Health inspection·March 24, 2025

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. Code of Federal Regulations, Title 42, Section 483.21(b)(1), 483.10(c)(3)(i) Comprehensive Care Plans. §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident'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 resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40. California Code of Regulations, Title 22, Section 72311. Nursing Service- General. (a)Nursing service 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. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (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 1/21/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding resident rights. As a result of the investigation, the facility failed to: 1. Ensure a hazard free environment as much as possible and provide supervision and necessary assistance to reduce Resident 12’s fall likelihood, including but not limited to Certified Nursing Assistant (CNA) 4 and/or Licensed Vocational Nurse (LVN) 6 providing supervision/monitoring to Resident 12, who was assessed as a high fall risk and had a history of multiple falls. As an example of this failure, CNA 4 and LVN 6 Resident 1 allowed Resident 12 to be unsupervised and alone inside the facility's conference room with the door closed on 12/28/2024. 2. Develop and implement Resident 12’ care plans. This includes but is not limited to ensuring CNA 4, LVN 6, and all nurses (any CNAs, LVNs, and Registered Nurses [RNs]) in the nursing station implemented Resident 12's care plans by providing frequent visual checks and keeping Resident 12 at the nursing station for monitoring. 3. Implement the facility’s policy and procedures, including these: Safety and Supervision of Residents, Fall and Fall Risk, Managing, and Care Plans, Comprehensive Person-Centered. Following these failures, Resident 12 fell inside the facility’s conference room on 12/28/2024 at 12 p.m. As a result of the fall, Resident 12 sustained a fracture (a break or crack in a bone) of the dens (bony projection of the spine that allows the head to rotate) of cervical spine 2 (C2 - the upper portion of the spine located in the neck). Resident 1 was transferred and admitted to General Acute Care Hospital (GACH) 1 on 12/28/2024 at 4:10 p.m. for further evaluation. A review of Resident 12’s Admission Record, indicated the facility admitted Resident 12, an 82-year-old female, to the facility on 9/16/2022, with diagnoses that included congested heart failure, type 2 diabetes, and end stage renal disease with hemodialysis. A review of Resident 12's first untitled care plan (CP), initiated on 7/14/2023, and revised on 8/2/2024, indicated Resident 12 was at risk for falls related to limited mobility, balance problems, confusion, poor safety awareness, history of multiple falls, and use of psychotropics (medications that affect the mind, emotions, and behavior) and diuretic (medication that causes the kidneys to make more urine). The CP interventions included to anticipate and meet Resident 12's needs, follow facility's fall protocol, and provide a safe environment. A review of Resident 12's Fall Risk Assessment, dated 4/15/2024, indicated Resident 12 was at high risk for falls due to history of falls, use of psychotropics, antihypertensive (medication to treat high blood pressure), and hypoglycemic agents (medications to treat high blood sugar), urinary incontinence, agitated behavior, and predisposing conditions. A review of Resident 12's History and Physical Examination, dated 4/16/2024, indicated Resident 12 did not have the capacity to understand and make decisions. A review of Residents 12's Physical Therapy Encounter Notes, dated 6/7/2024, indicated Resident 12 required maximal assistance (assisting person performed 75 percent [%] of the task) for bed mobility and transfers. A review of Resident 12's second untitled CP, initiated on 6/14/2024, and revised on 8/7/2024, indicated Resident 12 had an unwitnessed fall on 6/14/2024. The CP interventions included to provide frequent visual checks and keep Resident 12 at the nursing station so staff can monitor and help Resident 12 immediately if Resident 12 tried to stand up without assistance. A review of Resident 12's third untitled CP, initiated on 9/21/2024, indicated Resident 12 had a witnessed fall on 9/21/2024. The CP interventions included to provide frequent visual checks. A review of Resident 12's Minimum Data Set (MDS, a resident assessment tool), dated 10/26/2024, indicated Resident 12 had severely impaired cognition. The MDS indicated Resident 12 normally used a wheelchair for mobility and was dependent on staff for toileting, and personal hygiene, and chair/bed-to-chair transfer. A review of Resident 12's Change in Condition Evaluation (CICE), dated 12/28/2024, timed at 12:15 p.m., indicated on 12/28/2024, untimed, Resident 12 had an unwitnessed fall in the facility's conference room located in front of the nursing station. The CICE indicated Resident 12 suffered a bump to her head. The CICE indicated Resident 12 was awake, alert, verbally responsive, able to follow commands, and answer questions. The CICE indicated Resident 12's vital signs were stable and she had no neurological deficit. The CICE indicated RN 2 notified Resident 12's physician (MD 1) and MD 1 ordered to transfer Resident 12 to GACH 1 for further evaluation and treatment. A review of Resident 12's GACH 1 Emergency Note, dated 12/28/2024, timed at 4:10 p.m., indicated Resident 12 was brought in by ambulance from the skilled nursing facility (SNF) where Resident 12 had a mechanical fall (a fall that is caused by an external factor, such as tripping, slipping, or being pushed) out of a wheelchair, and hitting left side of the head and face. A review of Resident 12's GACH 1 Computed Tomography Scan (CT scan) Report of Resident 12's cervical spine, dated 12/28/2024, timed at 6 pm, indicated Resident 1 had a fracture through the dens (a break in the peg-like bone at the top of the C2 in the neck). A review of Resident 12's GACH 1 Magnetic Resonance Imaging (MRI) Report of Resident 12's cervical spine, dated 12/28/2024, timed at 9:05 pm, indicated Resident 12 had a fracture of the dens of C2. The MRI Report indicated findings were concerning for nerve compression (occurs when a nerve is under too much pressure from surrounding tissues). The MRI Report indicated neurosurgical consultation was recommended for further evaluation and management guidance. A review of Resident 12's Neurosurgery Consultation Notes (NCN), dated 12/29/2024, untimed, indicated Resident 12 presented for evaluation of dens fracture and found to have severe stenosis (narrowing of any channel or passageway in the body) in the lower cervical spine sustained after a fall at the SNF. The NCN indicated Resident 12 was a high risk for postoperative complications due largely to age and comorbidities. The NCN indicated Resident 12's family would like to manage Resident 12 conservatively with a brace (a device fitted to a weak or injured part of the body, to give support). A review of Resident 12's GACH 1 Discharge Summary Notes (DS), dated 12/30/2024, untimed, indicated Resident 12 was a high risk for postoperative complications, quality of life, and there was an unclear benefit if Resident 12 were to have surgery. The DS indicated Resident 12 was to continue with cervical collar (C-collar - an instrument used to support the neck and spine and limit head movement after an injury) and follow-up with spine surgery for a repeat CT scan of the spine in four weeks. During an interview on 1/21/2025 at 8:30 a.m., CNA 4 stated on 12/28/2024, at around 8:30 a.m., she got Resident 12 ready for the day, transferred Resident 12 in Resident 12's wheelchair after breakfast, wheeled Resident 12 in the hallway, and left Resident 12 next to the nursing station. CNA 4 stated residents who needed to be monitored were taken to the nursing station at around 8:30 a.m. (daily) so nurses in the nursing station could monitor the residents who were left there (at the nursing station). CNA 4 stated she returned to the nursing station at 12 p.m. but she did not find Resident 12 in the hallway next to the nursing station where she left Resident 12 in the morning. CNA 4 stated when she went to the conference room, the conference room door was closed. CNA 4 stated she opened the conference room door and found Resident 12 on the floor next to Resident 12's wheelchair "by herself." CNA 4 stated Resident 12 had a large bump on Resident 12's head. CNA 4 stated there was no staff supervising Resident 12 in the conference room and staff were unable to see Resident 12 in the conference room from the nursing station because the conference room door was closed. During an interview on 1/21/2025 at 12 p.m., RN 2 stated on 12/28/2024, after 12 pm, LVN 6 called her into the conference room and when she entered the conference room, Resident 12 was on the floor. RN 2 stated Resident 12 should not be left in the conference room, unsupervised, since Resident 12 was confused and at high risk for falls. RN 2 stated Resident 12 was able to "wheel herself" around the facility. RN 2 stated Resident 12 needed frequent monitoring per Resident 12's care plans and staff did not follow Resident 12's care plans. During an interview on 1/22/2025 at 2:30 p.m., the Administrator (ADM) stated Resident 12 had history of multiple falls and needed frequent visual checks. The ADM stated Resident 12 was supposed to be at the nursing station for monitoring. The ADM stated all nurses at the nursing station were responsible for supervising/monitoring the residents who were around the nursing station. The ADM stated fall risk and confused residents needed to be monitored every one to two hours. The ADM stated the facility did not know how long Resident 12 was inside the conference room alone and unsupervised. The ADM stated no one witnessed Resident 12 going or being taken into the conference room (on 12/28/2024). During a telephone interview on 1/23/2025 at 3:53 p.m., LVN 6 stated on 12/28/2024, "before lunch time," LVN 6 checked on Resident 12 and Resident 12 was sitting in Resident 12's wheelchair, in front of the nursing station. LVN 6 stated Resident 12 was able to "wheel herself" to the nursing station. LVN 6 stated (on 12/28/2024) after 12 p.m., CNA 4 notified LVN 6 that Resident 12 had fallen in the conference room. LVN 6 stated when she arrived in the conference room, Resident 12 was on the floor next to the door. LVN 6 stated Resident 12 had a bump on Resident 12's left side of the head. LVN 6 stated she could not remember if there were any nurses at the nursing station monitoring the residents at that time. LVN 6 stated Resident 12 should not be left alone and unsupervised in the conference room. LVN 6 stated Resident 12 needed to be monitored every hour and frequently because Resident 12 was confused and at high risk for falls. LVN 6 stated since Resident 12's fall was unwitnessed in the conference room, Resident 12 was not being supervised. LVN 6 stated she did not see Resident 12 going or being taken to the conference room. LVN 6 stated "We" did not follow Resident 12's care plans to monitor Resident 12 frequently. A review of the facility's P&P titled, "Safety and Supervision of Residents," revised 7/2017 (most updated), the P&P indicated, "Resident safety supervision and assistance to prevent accidents were facility-wide priorities." The P&P indicated, "The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate (sufficient for a specific need or requirement) supervision." The P&P indicated, "Implementing interventions to reduce accident risks and hazards included the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary; d. Ensuring that interventions are implemented ... The P&P indicated, "Resident supervision is a core component of the systems approach to safety. The type and frequency of supervision may vary among residents and over time for the same residents." A review of the facility's P&P titled, "Fall and Fall Risk, Managing," revised 3/2018 (most updated), the P&P indicated, "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The P&P indicated, "The staff will implement a resident-centered fall prevention plan to reduce the risk factor(s) of falls for each resident at risk or with a history of falls." A review of the facility's P&P titled, "Care Plans, Comprehensive Person-Centered," revised 3/2022 (most updated), the P&P 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 P&P indicated, "The comprehensive, person-centered care plan ... describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including ... which professional services are responsible for each element of care ... builds on the resident's strengths; and reflects currently recognized standards of practice for problem areas and conditions." As a result of the investigation, the facility failed to: 1. Ensure a hazard free environment as much as possible and provide supervision and necessary assistance to reduce Resident 12’s fall likelihood, including but not limited to Certified Nursing Assistant (CNA) 4 and/or Licensed Vocational Nurse (LVN) 6 providing supervision/monitoring to Resident 12, who was assessed as a high fall risk and had a history of multiple falls. As an example of this failure, CNA 4 and LVN 6 Resident 1 allowed Resident 12 to be unsupervised and alone inside the facility's conference room with the door closed on 12/28/2024. 2. Develop and implement Resident 12’ care plans. This includes but is not limited to ensuring CNA 4, LVN 6, and all nurses (any CNAs, LVNs, and Registered Nurses [RNs]) in the nursin