Health inspection·March 12, 2025

California Code, Health and Safety Code - HSC § 1424 (f)(1) A willful material falsification or willful material omission in the health record of a resident of a long-term health care facility is a violation. On 2/26/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding resident rights and quality of care/treatment. As a result of the investigation, the CDPH determined the facility failed to ensure the health record of Resident 2 pertaining to restorative nursing services (RNS- specialized nursing interventions provided by a restorative nursing assistant [RNA] focused on helping to maintain or regain functional abilities to achieve the highest level of well-being, often after rehabilitation or to prevent decline) provision was not willfully falsified. The facility failed to: 1. Ensure RNA 5 did not initial Resident 2’s Restorative Nursing Flow Sheet (RNFS) when RNA 5 did not provide Resident 2 with range of motion (ROM- exercises and/or movements designed to improve the flexibility and mobility of joints) as ordered by the physician on 2/25/2025, 2/26/2025 and other unspecified days in 2/2025. 2. Ensure RNA 1 and RNA 2 did not initial Resident 2’s RNFS to indicate RNS was provided to Resident 2 on 1/16/2025, 1/24/2025, 1/27/2025, 1/28/2025, 1/29/2025, 1/30/2025, and 1/31/2025 when RNA 1 and RNA 2 were not clocked in to work on those dates. These failures resulted in Resident 2’s medical records to contain inaccurate information that could affect Resident 2’s care and result in ROM decline. A review of Resident 2’s Admission Record, indicated the facility admitted Resident 2, a 34 year old female, on 10/4/2023 with diagnoses that included conversion disorder with mixed symptom presentation (mental health condition characterized by physical symptoms that cannot be explained by a medical or neurological condition), dysarthria (speech disorder characterized by difficulty in articulating words and producing clear speech due to weakness or poor coordination of the muscles involved in speech production), anarthria (characterized by the complete inability to articulate speech. caused by damage to the brain or nerves that control the muscles involved in speech production, such as the lips, tongue, and vocal cords), and unspecified neuropathy (A condition that involves damage to the peripheral nervous system from injury or disease process). A review of Resident 2’s physician order (PO) dated 6/11/2024, indicated Resident 2 to have RNA for bilateral lower extremity (BLE) active-assisted ROM exercises (AAROM- the joint receives partial assistance from an outside force) daily, five (5) days per week of 20 repetitions, three (3) sets of each exercise or as tolerated by patient. A review of Resident 2’s Minimum Data Set (MDS- resident assessment tool), dated 1/9/2025, indicated Resident 2 had moderately impaired cognition. The MDS indicated Resident 2 was dependent on staff for toileting hygiene, lower body dressing, putting on/taking off footwear, and chair/bed-to-chair transfers. The MDS indicated Resident 2 required substantial/maximal assistance with showering/bathing self, personal hygiene, and rolling left and right. A review of Resident 2’s RNFS for 1/2025 and 2/2025, indicated on 1/16/2025, 1/30/2025, and 1/31/2025, RNA 2 initialed Resident 2’s RNFS to indicate RNA 2 provided AAROM exercises to Resident 2 as ordered by Resident 2’s physician. The RNFS indicated on 1/24/2025, 1/27/2025, 1/28/2025, and 1/29/2025, RNA 1 initialed Resident 2’s RNFS to indicate RNA 1 provided AAROM exercises to Resident 2. The RNFS indicated on 2/3/2025, 2/5/2025 to 2/7/2025, 2/10/2025, 2/12/2025 to 2/14/2025, 2/18/2025 to 2/21/2025, 2/24/2025, and 2/25/2025, RNA 5 initialed Resident 2’s RNFS to indicate RNA 5 provided AAROM exercises to Resident 2 as ordered by the physician. During a concurrent interview and record review on 2/26/2025 at 1:44 pm, the Director of Staffing Developing (DSD) reviewed RNA 1 and RNA 2’s timecards and staffing sign-in sheets and Resident 2’s RNFS for 1/2025 and 2/2025. The DSD stated on 1/16/2025, 1/30/2025, and 1/31/2025, RNA 2 initialed Resident 2’s RNFS indicating RNA 2 provided the RNS, however RNA 2 was not working (on 1/16/2025, 1/30/2025, and 1/31/2025). The DSD stated on 1/24/2025, 1/27/2025, 1/28/2025, and 1/29/2025, RNA 1 initialed Resident 2’s RNFS indicating RNA 2 provided the RNS, however RNA 1 was not working (on 1/24/2025, 1/27/2025, 1/28/2025, and 1/29/2025). The DSD stated RNA 1 and RNA 2 no longer worked at the facility. The DSD could not say if Resident 2 received RNS on 1/16/2025, 1/24/2025, 1/27/2025, 1/28/2025, 1/29/2025, 1/30/2025, and 1/31/2025. The DSD stated if Resident 2 did not receive RNS as ordered by the physician, Resident 2 could have a decline in mobility that could cause Resident 2 to be unable to use Resident 2’s limbs and would make Resident 2 more dependent with care and activities of daily living. During an interview on 2/26/2025 at 11:06 am, Resident 2 stated the RNAs (unidentified) did not provide RNS to Resident 2 on 2/24/2025 or 2/25/2025. Resident 2 stated the RNAs (unidentified) say they are providing RNS, but they either do not do it or only complete the order partially. During a concurrent observation and interview on 2/26/2025 at 2:49 pm, RNA 5 was observed providing RNS to Resident 2. RNA 5 was observed providing BLE AAROM to Resident 2. RNA 5 was observed doing one set of 10 repetitions of BLE AAROM. RNA 5 stated RNA 5 was providing Resident 2 with leg extensions (to straighten the knee and hip from a bent or flexed position), leg flexion (to bend the knee and hip from a straight or extended position), lateral (side to side) movement, ankle rotation, flexion and extension. During a concurrent interview and record review on 2/26/2025 at 3:14, RNA 5 reviewed Resident 2’s RNFS dated 2/2025. RNA 5 stated Resident 2 was supposed to get three sets of 20 repetitions (of BLE AAROM). RNA 5 stated RNA 5 only provided one set of 10 repetitions to Resident 2. RNA 5 stated RNA 5 did not provide RNS to Resident 2 on 2/25/2025. RNA 5 stated RNA 5 initialed Resident 2’s RNFS on 2/25/2025 indicating the treatment was completed even though RNA 5 did not complete the treatment because RNA 5, “was supposed to.” RNA 5 stated there were other dates in 2/2025 (unable to recall exact dates) where RNA 5 either did not give the complete treatment to Resident 2 or did not do Resident 2’s RNS at all because RNA 5 “did not have time.” RNA 5 stated if Resident 2 did not receive RNS as ordered by the physician, Resident 2 could become contracted, be in pain, and have a loss of function. RNA 5 stated RNA 5 should not have documented that RNA 5 completed Resident 2’s RNS on 2/25/2025 or the other dates in 2/2025 (unable to recall exact dates) so other staff could know Resident 2 did not receive RNS. RNA 5 stated documenting Resident 2’s RNS was complete when it was not meant that Resident 2 was not getting the care and services ordered by Resident 2’s physician and cannot make up for the loss in treatment. During an interview on 2/26/2025at 4:57 pm, Registered Nurse (RN) 2 stated (in general) if RNAs did not complete a resident’s RNS order in its entirety or at all, they were not supposed to initial they completed the treatment, and were supposed to inform a licensed nurse the treatment was not completed. RN 2 stated documenting a treatment was completed when it was not, was considered willful falsification of medical records. RN 2 stated not delivering care to Resident 2 could lead to a decline in Resident 2’s health and Resident 2’s health would not improve. A review of the facility’s P&P titled, “Charting and Documentation,” revised 7/2017, indicated “All services provided to the resident, progress towards the care plan goals, or any changes in the resident’s medical, physical, functional or psychosocial condition, shall be documented in the resident’s medical record.” The P&P indicated, “The medical record should facilitate communication between the interdisciplinary team (IDT- group of health care professionals with various areas of expertise who work together toward goals of their residents) regarding the resident’s condition and response to care.” The P&P indicated, “Documentation in the medical record would be objective (not opinionated or speculative), complete, and accurate.” The facility failed to ensure the health record of Resident 2 pertaining to restorative nursing services (RNS- specialized nursing interventions provided by a restorative nursing assistant [RNA] focused on helping to maintain or regain functional abilities to achieve the highest level of well-being, often after rehabilitation or to prevent decline) provision was not willfully falsified. The facility failed to: 1. Ensure RNA 5 did not initial Resident 2’s Restorative Nursing Flow Sheet (RNFS) when RNA 5 did not provide Resident 2 with range of motion (ROM- exercises and/or movements designed to improve the flexibility and mobility of joints) as ordered by the physician on 2/25/2025, 2/26/2025 and other unspecified days in 2/2025. 2. Ensure RNA 1 and RNA 2 did not initial Resident 2’s RNFS to indicate RNS was provided to Resident 2 on 1/16/2025, 1/24/2025, 1/27/2025, 1/28/2025, 1/29/2025, 1/30/2025, and 1/31/2025 when RNA 1 and RNA 2 were not clocked in to work on those dates. These failures resulted in Resident 2’s medical records to contain inaccurate information that could affect Resident 2’s care and result in ROM decline. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 2.