Other·June 13, 2024

F725 The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.70(e). §483.35(a) Sufficient Staff. §483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. §483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. Code of Federal Regulations, Title 42, Section 483.25(c) Mobility

F688 §483.25(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 72329.2 Nursing Service - Staff. (a) Nursing service personnel shall be employed and on duty in at least the number and with the qualifications determined by the Department to provide the necessary nursing services for residents admitted for care. The Department may require a facility to provide additional staff as set forth in Section 72501(g). (e) Nursing stations shall be staffed with nursing personnel when residents are housed in the nursing unit. (f) Each facility shall employ sufficient nursing staff to provide a minimum daily average of 3.0 nursing hours per resident day. California Code of Regulations, Title 22, Section 72315. Nursing Services - Resident Care. (e) Each resident 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 residents 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. Resident Care Policies and Procedures. a) Written resident care policies and procedures shall be established and implemented to ensure that resident related goals and facility objectives are achieved. On 4/26/2024, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding administration and personnel. As a result of the investigation, the facility failed to ensure sufficient nursing staff, including Certified Nursing Assistants (CNAs) and Restorative Nursing Aides (RNAs) were assigned to provide care to Residents 1, 7, 9, 10, 11, 13, & 14 in accordance with the residents’ needs and preferences for Resident 1 and physician’s orders, and/or residents’ care plans and to provide restorative nursing services (RNS) as ordered by the physician for Residents 7, 9, 10, 11, 13, & 14, by failing to: A. Accommodate Resident 1’s needs and preferences regarding the call light response time, getting out of bed (OOB) and incontinence brief changes. B. Provide RNS to Resident 7 as ordered by the physician in 4/2024. For Resident 7, RNS were not provided for 5 days in 4/2024. C. Provide RNS to Resident 9 as ordered by the physician in 4/2024. For Resident 9, RNS were not provided for 4 days in 4/2024. D. Provide RNS to Resident 10 as ordered by the physician in 4/2024. For Resident 10, RNS were not provided for 6 days in 4/2024. E. Provide RNS to Resident 11 as ordered by the physician in 4/2024. For Resident 11, RNS were not provided for 3 days in 4/2024 F. Provide RNS to Resident 13 as ordered by the physician in 4/2024. For Resident 13, RNS were not provided for 3 days in 4/2024. G. Provide RNS to Resident 14 as ordered by the physician in 4/2024. For Resident 14, RNS were not provided for 4 days in 4/2024. These violations resulted in Residents 1, 7, 9, 10, 11, 13, & 14 did not receive the care in accordance with the residents’ needs and had the potential to result in a decline in the residents’ physical and psychosocial well-being for Resident 1, and a decline/further decline in Residents 7, 9, 10, 11, 13, & 14’s range of motion (ROM) with increased risks for pain and skin breakdown. A. A review of Resident 1’s Admission Record (AR 1) indicated the facility admitted Resident 1, a 64 years old male on 9/29/2023 with diagnoses including a history of stroke (brain damage due to blocked blood supply to the brain), left shoulder osteoarthritis (degenerative joint disease), epilepsy (brain disorder causing seizures), abnormalities of gait (manner of walking) and mobility, and lack of coordination. A review of Resident 1’s Initial History and Physical (H&P 1), dated 9/29/2023 indicated Resident 1 had fluctuating capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS 1) dated 4/5/2024 indicated Resident 1 did not have an impairment in cognition. MDS 1 indicated Resident 1 had an impairment on one side of Resident 1’s upper extremities and an impairment on both sides of Resident 1’s lower extremities. MDS 1 indicated Resident 1 was frequently incontinent of urine. MDS 1 indicated Resident 1 was dependent on staff for most self-care activities and required maximal/substantial assistance with mobility and transfers. A review of Resident 1’s Care Plan (CP) on ADL self-care performance deficit, dated 10/11/2023 indicated Resident 1 was totally dependent on staff for personal and toileting hygiene and lower body dressing. The CP indicated Resident 1 required substantial/maximal assistance with lying to sitting on one side of the bed. The CP interventions included to encourage the resident to use the bell to call for assistance. During an interview on 4/26/2024 at 11:04 AM, Resident 1 stated he wanted to get OOB earlier that day, but he had to wait until 10 AM because there was no staff to assist him. Resident 1 stated he has verbalized his concerns to the staff before. Resident 1 stated, “They don’t have enough staff. CNAs are overworked.” During an interview on 4/26/2024 at 11:49 AM, CNA 4 stated due to the staffing shortage, CNA 4 was able to change the residents’ incontinence brief twice per shift—one in the morning and one in the afternoon. CNA 4 stated changing and turning/repositioning of residents needed to be done every two hours and as needed for all residents. CNA 4 stated when answering call lights, some residents would get mad because of “waiting for a long time” because CNA 4 was busy with providing care to other residents. CNA 4 stated DSD 1 did not call the Registry for assistance with staffing when short-staffed. CNA 4 stated DSD 1 would not answer the staff phone calls to request for assistance with staffing when short-staffed. CNA 4 stated it was difficult to provide good care when assigned with 11 or 12 residents during the 7 AM – 3 PM shift. During an interview on 4/26/2024 at 12:49 PM, CNA 5 stated in 3/2024, each 7 AM – 3 PM shift CNA was assigned 14 residents each. CNA 5 stated each CNA was regularly getting assigned 12 to14 residents. CNA 5 stated Registry staff was requested to come in 4/2024 but the facility was still short-staffed, because the Registry staff would not “show up.” During an interview on 4/26/2024 at 1:09 PM, CNA 6 stated due to the staffing shortage, CNA 6 could not answer the call lights in a timely manner. CNA 6 stated CNA 6 would change the residents’ incontinence brief twice per shift—in the morning and after lunch. CNA 6 stated CNA 6 could go not back to the resident room to change and reposition/turn the resident at least every two hours as required. During an interview on 4/26/2024 at 1:28 PM, CNA 7 stated due to the staffing shortage, call lights were not answered because CNAs were busy providing care to the other residents. CNA 7 stated CNA 7 would change residents’ incontinence brief twice per shift and turning/repositioning was done “only for the people who really needed it.” CNA 7 stated all residents must be changed and turned/repositioned at least every two hours and as needed. During an interview on 4/26/2024 at 3:30 PM, Licensed Vocational Nurse 1 (LVN 1) stated the facility had staffing shortage for CNAs. During a telephone interview on 4/29/2024 at 12:34 PM, Registered Nurse 1 (RN 1) stated there was a staffing shortage for both CNAs and LVNs in the facility. RN 1 stated a lot of staff were quitting or calling off a lot, because they get overwhelmed with the workload. RN 1 stated RNAs were being reassigned to “help on the floor” with CNA duties. During a telephone interview on 4/29/2024 at 1:06 PM, DSD 1 stated when DSD 1 first started working at the facility, the facility’s Direct Care Service Hours Per Resident Day (DHPPD) was very high and the goal was to “stay in compliance” and not go over the “labor expense.” DSD 1 stated the company “did not want us to use Registry.” During an interview on 4/30/2024 at 2:07 PM, DSD 2 stated if RNAs were reassigned to do CNA duties, the on-call RNA was called or the RNA was asked to stay over to provide RNA services as ordered by the physician. DSD 2 stated it was the DSD’s responsibility to ensure sufficient staffing. DSD 2 stated if short-staffed, residents could develop skin breakdown, have a decline in ROM or mobility, and fall and sustain injuries. B. A review of Resident 7’s AR (AR 7) indicated the facility admitted Resident 7, a 49 years old female on 10/18/2021 with diagnoses including dementia and morbid obesity. A review of Resident 7’s H&P (H&P 7), dated 10/19/2023 indicated Resident 7 had worsening confusion. H&P 7 indicated Resident 7 did not have the capacity to understand and make decisions. H&P 7 indicated Resident 7 required assistance with mobility and personal care. A review of Resident 7’s MDS (MDS 7), dated 1/19/2024 indicated Resident 7 had moderate impairment in cognition. MDS 7 indicated Resident 7 had an impairment in both lower extremities. MDS 7 indicated Resident 7 was dependent on staff for most self-care activities and transfers. A review of Resident 7’s Order Summary Report (OSR 7) for 4/2024 indicated the following active physician’s order: 1) Order Date: 3/1/2024 - RNA Program: Apply multi-podus boot to left and right feet 4-6 hours as tolerated with skin checks every 2-3 hours every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday for 90 days. During an interview on 4/26/2024 at 10:22 AM, RNA 3 stated due to the shortage of CNAs on some days, the RNAs were tasked to do CNA duties and were assigned their own residents. RNA 3 stated there was no staff replacement to provide RNA services. RNA 3 stated when there was only 1 RNA assigned for the day, there was not enough time to provide RNA services, including ROM exercises, splinting and ambulation, to more than 30 residents in the facility with RNA orders. During a concurrent interview and record review on 4/30/2024 at 12:17 PM with RNA 3, Resident 7’s Documentation Survey Report (DSR) for 4/2024 was reviewed. RNA 3 stated there was no documented evidence that RNA services were provided to Resident 7 as ordered by the physician on 4/8/2024, 4/9/2024, 4/12/2024, 4/16/2024, and 4/19/2024. C. A review of Resident 9’s AR (AR 9) indicated the facility admitted Resident 9, an 86 years old female on 3/17/2021 with diagnoses including history of cerebral infarction (stroke, brain damage due to blocked blood supply to the brain), type 2 diabetes mellitus (disorder causing elevated sugar level in the blood), and dementia. A review of Resident 9’s H&P (H&P 9), dated 8/13/2023 indicated Resident 9 had fluctuating capacity to understand and make decisions. A review of Resident 9’s MDS (MDS 9), dated 3/21/2024 indicated Resident 9 had severe impairment in cognition. MDS 9 indicated Resident 9 was dependent on staff for most self-care activities and mobility. A review of the Resident 9’s OSR (OSR 9) for 4/2024 indicated the following active physician’s order: 1) Order Date: 3/1/2024 – RNA Program: Passive ROM exercises to right upper extremity five times per week as tolerated every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday for 90 days. During a concurrent interview and record review on 4/30/2024 at 12:17 PM with RNA 3, Resident 9’s DSR for 4/2024 was reviewed. RNA 3 stated there was no documented evidence that RNA services were provided to Resident 9 as ordered by the physician on 4/8/2024, 4/9/2024, 4/12/2024, and 4/17/2024. D. A review of Resident 10’s AR (AR 10) indicated the facility admitted Resident 10, a 77 years old male on 11/7/2020 with diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting the right dominant side. A review of Resident 10’s H&P (H&P 10), dated 6/29/2023 indicated Resident 10 had the capacity to understand and make decisions. A review of Resident 10’s MDS (MDS 10), dated 2/2/2024 indicated Resident 10 had no impairment in cognition. MDS 10 indicated Resident 10 was dependent on staff with toileting hygiene, showering/bathing, and mobility. A review of Resident 10’s OSR (OSR 10) for 4/2024 indicated the following active physician’s orders: 1) Order Date: 3/1/2024 – RNA Program: RNA for right resting hand splint daily 4-6 hours as tolerated with skin checks. Release every 2 hours for skin check every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday for 90 days. 2) Order Date: 3/1/2024 – RNA Program: PROM exercises to both lower extremities and right upper extremity daily five times per week as tolerated every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday for 90 days. During a concurrent interview and record review on 4/30/2024 at 12:17 PM with RNA 3, Resident 10’s DSR for 4/2024 was reviewed. RNA 3 stated there was no documented evidence that RNA services were provided to Resident 10 as ordered by the physician on 4/9/2024, 4/15/2024, 4/16/2024, 4/19/2024, 4/22/2024, and 4/23/2024. E. A review of Resident 11’s AR (AR 11) indicated the facility admitted Resident 11, a 94 years old female on 1/3/2024 with diagnoses including history of falling and displaced bimalleolar fracture of right lower leg. A review of Resident 11’s H&P (H&P 11), dated 1/3/2024 indicated Resident 11 had fluctuating capacity to understand and make decisions. A review of Resident 11’s MDS (MDS 11), dated 1/16/2024 indicated Resident 11 had severe impaired cognitive skills for daily decision-making. MDS 11 indicated Resident 11 was dependent on staff for all self-care activities and mobility. A review of Resident 11’s OSR (OSR 11) for 4/2024 indicated the following active physician’s orders: 1) Order Date: 2/15/2024 – RNA Program: PROM exercises to left and right lower extremities five times per week as tolerated every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday for 90 days. During a concurrent interview and record review on 4/30/2024 at 12:17 PM with RNA 3, Resident 11’s DSR for 4/2024 was reviewed. RNA 3 stated there was no documented evidence that RNA services were provided to Resident 11 as ordered by the physician on 4/9/2024, 4/17/2024, and 4/19/2024. F. A review of Resident 13’s AR (AR 13) indicated the facility admitted Resident 13, a 52 years old male on 3/20/2024 with diagnoses including right femoral neck fracture, g