Health inspection·April 2, 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. F688 §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. 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 2/10/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the Recertification Survey. The facility failed to provide therapy services for Residents 48, who had limited range of motion (ROM, full movement potential of a joint [where two bones meet]) by failing to: 1. Provide Occupational Therapy (OT, rehabilitative profession aimed to increase or maintain a person's capability to participate in everyday life activities) evaluation after identifying a decline in Resident 48's range of motion in the left shoulder, left elbow, left wrist, and left hand during the OT Joint Mobility Screen (JMS, brief assessment of a resident's ROM) dated 8/22/2024. 2. Provide OT Evaluation and treatment for Resident 48 prior to the application of a left resting hand splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) for one to six (1-6) hours in accordance with professional standards of practice on 8/22/2024. 3. Provide Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment from 8/2024 to 2/2025 (over five months) to Resident 48 for passive range of motion (PROM, movement at a given joint with full assistance from another person) to left upper extremity (UE, shoulder, elbow, wrist, hand/fingers) in all planes (all possible joint movements) five (5) times a week in accordance with the physician's order dated 8/22/2024 . 4. Provide RNA treatment from 8/2024 to 2/2025 (over five months) for the application of a left resting hand splint for 1-6 hours as tolerated five times a week in accordance with the physician's order dated 8/22/2024. 5. Report Resident 48's refusals and missed RNA treatments on 9/2024, 10/2024, 12/2024, 1/2025, and 2/2025 to the Charge Nurse and Therapy staff in accordance with the facility's job description titled, "Restorative Nursing Assistant/CNA." 6. Provide Resident 48 with a nursing assessment after Restorative Nursing Aide (RNA 3) reported Resident 48's refusals to participate in RNA throughout 11/2024 in accordance with facility policy and procedure. As a result on 1/15/2025, Resident 48 an 86-year-old female developed a Stage IV pressure injury (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) on the left middle finger, due to the worsening contracture (loss of motion of a joint) and fisted position of the left hand from 9/2024 to 1/2025 (over four months). A review of Resident 48's Admission Record indicated the resident was admitted to the facility on 9/2/2022 with diagnoses including hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting left non-dominant side and muscle weakness. A review of Resident 48's Care Plan initiated on 9/15/2022 indicated the resident had the potential for limitations in joint mobility related to decreased physical mobility, history of cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), osteoporosis (weak and brittle bones) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). The care plan goal indicated Resident 48 would have no further loss of ROM daily for three months. The care plan interventions indicated to monitor for pain or stiffness, position resident to prevent further contractures with pillow or splint as needed, RNA to perform PROM to left UE (LUE) in all places as tolerated 5 times a week, RNA to apply left resting hand splint for 1-6 hours or as tolerated 5 times a week. A review of Resident 48's Care Plan initiated on 9/15/2022 indicated the resident was at risk for complications due to alteration in musculoskeletal status related to diagnosis of hemiplegia and hemiparesis, osteoarthritis of knee and hip, osteoporosis, advanced age, contractures, joint pain. The care plan goal indicated complications related to fracture (broken bone), such as contracture formation, and immobility would be minimized. The care plan interventions included to assist the resident with the use of supportive devices (splints) as recommended; monitor/document/report to medical doctor (MD) as needed signs and symptoms or complications related to arthritis (swelling and tenderness of a joint causing pain and stiffness): joint pain, joint stiffness, swelling, decline in mobility, decline in self-care ability, contracture formation/joint shape changes, pain after exercises. According to a review of the OT Joint Mobility Screening (JMS) dated 2/14/2024, Resident 48 had full range of motion in both wrists, both hand/fingers, both elbows, and both shoulders. The JMS indicated Resident 48 did not have minimal to severe loss of UE passive ROM and did not have a diagnosis or condition that placed Resident 48 at risk for contracture development. The JMS indicated skilled OT evaluation and RNA program was not recommended. A review of Resident 48's OT JMS dated 6/1/2024, indicated the resident had full range of motion in both wrists, both hand/fingers, both elbows, and both shoulders. The JMS indicated Resident 48 did not have minimal to severe loss of UE passive ROM and did not have a diagnosis or condition that placed Resident 48 at risk for contracture development. The JMS indicated skilled OT evaluation and RNA program was not recommended. A review of Resident 48's OT JMS dated 8/22/2024, indicated the resident had full range of motion in the right wrist, right hand/fingers, right elbow, and right shoulder. The JMS indicated Resident 48 had moderate loss (26-50 percent (%) loss) of range of motion in the left wrist, left hand/fingers, and left shoulder and minimal loss (less than 25% loss) range of motion in the left elbow. The JMS indicated Resident 48 had minimal to severe loss of UE passive ROM and had a diagnosis or condition that placed Resident 48 at risk for contracture development. The JMS indicated skilled OT evaluation was not recommended, and RNA program was recommended. The comments indicated "PROM left UE, left resting hand splint, [right]UE AAROM." A review of the Physician's Order Summary Report (OSR) dated 8/22/2024 indicated Resident 48 to receive RNA services, perform PROM LUE in all planes as tolerated, frequency 5 times a week. The OSR indicated the RNA to apply left resting hand splint for 1-6 hours or as tolerated, frequency 5 times a week. A review of Resident 48's 8/2024 RNA Daily Survey Report (DSR), the DSR indicated Resident 48 did not complete RNA treatment (RNA entry was blank or "not available") to perform PROM LUE in all planes as tolerated, 5 times a week on the following days: 8/30/24. A review of the RNA DSR dated 8/2024, indicated Resident 48 refused RNA treatment to perform PROM LUE in all planes as tolerated, five times a week on 8/26/2024. Resident 48 did not complete RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, five times a week on 8/30/2024. The DSR indicated Resident 48 refused RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, five times a week on 8/26/2024. A review of the OT JMS dated 9/1/24, indicated Resident 48 had full range of motion in the right wrist, right hand/fingers, right elbow, and right shoulder. The JMS indicated Resident 48 had moderate loss of motion in the left wrist, left hand/fingers, and left shoulder and minimal loss of motion in the left elbow. The JMS indicated Resident 48 had minimal to severe loss of UE passive ROM and had a diagnosis or condition that put Resident 48 at risk for contracture development. The JMS indicated skilled OT evaluation was not recommended. A review of Resident 48's Minimum Data Set (MDS, a resident assessment tool) dated 9/1/24, indicated Resident 48 had severe cognitive impairments. The MDS indicated Resident 48 did not exhibit any behavior for rejection of care that was necessary to achieve health and well-being. The MDS also indicated Resident 48 required substantial/maximal assistance from staff for oral hygiene, bathing, dressing, personal hygiene, sit to stand, and bed to chair transfers. The MDS indicated Resident 48 had functional range of motion impairments on one side of the upper extremity and impairments on one side of the lower extremity. According to a review of Resident 48's 9/2024 RNA DSR, Resident 48 did not complete RNA treatment to perform PROM LUE in all planes as tolerated, five times a week on the following days: 9/2, 9/4, 9/5, 9/11, 9/17, 9/18, 9/24, 9/25, and 9/30/2024. A review of Resident 48's 9/2024 RNA DSR, indicated the resident refused RNA treatment to perform PROM LUE in all planes as tolerated, five times a week on 9/13/2024. The DSR indicated Resident 48 did not complete RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, five times a week on the following days: 9/2 - 9/5, 9/11, 9/13, 9/16, 9/17, 9/18, 9/20, 9/24 - 9/27 and 9/30/2024. A review of Resident 48's 10/2024 RNA DSR, indicated the resident did not complete RNA treatment to perform PROM LUE in all planes as tolerated, five times a week on the following days: 10/1, 10/2, 10/4, 10/8, 10/11, 10/14, 10/18, 10/21, 10/22, 10/25, 10/28 and 10/31/2024. The DSR indicated Resident 48 did not refuse RNA treatment to perform PROM LUE in all planes as tolerated, five times a week. A review of Resident 48's 10/2024 RNA DSR, the DSR indicated Resident 48 did not complete RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, five times a week on the following days: 10/1, 10/4, 10/8, 10/11, 10/14, 10/18, 10/21, 10/22, 10/25, 10/28 and 10/31/2024. The DSR indicated Resident 48 refused RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 10/7, 10/15, 10/17, 10/23 and 10/24/2024. A review of Resident 48's RNA Weekly Summary (WS) dated 10/1/24, indicated the resident completed RNA treatment five times in the last week for AAROM, PROM, and splint application. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. During a review of Resident 48's RNA WS dated 10/8/24, the WS indicated Resident 48 completed RNA treatment 5 times in the last week for AAROM, PROM, and splint application for left hand. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. During a review of Resident 48's RNA WS dated 10/22/24 an 10/30/2024 the WS indicated Resident 48 completed RNA treatment for AAROM and PROM. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. During a review of Resident 48's 11/2024 RNA DSR, the DSR indicated Resident 48 did not complete RNA treatment to perform PROM LUE in all planes as tolerated, five times a week on the following days: 11/4, 11/7, 11/13, 11/21 and 11/25/2024 and refused RNA treatment to perform PROM LUE in all planes as tolerated, five times a week on the following days: 11/1/24, 11/8/24, 11/11/24, 11/12/24, 11/15/24, 11/19/24, 11/20/24, 11/22/24, 11/26 - 11/29/24 During a review of Resident 48's 11/2024 RNA DSR, the DSR indicated Resident 48 did not complete RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 11/1/24, 11/4/24, 11/6/24, 11/7/24, 11/13/24, 11/15/24, 11/20/24, 11/21/24, 11/25/24, 11/26/24, 11/27/24 and refused RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 11/8/24, 11/11/24, 11/12/24, 11/14/24, 11/19/24, 11/22/24, 11/28/24, 11/29/24. During a review of Resident 48's RNA WS dated 11/1/24, the WS indicated Resident 48 completed RNA treatment 5 times in the last week for AAROM and splint for left hand. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. During a review of Resident 48's RNA WS dated 11/8/24 and 11/15/2024, the WS indicated Resident 48 completed RNA treatment 5 times in the last week for AAROM of both lower extremities, PROM of LUE, and splint for left hand. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. The WS indicated "refuse" in comments. The WS was reviewed and co-signed by an unidentified nursing staff. During a review of Resident 48's RNA WS dated 11/22/2024 and 11/29/2024, the WS indicated Resident 48 completed RNA treatment 5 times in the last week for AAROM of both lower extremities and PROM of LUE. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. The WS indicated "refuse" in comments. The WS was reviewed and co-signed by an unidentified nursing staff. During a review of Resident 48's MDS dated 12/1/24, the MDS indicated Resident 48 had severe cognitive impairments. The MDS indicated Resident 48 did not exhibit any behavior for rejection of care that was necessary to achieve health and well-being. The MDS also indicated Resident 48 required substantial/maximal assistance from staff for oral hygiene, bathing, dressing, personal hygiene, sit to stand, and bed to chair transfers. The MDS indicated Resident 48 had functional limitations in range of motion impairments on one side of the upper extremity and impairments on one side of the lower extremity. During a review of Resident 48's OT JMS dated 12/3/24, the JMS indicated Resident 48 had full range of motion in the right wrist, right hand/fingers, right elbow, and right shoulder. The JMS indicated Resident 48 had moderate loss of motion in the left wrist, left hand/fingers, and left shoulder and minimal loss of motion in the left elbow. The JMS indicated Resident 48 did not have minimal to severe loss of UE passive ROM and had a diagnosis or condition that put Resident 48 at risk for contracture development. The JMS indicated skilled OT evaluation was not recommended, and an RNA program was recommended. During a re