Health inspection·April 4, 2025

§ 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 §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. 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 2/19/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident regarding quality of care and falls. The facility failed to ensure Resident 1, who had a history of falls, was cognitively impaired (had impairment in the ability to think, understand, and reason), and required assistance with transferring and toileting, was provided with the necessary care and services to prevent falls by failing to: 1. Follow the Physician's Order dated 11/27/2024 for Resident 1 to receive visual checks every 30 minutes for fall management, after Resident 1 had an unwitnessed fall on 11/25/2024. 2. Review and update the High Risk for Falls Care Plan after a second fall and change in condition on 12/6/2024. 3. Develop and implement new and/or additional interventions to prevent recurring falls and promote safety for Resident 1 during an Interdisciplinary Team Meeting (IDT, a gathering of healthcare professionals to review and update a resident's care plan) on 12/6/2024. 4. Implement the facility's policy and procedure titled, "Care Planning (IDT) Policy," reviewed 10/10/2024, to revise care plans per RAI [Resident Assessment Instrument: a standardized assessment tool used in long-term care settings to evaluate the health, functional status, and needs of resident] schedules and as changes in the resident's condition dictates. 5. Implement he facility's policy and procedure titled, "Falls and Fall Risk, Managing," reviewed 10/10/2024, to identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. As a result, on 2/3/2025 Resident 1 fell (third fall in approximately two month) while in the bathroom. Resident 1 was transferred to General Acute Care Hospital (GACH) 1 and was diagnosed with a hematoma (a pool of blood that forms under the skin or in between tissues) to the head and a left nondisplaced acromial fracture laterally (a broken left shoulder blade). A review of Resident 1's Admission Record indicated the facility re-admitted the resident on 6/13/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), anemia (a condition where the body does not have enough healthy red blood cells), psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality), dependence on renal dialysis (hemodialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed), hemiplegia (total paralysis of the arm, leg, and truck on the same side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (CVA, stroke, loss of blood flow to part of the brain). A review of Resident 1's History and Physical (H&P) dated 6/17/2024, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 11/25/2024, indicated the resident had severe cognitive impairment (problems with the ability to think, understand, and reason). The MDS indicated Resident 1 required partial/moderate assistance from staff with toileting hygiene and supervision or touching assistance with personal hygiene, rolling left and right, lying to sitting on the side of the bed, sit to standing, chair/bed to chair transfers, and toilet transfers. The MDS indicated the resident required partial/moderate assistance from staff for walking 10 feet and did not have any falls with a major injury since admission to the facility (6/13/2024). A review of Resident 1's Change of Condition (COC) documentation dated 11/25/2024 at 5:45 PM, indicated the resident had an unwitnessed fall, the physician was notified, and recommended to discontinue metoprolol (medication used to treat high blood pressure). A review of the Physician’s Order dated 11/25/2024, indicated Resident 1 was to wear anti-slip socks only to prevent a fall every shift. According to a review of Resident 1's IDT – Fall Note dated 11/27/2024 at 4:10 PM, the resident was found on the floor laying (11/25/2024) on his back with the back of his head on top of the left footrest of the wheelchair. The IDT – Fall Note indicated Resident 1 stated he was reaching for crackers then fell on the floor, slid from the wheelchair and hit his head. The document indicated Resident 1 fell while trying to pick up crackers without assistance. The document indicated the IDT recommended new interventions for Resident 1 to continue toileting every two hours, to monitor the resident with visual checks every 30 minutes for fall management, and for the resident to only wear anti-slip socks to prevent falls. The document indicated an intervention for Resident 1 to be screened by Physical Therapy (PT) after the fall. A review of the Physician’s Order dated 11/27/2024, indicated for Resident 1 to receive visuals checks every 30 minutes every shift for fall management. A review of Resident 1's Rehab - Post Fall Assessment dated 11/27/2024 at 6:43 PM, indicated the resident did not have any changes in safety awareness, range of motion, strength, transfers or gait. The assessment indicated Resident 1 did not have any complaints of pain or discomfort and recommended to continue with Restorative Nursing Assistant (RNA) treatment and to continue to monitor the resident for any changes. A review of Resident 1's Change of Condition form dated 12/6/2024 at 7:05 AM, indicated the resident had a fall, was found lying on the floor between the bed and the wheelchair. The COC form indicated Resident 1 was found with a skin tear on his right ear with swelling, the physician was notified and recommended to start neuro checks (assess the function of the neurological/nervous system) with treatment to the resident's right ear. A review of Resident 1's Rehab - Post Fall Assessment dated 12/6/2024 at 12:48 PM, indicated the resident fell in his room, had a change in safety awareness, and did not have any change in range of motion, strength, transfers, or gait. The assessment further indicated this was Resident 1's second fall in two weeks. The assessment indicated Resident 1 would benefit from skilled physical therapy service to include safety awareness and improve functional mobility. A review of Resident 1's Morse Fall Risk Screen (an assessment tool that predicts the likelihood a resident will fall) dated 12/6/2024 indicated the resident was at high risk for falling with a score of 65 (a score of 45 or higher indicated a resident was at high risk for potential falls). The fall risk screen indicated Resident 1 had a history of falling, more than one diagnosis on the chart, did not use any ambulatory aids (was either on bedrest, utilized a wheelchair, or required nurse assistance), exhibited weak gait (steps are short, and resident may shuffle), and overestimated or forgot their limits. The fall risk screen indicated Resident 1 was referred to the IDT. A review of Resident 1's Interdisciplinary Team Meeting-Fall document dated 12/6/2024 at 4:26 PM, indicated the resident was lying on the floor of the right side of his bed and his wheelchair noted with a skin tear on his right ear with swelling. The note indicated Resident 1 was wearing shoes at the time of the fall. The document indicated Resident 1 stated he was trying to transfer himself from his bed to the wheelchair. The document indicated Resident 1 had poor judgement, poor safety awareness, CVA with right hemiparesis, and dementia. The document indicated Resident 1 perceived himself as independent and would not call for assistance. The document indicated new intervention recommendations from the IDT for Resident 1 was to be screened by physical therapy for transferring from the wheelchair to bed and to continue 30-minute visual checks. A review of Resident 1's COC form dated 2/3/2025 at 1:47 AM, indicated the resident had a fall, was found lying on the floor in the restroom between the toilet and wall. The COC form indicated Resident 1 obtained a skin tear to his left forearm and knee with bleeding noted, the physician was notified and recommended to start neurochecks with treatment to the resident's left forearm and knee. According to a review of Resident 1’s "Q (every) 30 minutes visual checks" form dated 2/3/2025, at 2 AM there was documentation of "N/A" (not applicable) for Resident 1's location and behavior. A review of Resident 1's Nurses Notes dated 2/3/2025 at 10:05 AM, indicated the resident was picked up by transportation via gurney for dialysis. The note indicated Resident 1 was complaining of pain on his left shoulder and was given 50 milligrams (mg) of Tramadol (a medication used for the short-term relief of moderate to severe pain) by mouth as ordered for the resident's pain. A review of Resident 1's Nurses Notes dated 2/3/2025 at 11:40 AM indicated a phone call was received from the dialysis center that Resident 1 was transferred to GACH 1 from the dialysis center for further evaluation due to a hematoma to the left side of the head and increased pain to the left shoulder. The note indicated Resident 1's physician and responsible party were notified. A review of Resident 1's Dialysis Form documentation dated 2/3/2025, indicated that no dialysis treatment was initiated because Resident 1 was sent to the emergency room (ER). A review of Resident 1's left shoulder x-ray report from GACH 1 dated 2/3/2025 at 2:36 PM, indicated the resident had a nondisplaced acromial fracture laterally (a broken left shoulder blade). A review of Resident 1's Nursing Note dated 2/3/2025 at 10:37 PM, indicated the resident returned to the facility at 9:16 PM from GACH 1. The note indicated that per report from GACH 1's emergency department Resident 1 was to keep the left upper extremity (left arm) non-weight bearing (NWB, a restriction that requires a patient to avoid putting weight on an affected limb), follow up with orthopedics (a physician that specializes in the treatment of injuries to bones), and receive Tylenol (acetaminophen, a medication used to treat pain) 650 mg by mouth every six hours. A review of Resident 1's IDT - Fall document dated 2/4/2025 at 10:45 AM, indicated staff responded to Resident 1 yelling from his room at approximately 1:45 AM. The document indicated Resident 1 was found lying on the floor in the restroom between the toilet and the wall. The document indicated Resident 1 was noted with a skin tear on his left forearm and knee with bleeding. The document indicated Resident 1 stated he did not know how he fell and may have tripped over his foot. The document indicated Resident 1 had poor judgment, poor safety awareness, CVA with right hemiparesis, gait/balance problems, non-compliant behavior, and dementia. The document indicated Resident 1 perceived himself as independent and would not call for assistance. The document did not indicate any new interventions to prevent future falls. A review of Resident 1's Care Plan revised 2/5/2025, indicated the resident was at high risk for falls and injury related to limitation of mobility, history falls, use of psychotropic medication (medication used to treat mental health disorders), ascites (a condition where excess fluid accumulates in the abdominal cavity), dementia, ESRD on hemodialysis, hepatic encephalopathy (brain dysfunction caused by liver dysfunction), hyperlipidemia, seizure disorder (a neurological condition characterized by recurrent, unprovoked episodes of abnormal brain electrical activity), Type II diabetes, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, hypertension (high blood pressure), psychosis, anxiety disorder (excessive and persistent worry, fear, and nervousness that can interfere with daily life), depression, Congestive Heart Failure (CHF, a condition where the heart muscle is weakened and cannot pump blood efficiently throughout the body), and a recent fall. The care plan indicated goals of managing Resident 1 were to minimize fall and injury, managing risk factors to minimize falls and injury, and for the resident to follow safe technique when performing functional mobility and Activities of Daily Living (ADL, basic self-care tasks that individuals perform daily) to prevent falls and injury. The care plan indicated interventions that included Resident 1 wearing anti-slip socks only, 30-minute visual monitoring for fall management, and providing the resident with assistance as needed with transfers and ambulation. The care plan indicated the interventions were updated after Resident 1 fell on 11/25/2024 and 2/3/2025. The care plan did not indicate the interventions were updated after Resident 1's fall on 12/6/2024. During a telephone interview with Resident 1's Responsible Party (RP) on 2/19/2025 at 11:42 AM, the RP stated the facility called the RP to let her know Resident 1 fell on 2/3/2025. The RP stated she was told Resident 1 fell in the bathroom and required a lot of help. The RP stated Resident 1 would get confused because the resident had a stroke and had dementia. The RP stated half of Resident 1's body did not work because of the stroke. During a telephone interview on 2/19/2025 at 1:09 PM, Certified Nursing Assistant (CNA) 1 stated she was the assigned to Resident 1 when he fell on 2/3/2025 around 1:40 AM to 2 AM. CNA 1 stated she did not witness Resident 1 fall because she was on break at the time. CNA 1 stated prior to taking her break she notified the registry (staffing agency) CNA that she was going to take her break. CNA 1 stated when she returned from her 10-minute break, Resident 1 was already back in bed. CNA 1 stated the charge nurse informed her Resident 1 fell. CNA 1 stated Resident 1 was a major fall risk and would get out of bed frequently. CNA 1 stated Resident 1 needed assistance with transferring from the bed to the wheelchair and to the bathroom. CNA 1 stated Resident 1 was not stable when out of bed and walking. CNA 1 stated Resident 1 was on visual checks every 30 minutes because he was not safe to get out of bed on his own. During a telephone interview on 2/19/2025 at 1:20 PM, Licensed Vocational Nurse (LVN) 1 stated she