Health inspection·January 11, 2024

§ 483.90- F921 Safe/Functional/Sanitary/Comfortable Environment (i) The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. § 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. On 12/5/23, the California Department of Public Health (CDPH) conducted an unannounced recertification survey. As a result of the investigation, the CDPH determined that the facility failed to provide a safe and sanitary environment for residents, staff, and the public by failing to ensure: 1. Staff immediately wiped/cleaned Resident 5's saliva on the floor due to excessive drooling (saliva flowing out of the mouth uncontrollably) to prevent risk of slip and fall for the residents, staff, and visitors. 2. Staff monitored Resident 5's excessive drooling and dripping of saliva on the floor to prevent incident of slip and fall in the facility. As a result, on 12/7/23 at 9:32 a.m., Health Facilities Evaluator Nurse (HFEN) 1 slipped and fell on the floor in the hallway. HFEN 1 had pain on the left foot, sustained skin redness and discoloration on both knees and skin redness on the left foot. During a review of Resident 5's Admission Record, the Admission Record indicated the facility admitted Resident 5, a 43 year-old male, on 12/13/22, with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). During a review of Resident 5's Physician Order dated 8/9/23, the Physician Order indicated to give Glycopyrrolate (used to treat chronic, severe drooling) tablet 4 milligrams (mg, unit of measurement) by mouth two times a day for extrapyramidal symptoms (EPS, serious side effects that can develop after taking certain antipsychotic [drug for mental disorder] medication). During a concurrent observation and interview on 12/7/23 at 9:32 a.m. with the Director of Nursing (DON), Resident 5 and other residents were lined up in the hallway to receive their medications from the medication nurse in the medication pass room located in the utility room. Four staff were standing on the opposite side while watching the residents walk towards the utility room. HFEN 1 was walking beside the DON in the hallway when HFEN 1 unknowingly stepped on slippery liquid then slipped and fell to the floor. The DON assisted HFEN 1 to get up from the floor and the DON wiped the wet skid marks on the floor with paper towels. There were trails of several drops of clear liquid on the floor along the side where residents were lined up. Resident 5's saliva was observed dripping on the floor as he walked towards the utility room to get his medications. The DON stated staff were aware of Resident 5's excessive drooling. The DON stated the slippery liquid was from Resident 5's excessive drooling that dripped on the floor that caused HFEN to slip and fall to the floor. During a concurrent interview and record review on 12/7/23 at 2:35 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated he was walking by when he saw HFEN 1 slipped and fell to the floor in the hallway where Resident 5 and other residents were lined up for medication pass. LVN 1 stated, Resident 5 had been on Glycopyrrolate for excessive drooling of saliva. LVN 1 stated, staff were aware that Resident 5's saliva was dripping uncontrollably from his mouth to the floor whenever Resident 5 walked in the room or hallway. LVN 1 stated, staff who were watching the residents for medication pass did not wipe clean Resident 5's saliva on the floor, knowing Resident 5 was excessively drooling and Resident 5's saliva was dripping on the hallway floor. LVN 1 stated, staff should immediately wipe clean Resident 5's saliva on the floor to prevent slip and fall for residents, staff, and visitors. During a concurrent interview and record review on 12/7/23 at 3:51 p.m. with the DON, DON stated Resident 5's care plan for excessive drooling did not indicate nursing measures on how to provide a safe and sanitary environment from Resident 5's uncontrollable and excessive drooling and dripping of saliva on the floor to prevent the risk of slip and fall of resident, staff, and the public. The DON stated, slip and fall incidents could be avoided but staff were not monitoring Resident 5’s drooling in the hallway and immediately wiped/cleaned Resident 5's saliva on the floor. The facility failed to provide a safe and sanitary environment for the residents, staff, and visitors by failing to ensure: 1. Staff immediately wiped/cleaned Resident 5's saliva on the floor due to excessive drooling to prevent risk of slip and fall for the residents, staff, and visitors. 2. Staff monitored Resident 5's excessive drooling and dripping of saliva on the floor to prevent incident of slip and fall in the facility. As a result, on 12/7/23 at 9:32 a.m., HFEN 1 slipped and fell on the floor in the hallway. HFEN 1 had pain on the left foot, sustained skin redness, discoloration on both knees and skin redness on the left foot. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of HFEN 1, and/or the residents, staff, and visitors.