Health inspection·July 2, 2025

§ 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 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 each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. § 483.20 Resident assessment. The facility must conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity. (b) Comprehensive assessments— (1) Resident assessment instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (viii) Physical functioning and structural problems. (x) Disease diagnoses and health conditions. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. (2) When required. Subject to the timeframes prescribed in § 413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2) (i) through (iii) of this section. The timeframes prescribed in § 413.343(b) of this chapter do not apply to CAHs. (ii) Within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purposes of this section, a “significant change” means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.) (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident's active record and use the results of the assessments to develop, review, and revise the resident's comprehensive plan of care. (e) Coordination. A facility must coordinate assessments with the preadmission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes— (1) Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. (2) Referring to all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. (g) Accuracy of assessments. The assessment must accurately reflect the resident's status. (h) Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals. (i) Certification. (1) A registered nurse must sign and certify that the assessment is completed. (2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. § 483.21 Comprehensive person-centered care planning (b) Comprehensive care plans. (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; and (ii) Any services that would otherwise be required under § 483.24, § 483.25, or § 483.40 but are not provided due to the resident's exercise of rights under § 483.10, including the right to refuse treatment under § 483.10(c)(6). (2) A comprehensive care plan must be— (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to— (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. § 483.25 Quality of care. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: F689 §483.25(d) Accidents. The facility must ensure that – §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 5/13/2025, the California Department of Health (CDPH) made an unannounced visit at the facility to conduct an Annual Recertification Survey to determine facility’s compliance. As a result of the investigation, CDPH determined that the facility failed to: 1. Ensure a care plan was developed to identify risk factors and root cause for the 7/2/2024, 5/2/2025 and 5/13/2024 fall incidents in accordance with the facility’s policy and procedure titled” Fall Management Program,” revised 3/13/2021. 2. Ensure the care plan interventions were revised, updated, implemented and evaluated after each unwitnessed falls (7/2/2024, 5/2/2025 and 5/13/2025) when the bed and wheelchair alarms were not effective by addressing what caused the fall, identifying Resident 1’s behavior of getting up from the chair and bed unassisted, poor safety awareness due to severe cognitive impairment and inability to communicate as a result of dementia (a progressive state of decline in mental abilities), in accordance with the facility’s P&P on “Dementia Care.” 3. Ensure that Resident 1 was provided person-centered observation or monitoring systems to address the identified risk factors for falls, in accordance with the facility P&P on “Resident Safety.” revised 4/15/2021. 4. Ensure Resident 1 was checked on at least every two hours by nursing service personnel or provide more frequent safety checks in accordance with the facility’s P&P titled “Resident Safety”, revised 4/15/2021. 5. Ensure that Resident 1’s care plan was updated as necessary after suffering a fall on 7/2/24 5/2/2025 and 5/13/2024 in accordance with facility P&P, titled “Fall Management Program” last revised 3/13/2021. 6. Ensure more frequent observation of activities and whereabouts were conducted after Resident 1 suffered a fall on 7/2/24, 5/2/2025 and 5/13/2024 in accordance with facility’s P&P, titled “Fall Management Program”, last revised 3/13/2021. As a result of these failures, Resident 1 had unwitnessed falls and the fall on 5/13/2025 at 8:07 PM resulted in left hip pain, left forehead bruising (skin injury when small blood vessel bursts and blood pools under the skin). The resident was transferred to the General Acute Care Hospital (GACH) on 5/13/2025 via 911 emergency services. The GACH indicated Resident 1 sustained a left displaced femoral neck fracture (a break in the upper part of the thigh bone (femur), near the hip joint, where the broken bone fragments have moved out of their normal alignment) and underwent a left hip hemiarthroplasty (a surgical procedure that replaces or reconstructs a joint) on 5/15/2025. A review of Resident 1’s Admission Record [AR], indicated the resident was originally admitted on 8/5/2017, and readmitted on 6/26/2020, with diagnoses that included dementia, Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), fractures, and muscle wasting (weakening, shrinking, and loss of muscle). A review of Resident 1’s Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 4/2/2025, indicated the resident had severely impaired cognition. The MDS indicated that the resident required substantial assistance (helper does more than half the effort) on activities such as toileting, bathing, dressing, changing position from sitting to lying and lying to sitting on side of the bed. The MDS also indicated Resident 1 was dependent (helper does all the effort on activities such as transferring from chair to chair or bed to chair. The MDS also indicated the resident was not assessed on activities such as sitting to stand “due to medical condition or safety concerns”. Further review of the MDS also indicated Resident 1 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) to operate and move while on a manual wheelchair for at least 150 feet. The MDS assessment did not indicate that Resident 1 had prior falls during the MDS assessment period. A review of Resident 1’s care plan for communication, initiated on 11/11/2023, indicated the resident has communication problems related to confusion, language barrier, and dementia. The interventions included evaluating the resident’s ability to communicate and comprehend. A review of Resident 1’s care plan for safety, initiated on 11/17/2023, indicated the resident has poor safety awareness related to impaired cognition and attempts to perform ADL [activities of daily living] beyond physical ability, “Resident 1 self-propels in wheelchair” and at risk for falls, and elopement (leaving the facility without permission) and injury. The intervention included for facility staff to include strategies to reduce the risk of falls and injury. A review of Resident 1’s care plan for falls, initiated on 11/17/2023, indicated the resident was at risk for falls related to the history of falls, dementia, Alzheimer’s disease, poor safety awareness, wheeling self around in the wheelchair and a Fall Score of 15 (High Risk for Falls). The care plan included the following interventions initiated on 11/17/2023: -Assist Resident with ambulation (walking) and transfers, utilizing therapy recommendations. -Determine Residents ability to transfer. -Evaluate fall risk of admission and [as needed]. -If fall occurs, alert provider. -If fall occurs, initiate frequent neuro (mental status changes) and bleeding evaluation per facility protocol. -If resident is a fall risk, initiate fall risk precautions. A review of Resident 1’s Fall Risk Evaluation (FRE), dated 7/1/2024, indicated Resident 1 was at risk for fall due to the following: 1. Resident 1 had “intermittent confusion.” 2. Resident 1 was chairbound (state of being confined to a chair/wheelchair) and incontinent (does not have the ability to control over urination or defecation). 3. Resident 1 had 1 to 2 predisposing diseases. 4. Resident 1 had a change in condition in the last 14 days from the time of assessment. 5. Resident 1 was recently hospitalized from the time of assessment “due to hypotension (low blood pressure) and bradycardia (slow heart rate).” 6. Resident 1 was taking “1 to 2 medications” at the time or within the last 7 days of assessment. A review of Resident 1’s FRE, dated 7/1/2024, indicated the following interventions will be implemented such as assist resident with ambulation and transfers, determine Resident 1’s ability to transfer”, “evaluate fall risk on admission and [as needed]” and if resident was a fall risk, “initiate fall risk precautions.” A review of a physician order dated 7/1/2024, indicated an order for Resident 1 to have bilateral landing pads or floor mats, (a thin foam that is placed beside the bed as a cushion for when a resident falls) due to risk of falls and to check the pads for placement every shift. A review of Resident 1’s Change in Condition Evaluation (CIC), dated 7/21/2024, timed at 10:49 PM, indicated Resident 1 was, observed to be sitting up right [at] her bedside on top of the landing pad. A review of a physician order dated 12/2/2024 (five months after Resident 1 fell on 7/21/2024), indicated an order for Resident 1 to have a bed alarm to remind the resident not to get up unassisted. The physician order further indicated for the charge nurse to monitor for proper placement and function of the bed alarm every shift and document “Y” if the alarm was in place and functioning properly, and “N” if not. A review of a physician order dated 12/2/2024, indicated an order for Resident 1 to have a wheelchair alarm to remind residents not to get up unassisted. The order further indicated for the charge nurse to monitor for proper placement and function of the wheelchair alarm every shift. A review of Resident 1’s FRE, dated 3/4/2025, indicated the following information regarding Resident 1’s fall risks: - Resident 1 was “disoriented (confused) x 3 at all times”. - Resident 1 was chairbound and incontinent. - Resident 1 had poor vision (with or without glasses). - Resident 1 had 1 to 2 predisposing diseases. - Resident 1 had balance problems while standing and walking. - Resident 1 requires the use of assistive devices such as a cane, wheelchair, or walker. - Resident 1 was taking “3 to 4 medications” at the time or within the last 7 days of assessment. A review of Resident 1’s care plan for risk of falls, initiated on 3/4/2025, revised on 3/12/2025, indicated the resident was at risk for falls related to confusion, gait (manner of walking or moving) and balance problems, poor communication and comprehension, and unaware of safety needs. The care plan interventions included placing a bed alarm to remind Resident 1 not to get up unassisted and to monitor for the alarm for proper placement and function of the bed alarm, initiated on 5/4/2025 (two months after Resident 1 had Fall Risk Evaluation on 3/4/2025) -May have a wheelchair alarm to remind Resident 1 not to get up unassisted. Charge nurse to monitor for pr