Health inspection·March 15, 2024

F921 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for patients, staff and the public. Title 22 72637(a) § 72637. General Maintenance. (a) The facility, including the grounds, shall be maintained in a clean and sanitary condition and in good repair at all times to ensure safety and well-being of patients, staff and visitors. An unannounced visit for recertification survey was conducted by California Department of Public Health (CDPH) from 2/6/2024 to 2/9/2024. During the course of the survey investigation, it was determined that the facility failed to provide a safe environment for Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 who were assessed at being at risk for falling, also safety of staff and visitors by failing to: 1. Ensure that the facility's roof was free from cracks, holes and other damage that allowed water from rain to penetrate through and drip into the space between the roof and ceiling. 2. Ensure that the ceiling structure inside the building did not become damaged from rainwater leaking in through holes, cracks, and other damage to the roof. 3. Maintain the ceiling structure free from moisture, water damage, active leaking, and degradation due to rainwater penetrating through cracks, holes, or other damaged areas of the roof. 4. Provide documented evidence that the facility routinely performs scheduled maintenance service to all areas in the facility that included the roof inspections. These deficient practices resulted in an outburst of 5 water leaks throughout the facility on 2/5/2024 during a rainstorm resulting in Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 to be displaced (being forced to leave their home). In addition, these deficient practices had the potential to lead to patient injury from slipping and falling and endangering the lives of the 70 patients remaining in the facility including the staffs and visitors. This placed them at risk for accidents, electrical shocks, electrical fires, collapsed ceiling and structural damage subjecting the patients to possible serious injuries. The facility's failure to ensure that the facility's roof was well maintained and in working order in order to provide a safe and comfortable environment for the patients. 1. During a review of Patient 1, a 62 years old female, Admission Record indicated the facility originally admitted the patient on 1/30/2009 and readmitted her on 2/15/2023 with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations that can result in fast heart rate, rapid breathing, and sweating), and hypertension (high blood pressure). During a review of Patient 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/4/2024, indicated the patient had intact memory and cognition (ability to think and reasonably). The MDS indicated the patient required supervision or touching assistance by facility staff with eating, oral hygiene, toilet hygiene, chair/bed-to-chair transfer, lower body dressing, personal hygiene, and could walk 150 feet distance. A review of Patient 1's History and Physical dated 2/17/2023, indicated the patient did not have capacity to make decisions. During a review of Patient 1's Care Plan, revised on 1/9/2024, indicted Patient 1 was at risk for falls/injury and the interventions including "staff will provide a safe and clutter-free environment." During a review of Patient 1's Care Plan, revised on 1/9/2024, indicated the Patient 1 sometimes wanders around the facility and confused as to where she is going and what she is doing. To ensure patient safety, the interventions indicated the facility staff will provide clutter free an environment and non-slippery floors. During a review of Patient 1's Care Plan, revised on 1/9/2024, indicated Patient 1 was, "at risk for falls/injury related to tremor (involuntary shaking movement" and to ensure Patient 1's safety, the facility staff will provide clutter free an environment. A record review of Patient 1's Change of Condition Assessment Form dated 2/6/2024 indicated that at 11:30 AM, "patient's room floor noted slightly wet due to roof leaking from the rain." 2. During a review of Patient 2 a 54 years old male, Admission Record indicated the facility originally admitted the patient on 2/25/2011 and readmitted on 2/14/2022 with diagnoses that included schizoaffective disorder (a disorder that affects a person's ability to think, feel, and behave clearly), abnormalities of gait and mobility and anxiety disorder. During a review of Patient 2's MDS, dated 11/19/2023, indicated the patient had moderate levels of memory and cognition (ability to think and reasonably). The MDS indicated Patient 2 required supervision or touching assistance by facility staff with eating, oral hygiene, upper and lower body dressing, sit to standing, toileting. The MDS also indicated that the patient used a wheelchair and required supervision or touching assistance for wheeling the chair for more than 150 feet. A review of Patient 2's History and Physical, dated 2/6/2023, indicated the patient had the capacity to make decisions. During a review of Patient 2's Fall Risk Assessment, dated 9/6/2023, indicated Patient 2 was at a risk for fall. During a review of Patient 2's Care Plan, revised on 9/6/2023, indicted Patient 2 was at "risk for falls/injury," and to ensure Patient 2's safety, the staff will "provide a safe and clutter-free environment." During a review of Patient 2's Care Plan, revised on 9/6/2023, indicated Patient 2 was at "at risk for spontaneous/pathological (when force or impact didn't cause the break to happen) /stress fracture related to osteoarthritis (occurs when flexible tissue at the ends of bones wears down)." To ensure Patient 2's safety the facility staff will "provide a safe and hazard free environment." 3. During a review of Patient 3 a 70 years old female, Admission Record indicated the facility originally admitted the patient on 12/6/2013 and then readmitted on 1/28/2021 with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations that can result in fast heart rate, rapid breathing, and sweating). During a review of Patient 3's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/8/2023, indicated the patient had severe cognition impairment and required supervision or touching assistance by facility staff with eating, oral hygiene, upper and lower body dressing, sit to standing, toileting and with walking 10 feet or more. A review of Patient 3's History and Physical dated 7/1/2023, indicated the patient does not have the capacity to make decisions. During a review of Patient 3's Fall Risk Assessment, dated 12/8/2023, indicated the patient was a risk for fall. During a review of Patient 3's Care Plan, revised on 12/14/2023, indicated Patient 3 was at "risk for falls/injury," and to ensure Patient 3's safety, "the facility staff will provide a safe and clutter-free environment." A review of Patient 3's Change of Condition Assessment form dated 2/6/2024 indicated that at 11:30 AM, "room floor noted slightly wet due to roof leaking from the rain." 4. During a review of Patient 4 a 85 years old female, Admission Record indicated the facility originally admitted the patient on 10/30/2019 and then readmitted on 11/1/2023 with diagnoses that included schizophrenia and anxiety disorder and abnormalities of gait and mobility. During a review of Patient 4's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/29/2023, indicated the patient had severe cognition impairment and required supervision or touching assistance by facility staff with eating, oral hygiene, upper and lower body dressing, sit to standing, toileting and with walking 10 feet or more. A review of Patient 4's History and Physical dated 11/11/2023, indicated the patient does not have the capacity to make decisions. During a review of Patient 4's Fall Risk Assessment, dated 11/2/2023, indicated the patient was a high risk for fall. During a review of Patient 4's Care Plan, revised on 12/20/2023, indicated the patient was at "risk for falls/injury," and to ensure safety, the facility "staff will provide a safe and clutter-free environment." A review of Patient 4's Change of Condition Assessment form dated 2/6/2024 indicated that at 11:40 AM, "room floor noted slightly wet due to roof leaking from the rain." During a review of Patient 5 a 94 years old female, Admission Record indicated the facility admitted the patient on 12/5/2023 with diagnoses that included schizophrenia anxiety disorder and abnormalities of gait and mobility. 5. During a review of Patient 5's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/12/2023, indicated the patient had severe cognition impairment and required substantial assistance by facility staff with eating, personal hygiene, sit to lying position. The MDS record also indicated Patient 5 required substantial/maximal assistance (where staff does more than half the effort) for toileting, showering, dressing, and bed to chair transfer. A review of Patient 5's History and Physical dated 12/7/2023, indicated the patient did not have the capacity to make decisions. During a review of Patient 5's Fall Risk Assessment, dated 12/6/2023, indicated the patient was a high risk for fall. During a review of Patient 5's Care Plan, revised on 12/6/2023, indicated the patient was at "risk for falls/injury," and to ensure safety the "staff will provide a safe and clutter-free environment." During a review of Patient 5's Care Plan, revised on 12/6/2023, indicated the patient had a seizure disorder (sudden, uncontrolled burst of electrical activity in the brain. It can cause changes in behavior, movements, feelings and levels of consciousness) with "risk for falls/injury," and the interventions including "provide safe environment ... free of safety hazards." A review of Patient 5's Change of Condition Assessment form dated 2/6/2024 indicated that at 11:40 AM, "room floor noted slightly wet due to roof leaking from the rain." 6. During a review of Patient 6 a 71 years old female, Admission Record indicated the facility originally admitted the patient on 9/4/2019 and readmitted her on 2/28/2023 with diagnoses that included schizophrenia, seizures and hypertension. During a review of Patient 6's MDS, dated 1/5/2024, indicated the patient had intact memory and cognition. The MDS indicated Patient 6 required setup or clean-up assistance with eating, chair/bed-to-chair transfer, and walk 150 feet, and supervision or touching assistance with oral hygiene, toilet hygiene, lower body dressing and personal hygiene. A review of Patient 6's History and Physical dated 3/2/2023 indicated that Patient 6 did not have the capacity to make decisions. During a review of Patient 6's Fall Risk Assessment, dated 1/12/2024 indicated the patient was at risk for falls. During a review of Patient 6's Care Plan, revised on 1/12/2024, indicated Patient 6 was at "risk for falls/injury," and to ensure safety the facility the "staff will provide a safe and clutter-free environment." During a review of Patient 6's Care Plan, revised on 1/12/2024, indicated the patient was at "risk for injury ...because of seizure activity," and the interventions included "to provide a safe environment; free of safety hazards." A review of Patient 6's Change of Condition Assessment form dated 2/6/2024 indicated that at 11:30 AM, "room floor noted slightly wet due to roof leaking from the rain." 7. During a review of Patient 7 a 79 years old female, Admission Record indicated the facility admitted the patient on 3/17/2020 with diagnoses that included vascular dementia (condition causes cognitive difficulty with reasoning and judgment), emphysema (a lung condition that causes shortness of breath), and anemia (a blood disorder that can result in symptoms that include extreme tiredness, weakness, and shortness of breath). During a review of Patient 7's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/25/2023, indicated the patient required supervision or touching assistance by facility staff with eating, oral hygiene, upper and lower body dressing, sit to standing, toileting and with walking 10 feet or more. A review of Patient 7's History and Physical dated 7/18/2023, indicated the patient does not have the capacity to make decisions. During a review of Patient 7's Fall Risk Assessment, dated 1/3/2024, indicated the patient was a risk for fall. During a review of Patient 7's Care Plan, revised on 1/3/2024, indicated the patient was at "risk for falls/injury," and the interventions including "staff will provide a safe and clutter-free environment." A review of Patient 7's Change of Condition Assessment form dated 2/6/2024 indicated that at 11:30 AM, "room floor noted slightly wet due to roof leaking from the rain." 8. During a review of Patient 8 a 70 years old male, Admission Record indicated the facility originally admitted the patient on 5/30/2023 and readmitted on 11/21/2023 with diagnoses that included schizoaffective disorder abnormalities of gait and mobility and dementia. During a review of Patient 8's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/6/2023, indicated the patient had moderate levels of memory and cognition (ability to think and reasonably). The MDS indicated Patient 8 required supervision or touching assistance by facility staff with eating, oral hygiene, upper and lower body dressing, sit to standing, toileting, and walking 10 feet or more. During a review of Patient 8's Fall Risk Assessment, dated 11/24/2023, indicated the patient was a risk for fall. During a review of Patient 8's Care Plan, revised on 12/27/2023, indicated the patient was at "risk for falls/injury related to generalized weakness, poor safety awareness," and the interventions including "staff will provide a safe and clutter-free environment." During a review of Patient 8's Care Plan, revised on 12/27/2023, indicated the patient was at "at risk for spontaneous/pathological/stress fracture related to osteoarthritis (occurs when flexible tissue at the ends of bones wears down)," and the interventions including "provide a safe and hazard free environment." 9. During a review of Patient 9 a 73 years old female, Admission Record indicated the facility originally admitted the patient on 1/11/2022 and readmitted her on 2/20/2022 with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and hypertension (high blood pressure). During a review of Patient 9's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/17/2024, indicated the patient had intact memory and cognition (ability to think and reason). The MDS indicated Patient 9 required setup or clean-up assistance with eating, oral hygiene, toilet hygiene, chair/bed-to-chair transfer, lower body dressing, personal hygiene, and was able to walk 150 feet distance. During a review of Patient 9's Fall Risk Assessment, dated 1/3/2024, indicated the patient was at risk for fall. During a review of Patient 9's Care Plan, revised on 1/17/2024, indicated Patient 9 was at risk for falls/injury and to provide safety the facility "staff will provide a safe and clutter-free environment." 10. During a review of Patient 10 a 57 years old female, Admission Record indicated the facility originally admitted the patient on 7/28/2021 and readmitted her on 12/04/2023 with diagnoses that included schizophrenia and anxiety. During a review of Patient 10's MDS, dated 12/12/2023, indicated the patient had intact memory and cognition. The MDS indicated Pa