Health inspection·October 25, 2024

F689 42 CFR §483.25(d) Accidents. The facility must ensure that - (d)(1) The resident environment remains as free of accident hazards as is possible; and (d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. 42 CFR §483.40 Behavioral Health Services Each resident must receive and the facility must provide the necessary behavior health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.

F744 §483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. (b) Based on the comprehensive assessment of a resident, the facility must ensure that - (3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. 22 CCR § 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. 22 CCR §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 9/10/2024, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility for an facility reported incident. As a result of the investigation, CDPH determined the facility failed to: 1. Develop an appropriate care plan for Resident 1's Dementia through an Interdisciplinary Team (IDT) approach, with appropriate interventions including implementation of individualized care and maximizing the resident's safety. 2. Provide for Resident 1, 2:1 staff supervision (ratio of 2 residents and 1 one certified nursing staff) due to impulsive behavior, per the care plan interventions. As a result, on 8/20/2024, Resident 1 had a fall with pain and facial grimacing in the facility Day Room. On 8/24/2024, Resident 1 had right leg pain with swelling (which was not previously assessed), and was transferred to General Acute Care Hospital (GACH) 2 on 8/25/2024. At GACH 2, Resident 1 was diagnosed with a dislocation of the right hip and was placed under general anesthesia for a closed reduction right total hip arthroplasty (surgical procedure where the orthopedic surgeon removed the diseased parts of the hip joints and replaced with new, artificial parts). A review of Resident 1's Admission Record indicated the resident was an 85 year-old female, originally admitted to the facility on 5/13/2024 with diagnoses including left pubis fracture (bone that forms the lower front part of the hip bone), vascular dementia, and history of falling. A review of Resident 1's Morse Fall Risk Screen dated 5/13/2024, indicated the resident had a history of falling, had more than one diagnosis, and overestimates or forgets limits. The Fall Risk Screen indicated Resident 1 was a high risk for falls with a score of 55 (a score of 45 or more indicated a resident was a high risk for falling). A review of Resident 1's Care Plan regarding 'the resident crawled out of bed with poor judgement, poor safety awareness, dementia, and recent falls in the last 30 days,' dated 5/13/2024 indicated the interventions were to provide Resident 1 a 2:1 sitter due to impulsive behavior, crawling / getting out of bed unassisted. A review of Resident 1's IDT Meeting dated 5/16/2024 indicated the resident had a diagnosis of a previous right total hip arthroplasty from the past, had diagnosis of dementia while at home (prior to admission to facility), and the IDT discussed with the Family Member Resident 1's prior level of function and mentation while at home. According to a review of Resident 1's History and Physical (H&P) dated 7/20/2024, the resident did not have capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 5/19/2024, indicated the resident had a prior fall in the last month and a fracture related to a fall in the last 6 months. The MDS dated 8/19/2024, indicated the resident was dependent on staff for toileting, personal and oral hygiene and was severely impaired in cognitive skill for daily decision making. The MDS, under active diagnoses, indicated a musculoskeletal other fracture (non-descriptive), an active diagnosis including age - related osteoporosis without current pathological fracture, and the resident had Non-Alzheimer's Dementia. A review of the Physician's Order dated 7/30/2024, indicated Resident 1 received Donepezil Hydrochloride (medication treats mild, moderate, and severe dementia) 10 mg tablet by mouth every evening for dementia. A review of Resident 1's Change of Condition form (COC) dated 8/20/2024 at 6:45 PM, indicated the resident sustained a fall on 8/20/2024 at night. The COC indicated the resident was in the wheelchair with the footrest on and was sitting with other residents in the Day Room watching television. The COC indicated Certified Nursing Assistant (CNA) 1 was checking on the charting and when she raised her head up, Resident 1 was on the floor in front of the wheelchair. The COC indicated CNA 2 was by the Day Room door talking to another resident when she heard a noise and saw Resident 1 on the floor. The COC indicated Resident 1 sustained a bump on the left back side of the head, 911 was called and Resident 1's physician was notified. The physician gave orders to apply an ice pack to resident's head, as the resident had pain with facial grimacing, and ordered to transfer Resident 1 to a hospital. A review of Resident 1's GACH 1 Emergency Documentation (ED) dated 8/20/2024, indicated the resident was brought in for evaluation of a ground level fall with a left sided parietal scalp hematoma (bump on the head caused by damage to the skin and muscle on the outside of the skull). The ED indicated the resident's Computed Tomography scan (CT - an imaging procedure that uses special x-ray equipment to create detailed pictures or scans of areas inside the body) of the head, maxillofacial (face), and spine were without evidence of traumatic injuries. The ED indicated the resident was discharged to the skilled nursing home on 8/21/24. According to a review of Resident 1's GACH 2 ED dated 8/25/2024, the resident was brought in from a nursing home after a recent fall and right hip dislocation. A pelvic x-ray dated 8/25/2024 indicated a status post total right hip arthroplasty with dislocation of the femoral and acetabular component (parts of the hip joint, which is a ball-and-socket joint where the thigh bone [femur] meets the pelvis [acetabulum]). The GACH 2 operative note dated 8/27/2024 indicated Resident 1 had a closed reduction under general anesthesia right total hip arthroplasty dislocation (procedure that involves manually moving the hip back into place). Resident 1 was discharged from GACH 2 on 8/27/2024. During a concurrent interview and record review on 9/11/2024 at 11:04 AM, Resident 1's care plans dated 5/13 and 5/26/2024 were reviewed with the Director of Staff Development (DSD). The DSD stated the care plan was developed for Resident 1 to prevent falls and a 2:1 meant one CNA would supervise two residents, preferably in one room. The DSD stated and confirmed this intervention was to be implemented on the day of Resident 1's fall on 8/20/2024. After review of the Nursing Staff assignment and Sign-In Sheet for the 8/20/2024 3 PM to 11 PM shift, the DSD stated Resident 1 did not have a 2:1 CNA assigned on 8/20/2024 and that the supervising nurse was responsible in assigning the CNA who would monitor residents 2:1. On 9/11/2024 at 12:15 PM, after review of the Huddle Report Form / Daily Clinical Meeting Report for 8/20/2024, the DSD stated and confirmed there was no report of Resident 1's care plan intervention for a 2:1 sitter. The DSD stated it was important to follow the care plan interventions to ensure Resident 1's safety and not following the care plan could lead to a fall with possible injury or death. During a phone interview on 9/11/2024 at 12:59 PM, CNA 2 stated she was assigned to a group of residents and could not recall how many. CNA 2 stated she was assigned to Resident 1 and the resident was not assigned as a 2:1. CNA 2 stated after dinner, Resident 1 was in the day room watching television with about 10 other residents and two CNA's (CNA 1 and CNA 2). CNA 2 stated she was standing by the door, turned her head from the residents in day room, and talked to a resident in the hallway. CNA 2 stated she recalled hearing Resident 1 state "pain" and when she turned to Resident 1, she observed the resident on the floor. During an interview on 9/11/2024 at 3:23 PM, CNA 1 stated Resident 1's fall occurred in the day room and recalled about nine residents in the room. CNA 1 stated she was watching all the residents in the day room and was not assigned to watch a specific resident. CNA 1 stated she did not witness the fall. CNA 1 stated she was sitting inside the day room charting for about five minutes when she heard Resident 1 scream, when she turned to Resident 1, she observed the resident sitting on the floor. During an interview on 9/11/2024 at 4:01 PM, CNA 3 stated Resident 1 had a fall in August 2024, was confused, active, and moved in the bed. CNA3 stated the resident needed supervision because she was a high fall risk. On 9/12/2024 at 11:27 AM, during a concurrent interview and record review with the Assistant Director of Nursing (ADON), Resident 1's care plans were reviewed. The ADON stated and confirmed Resident 1 had dementia but did not have a dementia care plan with individualized interventions. The ADON stated the resident should have had 2:1 supervision. The ADON stated the resident was in the day room with two staff members and cannot say for certain if the fall could have been prevented. The ADON stated it was important to have a dementia care plan with goals and interventions to address the resident's behavior and ensure the resident was safe. The ADON stated there was a risk that the resident was not receiving care that was specific to her diagnoses of dementia. A review of the facility's policy and procedure (P&P) titled, "Dementia-Clinical Protocol," revised 11/2023, indicated for the individual with confirmed dementia, the IDT would identify a resident-centered care plan to maximize remaining function and quality of life. The policy indicated direct care staff would support the resident in initiating and completing activities and tasks of daily living: bathing dressing, mealtimes, and therapeutic and recreational activities would be supervised and supported throughout the day as needed. A review of the facility's P&P titled, "Falling Star Program," effective 8/2024, indicated residents identified as high risk for falls and those with recurrent falls would be placed in the "Falling Star Program." If resident scored a total of 45 points to 125 points on the Morse Fall Assessment, the resident would be checked visually by nursing staff every hour. The facility failed to: 1. Develop an appropriate care plan for Resident 1's Dementia through an IDT approach, with appropriate interventions including implementation of individualized care and maximizing the resident's safety. 2. Provide for Resident 1, 2:1 staff supervision due to impulsive behavior, per the care plan interventions. As a result, on 8/20/2024, Resident 1 had a fall with pain and facial grimacing in the facility Day Room. On 8/24/2024, Resident 1 had right leg pain with swelling (which was not previously assessed), was transferred to GACH 2 on 8/25/2024. At GACH 2, Resident 1 was diagnosed with a dislocation of the right hip and was placed under general anesthesia for a closed reduction right total hip arthroplasty. The above violations presented an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.