Health inspection·January 31, 2025

42 CFR § 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 residents' choices. 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. 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: (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 1/6/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct an investigation regarding a facility reported incident of Resident 1's fall with injury. The facility failed to provide a safe and accident-free environment for Resident 1, who had visual impairment (blindness, difficulty seeing), a left above the knee amputation (AKA - surgical removal of the portion of the leg above the knee), and had history of fall with injury, by failing to: 1.Follow the Physician's Order dated 4/15/2024 for Resident 1 to receive visual hourly safety checks for fall prevention. 2. Review and update the At Risk for Falls Care Plan after a fall and change in condition on 4/15/2024, including implementation of individualized care and maximizing the resident's safety. 3. Assist Resident 1 with mobility and repositioning around 7:30 PM on 12/19/2024, when the roommate (Resident 2) informed Licensed Vocational Nurse 1 that Resident 1 was on the edge of the bed and was going to fall. 4. Implement the facility's policy and procedure titled, "Fall Risk Assessment," revised 1/2024, to include the attending physician and facility staff to collaborate in identifying and documenting resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. 5. Implement the facility's policy and procedure titled, "Care Plans, Comprehensive Person-Centered," revised 5/2024, where the Interdisciplinary Team (a team of professionals from various fields who work together toward the goals of the resident) must review and update the care plan at least quarterly, in conjunction with the required quarterly Minimum Data Set assessment (MDS, a resident assessment tool). As a result, Resident 1, a 63-year-old female, had another fall off her bed on 12/19/2024, was screaming, crying, and the facility staff called 911 (emergency phone number for immediate medical assistance via ambulance). Resident 1 was transferred to General Acute Care Hospital (GACH) 1 where she moaned in pain, sustained a 5-centimeter (cm) laceration (a cut or tear in the skin that is caused by an injury) to her forehead and on 12/20/2024 was admitted to the intensive care unit for an acute stroke (a medical emergency that occurs when there is a sudden loss of blood flow to the brain, resulting in brain cell damage. It can also affect the spinal cord). A review of Resident 1's Admission Record, indicated the facility originally admitted the resident on 12/22/2021 with diagnoses including a left AKA, schizophrenia (a serious mental disorder in which people interpret reality abnormally, may result in delusions and behavior that impairs daily functioning, may have grandiose delusions [strong beliefs of things that are untrue]), and visual impairment. A review of Resident 1's At Risk for Falls care plan initiated 8/19/2022, related to diagnoses of visual impairment and impulsive behavior (acting without thinking of the consequences), lack of awareness, left AKA, muscle weakness, and right heel wound / pain indicated the goal was for Resident 1 to minimize the risk for falls. The care plan interventions indicated to maintain the call light within reach, to remind the resident to use the call light, and to remove hazards from the resident's environment. The care plan indicated the interventions were initiated on 8/19/2022 and had not been updated since 8/19/2022. A review of Resident 1's Actual Fall care plan dated 4/11/2024, indicated the resident fell from the wheelchair while in the resident's room. The care plan was revised on 4/15/2024 which indicated Resident 1 rolled out of bed in the covers and fell onto the floor to the right side of the bed. The care plan indicated interventions for visual hourly safety checks and to continue interventions on the at-risk plan. A review of the Physician's Order dated 4/15/2024 indicated to visually and hourly check Resident 1 for fall monitoring. A review of the MDS dated 11/22/2024 indicated Resident 1 had mildly impaired cognitive skills (problems or difficulty with memory, thinking, and following instructions, but it did not usually interfere with daily tasks). The MDS indicated Resident 1's functional abilities (dependent on help, for personal hygiene, putting on / taking off footwear, lying to sitting on the bed, bed to chair transfer, and ability for Resident 1 to ambulate at least 10 feet once standing) were not assessed. A review of Resident 1's MDS dated 12/9/2024, indicated the resident had modified independence of cognitive skills for daily decision making (some difficulty in new situations only). The MDS indicated Resident 1 was dependent on help (helper did all of the effort) for personal hygiene, putting on / taking off footwear, lying to sitting on the bed, and bed to chair transfer. The MDS indicated the ability for Resident 1 to ambulate at least 10 feet once standing was not attempted and Resident 1 did not perform this activity. The MDS indicated Resident 1 was always incontinent (having no or little control) of urine and bowel and had one fall with injury (skin tears, abrasions, lacerations, superficial bruises, hematomas [a collection of blood that forms outside of blood vessels. It can occur anywhere in the body, including the brain], and sprains; or any fall-related injury that causes the resident to complain of pain) since admission / entry, reentry, or the prior assessment. According to a review of Resident 1's Fall Risk Assessment dated 12/17/2024, the resident was at a high risk for potential falls. The assessment indicated Resident 1 had intermittent confusion, no falls in the past three months, was chair bound, and had poor vision with or without glasses. The fall risk assessment indicated Resident 1 required the use of assistive devices (i.e. cane, w/c, walker, furniture), had no noted blood pressure drop between lying and standing, had a loss of limb, and was taking hypoglycemics (medication to lower blood sugar levels), narcotics (medication used to treat pain), and psychotropics (medication that affects behavior, mood, thoughts, or perception). A review of the At Risk for Fall Care plan indicated there were no updates or revisions to include Resident 1's current status of high risk for falls with intermittent confusion. A review of Resident 1's Change of Condition documentation dated 12/19/2024 at 8:08 PM, indicated the resident had a fall. The documentation indicated at 7:40 PM, Resident 1 fell out of her bed and fell onto the floor. The documentation indicated Resident 1 was found to have a gash (a long deep slash, cut, or wound) on their forehead and was bleeding from area. The documentation indicated 911 was called and the paramedics decided to transfer Resident 1 to General Acute Care Hospital (GACH) 1. The documentation further indicated Resident 1's physician was notified. A review of Resident 1's Medication Administration Record (MAR) dated 12/1 - 12/31/2024 indicated to perform visual hourly safety checks for fall precaution. The MAR indicated to "document in MAR Y=Yes that the visual check was completed checking on the resident every hour." The MAR indicated the documentation of "2" referred to "Drug Refused." The MAR documentation on 12/8 - 12/11/2024 indicated Licensed Vocational Nurse (LVN) 1 documented "2," drug refused, from midnight to 7 AM for a total of 32 times. The MAR dated 12/19/2024 from 5 PM to 11 PM indicated LVN 1 documented "2." A review of Resident 1's Health Status Note documented by Licensed Vocational Nurse (LVN) 1 dated 12/19/2024 at 8:30 PM, indicated LVN 1 went on a break at 7:30 PM and returned at 7:50 PM. The health status note indicated that according to LVN 2 (who covered for LVN 1 while on break), Resident 1 was heard falling at 7:40 PM. LVN 2 went straight to the room and found Resident 1 on the floor with a gash on the forehead, and 911 was called. The note indicated Resident 2 (Resident 1's roommate) reported to LVN 1 around 6 PM that Resident 1 was at risk for falling as Resident 1 was observed on the edge of the bed. According to a review of Resident 1's Emergency Documentation (ED) from GACH 1 dated 12/19/2024, the resident was found on the floor from falling out of her bed striking her forehead on the floor and sustaining a laceration. The ED documentation indicated Resident 1 was moaning in pain and had a 5-centimeter horizontal shallow laceration to the forehead. A review of Resident 1's GACH 1 History and Physical (H&P) dated 12/20/2024 indicated the resident had a magnetic resonance imaging (MRI, a noninvasive medical imaging test that used radio waves and strong magnetic fields to create detailed pictures of the inside of the body) scan done on 12/20/2024 for a head injury. The MRI indicated Resident 1 had a small region of acute infarct (a medical emergency that occurs when an organ or body part has a sudden interruption of blood supply, resulting in cell death and tissue damage due to and lack of oxygen, in the context of stroke) along the left corona radiata (a bundle of nerve fibers that carries information between the brain stem and cerebral cortex, or the outer layer of the brain). The H&P indicated Resident 1 was initially admitted to the intensive care unit, was later downgraded to the telemetry unit (a hospital floor where patients are monitored for cardiac activity), was administered aspirin and a statin (a class of medications that reduce the risk of stroke and heart attack) for her acute stroke with a neurology consult (a meeting with the brain doctor to treat the brain, spinal cord or nervous system). During a concurrent observation and interview on 1/6/2025 at 11:10 AM, in Resident 1's room, the resident was observed lying in bed with an adaptable call light within reach. Resident 1 was observed with the bed low and floor mats to the left and right side of the bed. Resident 1 was observed wearing a yellow wristband that indicated "fall risk" to the right wrist. Resident 1 stated she did not remember falling or hitting her head in the facility. Resident 1 stated she did not remember anything about falling. A review of Resident 2's Admission Record indicated the facility admitted the resident on 3/20/2024 with diagnoses including muscle weakness, anxiety disorder, and depression. A review of Resident 2's MDS dated 11/20/2024, indicated the resident was cognitively intact (the ability to think, understand, and reason). During an interview on 1/6/2025 at 12:38 PM, in Resident 2's room, Resident 2 stated she knew Resident 1 and she was roommates with Resident 1 since being admitted to the facility 3/2024. Resident 2 stated she remembered when Resident 1 fell on 12/19/2024 around 8 PM. Resident 2 stated before Resident 1 fell she saw the resident close to the edge of her bed. Resident 2 stated she called LVN 1 and told LVN 1 Resident 1 was about to fall. Resident 2 stated LVN 1 told her, "Don't worry. Resident 1 was not going to fall." Resident 2 stated LVN 1 stood at the door and told her not to worry and walked away. Resident 2 stated, "LVN 1 did not come into the room at all." Resident 2 stated shortly after notifying LVN 1, Resident 1 fell and landed close to Resident 2's bed. Resident 2 stated after Resident 1 fell, the resident was crying and screaming. Resident 2 stated LVN 1 came into the room after the paramedics came. Resident 2 stated Resident 1, "Needed a lot of help doing things, she only had one leg, and she had fallen from the wheelchair before." During a telephone interview on 1/6/2025 at 2:37 PM, Certified Nursing Assistant (CNA) 1 stated he was Resident 1's CNA the night the resident fell. CNA 1 stated Resident 1 was always confused and shouted a lot at night. CNA 1 stated Resident 1 was always moving left and right and needed special pillows on the bed. During an interview on 1/6/2024 at 3:31 PM, LVN 2 stated she was working the 3 PM to 11 PM shift on 12/19/2024. LVN 2 stated she was at the nursing station doing documentation when she heard a noise and Resident 2 yelling for help. LVN 2 stated she went to Resident 1 and 2's room and saw Resident 1 on the floor. LVN 2 stated she saw Resident 1 had blood on her head. LVN 2 stated she asked Resident 1 what had happened, and the resident told her she fell, hit her head, and was in pain but could not provide their pain level. LVN 2 stated she called 911. LVN 2 stated Resident 1 hit the right side of her head and had a smear of blood on their face. LVN 2 further stated LVN 1 was assigned to take care of Resident 1 that night. On 1/7/2024 at 8:57 AM, during a telephone interview, LVN 1 stated on 12/19/2024 he was working the 3 PM to 11 PM shift and was taking care of Resident 1. LVN 1 stated he did not see Resident 1 fall. LVN 1 stated he went on break from 7:30 PM to 8 PM that night. LVN 1 stated he came back early from break because he was called and informed Resident 1 had fallen. LVN 1 stated when he got back to the facility Resident 1 was already in the ambulance. LVN 1 stated Resident 1 had some behaviors that were concerning such as leaning on the side of the bed, crying a lot, and behaviors that make you think the resident might have an accident. LVN 1 stated at baseline Resident 1 was confused and did not know much of what was going on. LVN 1 stated Resident 1 was at risk of falling and he could not remember if Resident 1 had floor mats the night the resident fell on 12/19/2024. During a concurrent interview and record review on 1/7/2025 at 9:32 AM, Resident 1's care plans, MAR dated 12/1 - 12/31/2024, and electronic health care record (EHR) were reviewed with Registered Nurse (RN) 1. RN 1 stated Resident 1 was unpredictable and had periods of confusion but could make their needs known. RN 1 stated Resident 1 was dependent on staff and required total care. RN 1 reviewed Resident 1's EHR and stated prior to the resident's fall on 12/19/2024, the resident fell previously on 4/15/2024. RN 1 stated Resident 1's at risk for falls care plan was not updated after the resident fell on 4/15/2024. RN 1 stated Resident 1's at risk for falls care plan was last updated on 8/19/2022. RN 1 stated after a resident had a fall, staff refer to the at-risk for falls care plan and update the care plan with additional interventions. RN 1 stated after a resident had a fall, an actual fall care plan should also be created. RN 1 stated care plans were updated with a change of condition, quarterly, and as needed. During the same interview, RN 1 re