Other·November 4, 2025

The following reflects the findings of the California Department of Public Health during the investigation of Complaint: 2612348 and 2615347 and Entity Reported Incident (ERI): 2611545 and 2624583. Event ID: 1D6F53-H1 Class A Citation was written. 42 CFR 483.25(d) (1) (2) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents 22 CCR 72523 (a) 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. 22 CCR 72311 (a)(2) Nursing Services-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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 9/12/25 at 11:15 am, an unannounced visit was conducted at the facility to investigate Entity Reported Incident numbers 2611545 and 2624583, and Complaint numbers 2612348 and 2615347, regarding a fall with injury when a Certified Nurse Assistant (CNA) did not use appropriate repositioning of Resident 1 during pericare (cleaning a patient's genital and anal areas). The facility failed to: 1. Ensure staff used proper turning technique and provided adequate supervision and assistance during pericare to prevent falls when Resident 1, who was deemed fully dependent for toileting hygiene, experienced a fall on 9/7/25. 2. Ensure implementation of effective intervention with the use of a draw sheet (sheet placed underneath a patient to assist with repositioning and transferring in a healthcare setting) or proper technique and positioning without a draw sheet for Resident 1 in accordance with the facility competency and training consistent with Resident 1's plan of care. As a result of this failure, Resident 1 sustained an avoidable fall during pericare leading to a scalp laceration (cut or tear in the scalp, the outer layer of the head), traumatic brain injury (TBI - an injury to the brain caused by an external force) with Intracranial Hemorrhage (ICH- bleeding within the brain cavity), left rib fracture (broken rib), left pneumothorax (collapsed lung), and a manubrial fracture (break in the upper part of sternum, breast bone) requiring urgent transfer to an acute care hospital and admission to the Intensive Care Unit (ICU - unit in hospitals that provides round-the-clock monitoring and treatment for people with serious illnesses or injuries). Resident 1 was an 82-year-old female, admitted to the facility on 6/24/24. Resident 1 was on primary hospice (comprehensive care program for terminally ill patients, focusing on comfort, quality of life, and symptom management rather than cure near the end of their life) with diagnoses of Parkinson's (progressive disorder that affects movement, balance and coordination disease with comorbidities (medical condition that is simultaneously present with another disease or other conditions in a patient), hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormones, hormones essential for regulating metabolism, growth, and other bodily functions), hyperlipidemia (high level of fat in blood), depression (mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that can significantly impact daily life), dysphagia (difficulty swallowing food or liquids), Coronary Artery Disease (CAD - condition where the arteries that supply the heart with blood become narrowed or blocked, usually due to the buildup of fat) and pacemaker (implanted electronic device that sends electrical impulses to the heart to help it beat at a steady and appropriate rate). During a review of Resident 1's hospice note (HN) titled, "[Skilled Nursing (SN)] For Routine Visit Summary," dated 8/28/25, the HN indicated, "... [Resident 1] requires [one to one (1:1- one caretaker to one patient care model)] assist with meals ... dependent in bathing, dressing, toileting, transferring, repositioning, and feeding. Patient bedridden [inability to get out of bed due to illness]. Requires changing and repositioning every two hours. Patient incontinent [unable to control your bladder or bowels, leading to leakage of urine or feces] of urine and feces. Contracture [permanent tightening and shortening of muscles leading to restricted movement in a joint] to right hand, and to [Bilateral (both) lower extremity] ...Facility responsible for the 24-hour custodial care [assistance with daily activities like bathing, dressing, and eating, provided to individuals who cannot perform these tasks themselves] for the patient and will notify [company name] Hospice of changes in patient condition... " During a review of the facility's document titled, "COMPETENCY CHECK-MOVING A RESIDENT IN BED," dated January 2025, the document indicated, "... Performance Criteria ... MOVING RESIDENT TO SIDE OF BED ... Stands on same side of bed to where resident will be moved ... With a draw sheet: Rolls draw sheet up and grasps draw sheet with palms up. Puts one hand at resident's shoulders and the other at resident's hips. Applies on knee against side of bed, leans back, and pulls draw sheet and resident on the count of three. Without a draw sheet: Slides hands under head and shoulders and moves toward self. Slides hands under midsection and moves toward self. Slides hands under hips and legs and moves toward self ..." During a review of the document titled, "[Emergency Medical Services (EMS)] Patient Care Report (3.5)x," dated 9/7/25, the document indicated, " ... Response Mode to Scene: Emergent (immediate response) .... Lights and Sirens ... Unit Arrived On Scene ... 9/7/25 at 21:58 ... unit left the Scene: 9/7/25 at 22:13 ... Patient arrived at destination ... 9/7/25 at 22:50 ... arrived ... patient laying supine on the linoleum floor with two pillows under her head, both saturated with blood. Per facility staff [unknown], CNAs had patient in a standing position next to the bed when she slipped, fell, and hit her head causing a deep/ open head laceration [cut] approximately 2 [inches- unit of measurement] in length. Staff denies any LOC [loss of consciousness] but states patient immediately began vomiting and had 3 episodes of vomiting prior to EMS arrival. Manual C-spine [way to protect the person's neck and spine from moving] was held as wound was dressed with a pressure bandage and c-collar [support brace for neck and spinal cord] was placed ... [Resident 1] was transported to [emergency room] ..." During a review of the Resident 1's "History and Physical (H&P)," dated 9/8/25 from Hospital A, the "H&P" indicated, Resident 1 was admitted on 9/7/25 after presenting to emergency department on transfer from care facility by EMS following a fall. The "H&P" indicated, "...Assessment of New and Established Problems: 82-year-old female status post ground level fall with Scalp laceration, TBI, mild, with ICH, Left rib fracture, Left pneumothorax, Manubrial fracture .... Plan and Recommendations: ... Admit to ICU ..." During a record review on 9/12/25 at 1:42 p.m. with the Director of nursing (DON) and the Administrator of the facility (ADM), Resident 1's "Medical Record (MR)," with the admission date of 6/24/24 was reviewed. The review of progress note titled, "Interdisciplinary Team [IDT - group of professionals including nurses, social workers, physical therapists, and others who collaborate to develop, implement, and evaluate a patient's comprehensive plan of care] note," dated 9/8/25, the IDT note indicated, " ... IDT for witnessed fall that occurs on 9/7/2025 around 10:00 PM. Discussed with IDT on 9/8/2025 at 9:00 AM. [CNA 1] informed Charge Nurse [CN 1]that resident had fallen in her room. Per [CNA 1], as she was performing a brief change for the resident had a bowel movement, she turned the resident on her right side, her feet dangled slightly off the bed, she stated to the resident "do not move", as she pulled out the soiled brief from the resident and place it on the trash bag by her side, when she turned to resume care to the resident, she had fallen off the bed into the floor. [CNA 1] called another CNA [unknown] across the hallway to call and informed the [CN 1]..." During a concurrent interview and record review on 9/12/25 at 1:55 p.m. with the DON, Resident 1's MR, dated 6/24/24 was reviewed. The DON stated she was present at the IDT meeting and the facility investigation indicated that CNA 1 was not being careful. The DON stated Resident 1 was in room 120 A, and the fall occurred on 9/7/24 at 10:00 p.m. The DON stated Resident 1's Brief Interview for Mental Status (BIMS - mandatory cognitive (the ability of the brain to think and reason) screening for residents, scored from 0-15, score of 13-15 indicating cognitively intact, score 8-12 moderate cognitive impairment, score 0-7 severe cognitive impairment ) was "0" and which indicated the resident was severely cognitive impaired. The DON stated Resident 1 was not restless, was not combative, was very light weight and was contracted [causes the joint to become stiff and fixed in a bent or flexed position, severely limiting a person's range of motion] in her extremities. The DON stated Resident 1 was fully dependent of care during toileting and repositioning. The DON stated CNA 1 cleaned Resident 1 and when CNA 1 turned to put the dirty brief in the trash, Resident 1 fell from the bed to the floor. The DON stated the facility investigation revealed CNA 1 did not have a draw sheet under the resident while turning and did not pull resident close to her as she should have based on her training and competency for repositioning of a resident in bed. The DON stated use of a draw sheet by CNA 1 and pulling Resident 1 close to her would have potentially prevented the fall. The DON stated Resident 1 was unable to hold on to assistive devices or support herself during the turning. The DON stated Resident 1's fall was preventable, and she expected CNA 1 to pay more attention, use assistance from another CNA if needed and follow her competency training (structured learning approach focused on developing specific, job-related knowledge and skills (competencies) that individuals must demonstrate before advancing). The DON stated the fall would have been potentially preventable if CNA 1 had followed the competency and training provided by the facility. The DON stated she was not sure why CNA 1 would ask the resident who was fully dependent for care and had a low BIMS score of "0" to "Do not move" and did not ensure safe positioning herself. The DON stated Resident 1 was also on an air pressure mattress (features a series of air cells that inflate and deflate in cycles to redistribute pressure across the body) which was provided by the Hospice company and was also one of the contributing factors to the fall. The DON stated she was unable to comment on the brand or type of mattress and since the incident, the facility notified the Hospice they were no longer using that particular air mattress and facility will arrange their own mattress. During a record review on 9/12/25 at 2:00 p.m. with the DON and the ADM, Resident 1's "IDT note," dated 9/8/25 was reviewed. The IDT note indicated, "... Assessment: [Licensed Vocational Nurse (CN 1)] and [Registered Nurse (RN)] immediately went into the room and found the resident on the right side of her bed, lying flat on her back with legs stretched out and arms crossed to her chest wearing only her shirt with no brief on. Upon assessment, blood was seen on the floor coming from the back of her head. There is an open laceration noted on the posterior [the back] part of her head. [CN 1] then placed a pressure dressing with gauze and bandage wrap. Resident was noted to be conscious and when asked what happened, she was able to answer and stated, "I don't know". Resident was not moved due to head injury. RN remained with the patient and [CN 1] called [NP] and informed him of the incident and ordered for the resident to be transferred out to acute [care hospital] for further evaluation and treatment. Per interview with the [CN 1], she stated that she was at the nurse's station doing her documentation, per her documentation, cause of fall was when the assigned CNA turned resident to her [resident 1] right side of the bed, CNA noted that resident did not have a draw sheet under her, as the CNA turned the resident, [Resident 1's] left leg fell forward [bringing] [Resident 1's] weight [down] and shifting her to fall off the bed and landed on the floor on her back. Resident's bed height was found at between waist and knee level Notification: MD notified of the incident and ordered to send resident out to [Emergency Room (ER)] for further evaluation and treatment. [Responsible person (RP)] was informed and [company name] Hospice. [Resident 1] was sent to [Hospital A] later on transferred to [Hospital B] ... RP called the facility and stated that [Resident 1] is in [ Intensive Care Unit (ICU - is a hospital unit that provides specialized, round-the-clock care for critically ill patients with life-threatening injuries or diseases)], she has laceration on the back of her head with multiple internal hematoma [collections of blood in or around the brain], left rib 1-3 [indicates a serious injury requiring immediate medical attention] was fractured and punctured her lungs, and lumbar fracture [break in one of the five bones (called vertebrae) of lower back, part of spine supports most of body's weight] with internal bleeding. Root Cause Analysis: Resident's cause of fall was weakness and residents positioning during [Activities of Daily Living (ADL -which are the fundamental self-care tasks necessary for independent living, including bathing, dressing, eating, using the toilet, continence, and mobility)] care." During an interview on 9/12/05 at 2:41 p.m. with CN 1, CN 1 stated she had been working at the facility for almost two years and was familiar with Resident 1. CN 1 stated at the time of the incident she was at the nursing station and heard CNA 1 calling her name. CN 1 stated she was one of the first responders to Resident 1's room right after the fall. CN 1 stated she observed Resident 1 was lying flat on the right side of the bed. CN 1 stated CNA 1 informed CN 1 that CNA 1 was changing Resident 1's brief and Resident 1 slipped out of her hand. CN 1 stated Resident 1 fell to the right side of bed, Resident 1 was not wearing a brief and had a little bit of blood on floor next to Resident 1 and there was nothing on Resident 1's face. CN 1 stated she thought it was coming from Resident 1's head, she assessed Resident 1's vital signs and called to send Resident 1 out by ambulance to ER. CN 1 stated CNA 1 turned Resident 1 and did not have a draw sheet under the resident as she should have one for repositioning residents. CN 1 stated CNA 1 was not able to pull [Resident 1] closer and when she turned [Resident 1], she lost her grip as she had a dirty brief in her other hand that she was putting in the trash. CN 1 stated, "I would personally say yes [CNA] should have second person to assist with repositioning Resident 1." CN 1 stated Resident 1 should have a draw sheet under her while in bed. CN 1 stated this fall for Resident 1 happened around 10:00 p.m. and CNA 1 started her shift at 2:30 p.m. CN 1 stated she would have expected CNA 1 to have changed Resident 1's brief at least once or twice before and CNA 1 should have been aware Resident 1 did not have a draw sheet to securely reposition Resident 1 during pericare. CN 1 stated Resident 1 would not have moved unless she was being moved, Resident 1 was not combative and dependent on care. During a concur