray, and the bedside tray needed to be next to the bed, so Resident 2 could reach both the water pitcher and cup. CNA 3 stated keeping the bedside tray, water pitcher and cup within reaching distance of Resident 2, kept Resident 2 safe from falls. During an interview on 3/11/2024 at 3:20 pm, CNA 5 stated Resident 2 was considered a high fall-risk resident. CNA 5 stated on 2/24/2024 at approximately 2 pm, CNA 5 checked on Resident 2 and observed Resident 2 sleeping. CNA 5 stated when CNA 5 checked on Resident 2, Resident 2's bedside tray was on the right side of the bed, not within reach of Resident 2. CNA 5 stated CNA 5 did not move the bedside tray closer to Resident 2 when CNA 5 checked on Resident 2. During an interview on 3/11/2024 at 3:31 pm, LVN 2 stated LVN 2 was the person who found Resident 2 after Resident 2 fell. LVN 2 stated Resident 2 was bleeding from Resident 2's occiput. LVN 2 stated keeping the bedside tray within reach would be considered an intervention used to prevent Resident 2 from falling. LVN 2 stated if Resident 2's bedside tray, water pitcher, and cup had been within reach, Resident 2's fall could have been avoided. A review of Resident 3’s Admission Record, indicated Resident 3 was a 77-year-old male admitted to the facility on 5/7/2015, with diagnoses that included dementia, generalized muscle weakness, and difficulty walking. A review of Resident 3's CP initiated on 4/21/2023, indicated Resident 3 was at risk for injuries related to falls. The CP goals indicated Resident 3 would have a significant decrease in injury as a result from falls. The CP interventions included to maintain call light within reach, and answer promptly, monitor, anticipate/intervene for factors causing prior falls such as bowel/bladder urgency and mobility problems such as standing, transferring, and walking, and to place Resident 3 in a highly monitored area. A review of Resident 3's MDS dated 1/15/2024, indicated Resident 3 had severely impaired cognition. The MDS indicated Resident 3 required setup or clean-up assistance with eating, oral hygiene, and upper body dressing. The MDS indicated Resident 3 required supervision or touching assistance with lower body dressing, putting on/taking off footwear, and lying to sitting on the side of the bed. The MDS indicated Resident 3 required partial/moderate assistance with showering/bathing self, sitting to standing, and chair/bed-to-chair transfers. The MDS indicated Resident 3 required substantial/maximal assistance with personal hygiene. The MDS indicated Resident 3 was dependent with toileting hygiene. A review of Resident 3's SBAR dated 3/10/2024, timed at 10:00 am, indicated Resident 3 had a fall. The SBAR indicated Resident 3 had a laceration to the right side of eyebrow with minimal bleeding. A review of Resident 3's PFA dated 3/10/2023, timed at 12:31 pm, indicated Resident 3 was found on the bathroom floor between the left side of toilet and bathroom wall. The PFA indicated Resident 3 was in a semi-seated position with both legs extended and head up, with right side of body lying toward the toilet bowl due to Resident 3 having right-sided weakness. The PFA indicated no one was present at the time Resident 3 fell. A review of Resident 3's GACH 1 General ED Report dated 3/10/2024, timed at 12:34 pm, indicated Resident 3 had a 2.5 cm laceration to the right eyebrow after falling into the toilet bowl. The report indicated Resident 3 received 4 sutures to repair and close the laceration. During an interview on 3/11/2024 at 2:45 pm, LVN 1 stated keeping Resident 3 in a highly monitored area meant to keep Resident 3 in activities or by the nursing station, being always monitored by staff. LVN 1 stated it was important to be aware of Resident 3's needs to avoid Resident 3 from getting hurt. LVN 1 stated on the morning of 3/10/2024, CNA 4 informed LVN 1 around 9:00 am that Resident 3 was taken to the activity room. LVN 1 stated the activity room did not open until 9:30 am or 10:00 am every day. LVN 1 stated on the morning of 3/10/2024, LVN 1 was busy with other residents and did not see Resident 3 go back to the room. LVN 1 stated based off Resident 3's care plan, someone should have assisted Resident 3 back to the room and to the restroom. LVN 1 stated Resident 3's fall and injury could have been avoided had Resident 3 been appropriately monitored. During an interview on 3/11/2024 at 2:37 pm, CNA 4 stated CNA 4 took Resident 3 to the activity room at approximately 9:20 am. CNA 4 stated the activity room usually opened between 9:30 am and 10:00 am. CNA 4 stated if the activity room was not open, the front desk receptionist will monitor Resident 3. CNA 4 stated CNA 4 did not see Resident 3 go back to the room. CNA 4 stated CNA 4 could not always keep track of Resident 3. CNA 4 stated Resident 3 needed to stay in a highly monitored area. During an interview on 3/11/2024 at 3:02 pm, Activities Assistant (AA) 1 stated on 3/10/2024, the activity room opened at 9:30 am. AA 1 stated Resident 3 did not go to the activity room that day. During an interview on 3/11/2024 at 3:20 pm, Receptionist 1 stated receptionists did not have to communicate with nurses or CNA when a resident left the front lobby area to back to their room. During a concurrent observation and interview on 3/12/2024 at 1:30 pm, with LVN 3, in Resident 2's room, Resident 2's room was observed. LVN 3 stated Resident 2 was part of the falling star program. LVN 3 stated the falling star program was used for residents who were considered high fall-risks. LVN 3 stated there was supposed to be a yellow star on Resident 2's name sign at the door. LVN 3 stated there was not a star next to Resident 2's name on the room sign. LVN 3 stated there was no star placed on the head or foot of Resident 2's bed. LVN 3 stated there was not a star placed on Resident 2's wheelchair. During a concurrent observation and interview on 3/12/2024 at 1:35 pm, with LVN 3, in Resident 3's room, Resident 3's room was observed. LVN 3 stated there was not a star next to Resident 3's name sign at the door. LVN 3 stated there was no star placed on the foot of Resident 3's bed. LVN 3 stated there was a star on the head of Resident 3's bed, however the star was yellow. LVN 3 stated the yellow star indicated Resident 3 was a fall risk. LVN 3 stated Resident 3 was not wearing a yellow wrist band to indicate Resident 3 was a fall risk. LVN 3 stated there was not a star placed on Resident 3's wheelchair. LVN 3 stated if a resident did not have the appropriate signage or was not wearing a wrist band, it was possible staff would not otherwise know Residents 2 or 3 were high fall risks, and Residents 2 and 3 could fall and get hurt. During an interview on 3/12/2024 at 12:55 pm, the Director of Nursing (DON) stated when a resident was identified as a high fall-risk, staff needed to implement interventions such as the use of floor mats to help avoid injuries, keeping the bed in the lowest position, keeping residents close to the nursing station when possible, and encourage residents to attend daily activities to help keep their attention diverted and so staff could keep an eye on the resident. The DON stated those interventions were supposed to prevent the possibility of falls and/or subsequent injuries. The DON stated water pitchers should be within reach of a resident. The DON stated it a water was not within reach of a resident and the resident reaches for the water pitcher; it was possible the resident could call. The DON stated it was possible Resident 2's fall and injury could have been avoided had staff kept the bedside tray and water pitcher within reach of Resident 2. The DON stated if staff had communicated with one another that Resident 3 was leaving the front lobby and going back towards Resident 3's room, Resident 3 could have gotten assistance to the bathroom and the fall and injury could have been avoided. During a concurrent interview and record review on 3/12/2024 at 1:45 pm, with the Administrator (ADM), the facility's P&P titled, "Fall Prevention Program," was reviewed. The ADM stated the PP indicated to use a red "falling star" emblem on a resident's head of bed, assistive devices such as wheelchairs, outside the resident's room on the name sign, and that a resident would wear a wrist band. The ADM stated the facility had never used red stars before. The ADM stated the facility only used yellow stars to indicate a resident was a high fall risk. The ADM stated using a yellow star to indicate a resident was a fall risk when the P&P indicated to use red, could be confusing to staff, and could leave to residents being at risk for falls. A review of the facility's P&P titled, "Fall Prevention Program," dated 12/2026, indicated the facility identified interventions related to the resident's specific risks and causes to try and prevent the resident from falling and tried to minimize complications from falling. The P&P indicated care plan interventions should include the treatment prescribed by the physician and interdisciplinary recommendations. The P&P indicated the care plan should include close observation and increased supervision, staff assistance to the toilet or bedside commode, and use of monitoring or sensor devices. The P&P indicated to implement the use of a "red star" for residents who were considered high fall-risks. The P&P indicated a "falling star" emblem be placed and/or located at the head of bed, assistive devices like wheelchairs, outside the resident's room on the name sign, and the use of a wrist band. The fa