Health inspection·August 8, 2025

F688 Code of Federal Regulations, Title 42, Section483.25(c) Mobility. § .25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident’s clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. California Code of Regulations, Title 22, Section § 72315. Nursing Service - Patient Care. (e) Each patient shall be encouraged and/or assisted to achieve and maintain the highest level of self-care and independence. Every effort shall be made to keep patients active, and out of bed for reasonable periods of time, except when contraindicated by orders of a licensed health care practitioner acting within the scope of his or her professional licensure. 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 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. On 6/23/2025, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding quality of care, treatment, and resident rights involving Resident 1. As a result of the investigation, the CDPH determined that the facility failed to ensure Resident 1 received appropriate treatment to prevent further decrease in Resident 1’s range of motion (ROM, the full movement potential of a joint or body part) in Resident 1’s left shoulder. This failure resulted in Resident 1 experiencing pain in the left shoulder during passive range of motion (PROM, a caregiver moving a resident's joint through its full range of motion without the resident actively contracting their muscles) exercise and had the potential for Resident 1 to experience join stiffness due to a decrease in ROM in Resident 1’s left shoulder. A review of Resident 1's Admission Record (AR), indicated Resident 1, a 104-year-old female, was admitted to the facility on 11/29/2019 and readmitted to the facility on 6/10/2022 with diagnoses including chronic obstructive pulmonary disease (COPD), dementia hemiplegia, and hemiparesis. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 3/27/2025, indicated Resident 1 was severely impaired in cognitive skills. The MDS indicated Resident 1 was dependent on staff for dressing, bathing, and personal, oral, and toileting hygiene. During a concurrent interview and record review on 6/23/2025 at 1:59 p.m., Restorative Nursing Assistant (RNA) 1 reviewed Resident 1’s RNA form, for June 2025. The RNA form indicated RNAs (in general) provided PROM exercise to Resident 1’s right arm, right leg, and left leg. RNA 1 stated RNA 1 did not provide PROM to Resident 1’s left arm. During a concurrent interview and record review on 6/23/2025 at 2:10 p.m., the Director of Rehabilitation (DOR) reviewed Resident 1’s Joint Mobility Assessment (JMA), dated 3/25/2025. The DOR confirmed the JMA indicated Resident 1 had impaired mobility (the ability to move or be moved freely and easily) to Resident 1’s left shoulder. The DOR stated the RNAs (in general) should be providing PROM to Resident 1’s left shoulder to prevent joint stiffness. During a concurrent observation and interview on 6/23/2025 at 2:20 p.m., the DOR provided PROM to Resident 1’s left shoulder. Resident 1 yelled out and had grimacing on Resident 1’s face. The DOR stated Resident 1’s left shoulder had some mobility limitation, and that Resident 1 was in pain when the DOR provided PROM to the left shoulder. The DOR stated the DOR was under the impression Resident 1 was being provided PROM to Resident 1’s left shoulder. During a concurrent interview and record review on 6/24/2025 at 1:54 p.m., Director of Nursing (DON) reviewed Resident 1’s untitled care plan, initiated on 4/8/2025. The care plan indicated Resident 1 was at risk for decline in ROM of Resident 1’s arms and legs. The care plan indicated interventions to include providing PROM to Resident 1’s left arm. The DON stated the goal of the interventions was to prevent a decline in Resident 1’s ROM for right and left arms and legs. A review of the facility's policy and procedure (P&P) titled, Joint Mobility Assessment, dated 1/1/2025, indicated, “A resident, who enters the facility without a limited range of motion, shall not experience reduction in range of motion unless the resident's clinical condition and associated diagnoses demonstrates that a reduction in range of motion is unavoidable… A resident with a limited range of motion or contracture shall receive appropriate treatment and services, based on the comprehensive assessment of the resident, to increase range of motion and/or to prevent further decrease if possible, depending on resident clinical condition.” A review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised December 2016, indicated, “A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.” The facility failed to ensure Resident 1 received appropriate treatment to prevent further decrease in Resident 1’s ROM in Resident 1’s left shoulder. This failure resulted in Resident 1 experiencing pain in the left shoulder during PROM exercise and had the potential for Resident 1 to experience join stiffness due to a decrease in ROM in Resident 1’s left shoulder. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.