Health inspection·August 13, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to transfer one of three sampled residents (Resident 1) immediately to the general acute care hospital (GACH), on 8/2/2024, when Resident 1 had an unavoidable fall that caused Resident 1 to sustain a right distal femur fracture (thigh broken bone) and required admission to a GACH for evaluation and treatment. Residents Affected - Few This deficient practice resulted Resident 1 ' s delayed transferred to the GACH on 8/3/2024, 10 hours after an X-ray (a photographic image of a part of the body) result indicated acute (sudden) comminuted supracondylar (broken bone into more than two pieces) fracture of the right distal femur, and had the potential for Resident 1 to experience severe pain, and risk for delayed care, and treatment. Findings: During an interview on 8/12/2024 at 10:50 a.m., with Resident 1, Resident 1 stated on 8/2/2024 around 3:00 p.m., Certified Nursing Assistant (CNA) 1 transferred her from the wheelchair to the bed using a Hoyer lift (mechanical lift- a device used to transfer residents from a bed to a chair or other similar places). Resident 1 stated the Hoyer lift sling broke and she fell. Resident 1 stated she had right femur surgery. During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes (abnormal blood sugar), hypertension (high blood pressure), and muscle weakness (decrease in muscle strength). During a review of Resident 1 ' s History and Physical (H&P), dated 7/9/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 7/11/2024, the MDS indicated Resident 1 had the ability to express ideas and wants, and had clear comprehension (capability of understanding something). The MDS indicated Resident 1 was totally dependent (full staff performance) with two persons physical assist for transfer (how the resident moves between surfaces including to or from: bed, chair, wheelchair, or standing position). During a review of Resident 1 ' s Fall report dated 8/2/2024 timed at 3:45 p.m., the report indicated Resident 1 required a Hoyer lift for transfer. The report indicated on 8/2/2024, Resident 1 was being transferred from the wheelchair to the bed. The report indicated during the transfer, the Hoyer lift sling broke and Resident 1 fell on the floor. The report indicated Resident 1 ' s right leg Page 1 of 7 055519 055519 08/13/2024 Downey Post Acute 13007 S. Paramount Blvd. Downey, CA 90242

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was noted with slight swelling. The report indicated Resident 1 was assisted back to bed and reported 10 out of 10 pain on a pain scale (0=no pain, 1-3=mild pain, 4-6=moderate pain, 7-10= severe pain) to her right leg. During a review of Resident 1 ' s Situation, Background, Appearance, Review (SBAR) Communication Form, dated 8/2/2024, timed at 3:55 p.m., the SBAR indicated on 8/2/2024, at 3:50PM, Resident 1 slid off the Hoyer lift on to her right leg, when the lift ' s sling snapped (broke). The SBAR indicated Resident 1 ' s right leg was noted with slight swelling and the resident reported a level of 10 out of 10 pain. During a review of Resident 1 ' s Order Summary, dated 8/2/2024 the order summary indicated an X-ray of the right knee, and right hip. During a review of Resident 1 ' s X-ray result dated 8/2/2024, the X- ray result indicated acute comminuted supracondylar (broken bone into more than two pieces) fracture of the right distal femur. During a review of Resident 1 ' s Progress Note dated 8/3/2024 timed at 9:30 a.m., the progress note indicated Resident 1 was transferred to GACH for further evaluation and treatment due to a fall. During a review of Resident 1 ' s GACH admission Record, dated 8/3/2024, timed 10:23 a.m., the GACH admission record indicated Resident 1 was admitted to the GACH on 8/3/2024 with a diagnosis of acute right femoral fracture. The GACH admission record indicated, Unfortunately, the resident was not sent to the emergency room at that time but did arrive here this morning approximately 12 hours later. The admission record indicated Resident 1 had severe right knee pain related to acute right distal femoral fracture. During a review of Resident 1 ' s GACH Computed Tomography ([CT] a procedure that uses a computer linked to a machine to make a series of detailed picture of areas inside the body) Report, dated 8/3/2024 timed 4:05 p.m., the CT result indicated comminuted fracture of right distal femur. During a review of Resident 1 ' s GACH Physician Daily Progress Note dated 8/5/2024, the GACH physician daily progress note indicated Resident 1 had an open reduction internal fixation ([ORIF]-surgical procedure to stabilize and heal a broken bone) on the right distal femur. During a review of Resident 1 ' s GACH Discharge Note, dated 8/8/2024, the discharge note indicated Resident 1 was discharged back to the facility. During a review of Resident 1 ' s Progress Note dated 8/8/2024 timed 3:07 p.m., the progress note indicated Resident 1 returned to the facility from GACH with a diagnoses of status post (after) right knee ORIF. During a telephone interview on 8/12/2024 at 10:50 a.m., with Resident 1 ' s Responsible Party (RP), the RP stated the facility had not transferred Resident 1 to the GACH until the morning of 8/3/2024. The RP stated the facility was aware that Resident 1 had severe pain on the right leg and had a right knee femur fracture. The RP stated the facility had not explained to him or Resident 1 the reason it took the facility more then 15 hours to transfer Resident 1 to the GACH. During an interview on 8/12/2024 at 4:25 p.m., with the Director of Nursing (DON), the DON stated on 8/2/2024 at 3:30 p.m., CNA 1 notified her that while CNA 1 was transferring Resident 1 from the 055519 Page 2 of 7 055519 08/13/2024 Downey Post Acute 13007 S. Paramount Blvd. Downey, CA 90242

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wheelchair to the bed with the Hoyer lift, the Hoyer lift sling strap broke. The DON stated she (DON) immediately went to Resident 1 ' s room and observed Resident 1 on the floor next to her bed. The DON stated she (DON) and six other staff assisted Resident 1 into bed. The DON stated Resident 1 complained of right leg pain. The DON stated she (DON) notified Resident 1 ' s physician (MD 1) and obtained orders for an X- ray of the right knee. The DON stated on 8/2/2024 at 11:00 p.m., the facility received the X-ray result which noted acute comminuted supracondylar fracture of the right distal femur. The DON stated on 8/3/2024 around 9:30 a.m., (10 hours later) Resident 1 was transferred to the GACH for evaluation and treatment. During a concurrent interview and record review on 8/13/2024 at 12:20 p.m., with the DON, Resident 1 ' s Progress Notes dated 8/2/2024, was reviewed. The DON stated the progress note indicated transportation was arranged for transferring Resident 1 to the GACH. The DON stated the progress noted indicated, on 8/3/2024 at 9:30 a.m., (10 hours later) Resident 1 was picked up by Emergency Medical Technician ([EMT] trained medical professional that provides emergency medical services, and transport patients to medical facilities) and transported to the GACH for evaluation and treatment after fall. The DON stated the facility should not have waited longer than one hour to transfer Resident 1 to the GACH. The DON stated the failed to transfer Resident 1 immediately to the GACH when the X-ray result indicated Resident 1 had a right distal femur fracture, and Resident 1 had a pain level of 10 out of 10 to her right leg. The DON stated 10 hours delayed transfer to the GACH placed Resident 1 at risk for delayed care, treatment, and required interventions. During a review of the facility ' s policy and procedure (P&P) titled Significant Change of Condition, Response, revised 12/2023, the P&P indicated the facility will ensure each resident receives quality of care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being. The P&P indicated there will be certain circumstances (condition) where immediate attention will be warranted (there is a reason) and nursing will be responsible for notifying the appropriate department for evaluation. During a review of the facility ' s P&P tilted Fall Management System, revised 12/2023, the P&P indicated the facility will provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. 055519 Page 3 of 7 055519 08/13/2024 Downey Post Acute 13007 S. Paramount Blvd. Downey, CA 90242

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services to prevent a fall for one of three sampled residents (Resident 1) by failing to: 1. Ensure Certified Nursing Assistant (CNA 1) provided a two-person physical assist (help from two persons) when using a Hoyer Lift (mechanical lift- a device used to transfer residents from a bed to a chair or other similar places) to transfer Resident 1 from a wheelchair to the bed. This deficient practice caused Resident 1 to fall, sustain a right distal femur fracture (thigh broken bone), was admitted to a general acute care hospital (GACH), and had an open reduction internal fixation ([ORIF]-surgical procedure to stabilize and heal a broken bone). Findings: During an interview on 8/12/2024 at 10:50 a.m., with Resident 1, Resident 1 stated on 8/2/2024 around 3:00 p.m., CNA 1 transferred her from the wheelchair to the bed using a Hoyer lift. Resident 1 stated the Hoyer lift sling broke and she fell. Resident 1 stated she had right femur surgery. Resident 1 stated she was unable to perform her bicycle exercises, was very upset, and was in pain. During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes (abnormal blood sugar), hypertension (high blood pressure), and muscle weakness (decrease in muscle strength). During a review of Resident 1 ' s History and Physical (H&P), dated 7/9/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 7/11/2024, the MDS indicated Resident 1 had the ability to express ideas and wants, and had clear comprehension (capability of understanding something). The MDS indicated Resident 1 was totally dependent (full staff performance) with two persons physical assist for transfer (how the resident moves between surfaces including to or from bed, chair, wheelchair, or standing position). During a review of Resident 1 ' s Fall report dated 8/2/2024 timed at 3:45 p.m., the report indicated Resident 1 required a Hoyer lift for transfer. The report indicated on 8/2/2024, Resident 1 was being transferred from the wheelchair to the bed. The report indicated during the transfer, the Hoyer lift sling broke and Resident 1 fell on the floor. The report indicated Resident 1 ' s right leg was noted with slight swelling. The report indicated Resident 1 was assisted back to bed and reported 10 out of 10 pain on a pain scale (0=no pain, 1-3=mild pain, 4-6=moderate pain, 7-10= severe pain) to her right leg. During a review of Resident 1 ' s Situation, Background, Appearance, Review (SBAR) Communication Form, dated 8/2/2024, timed at 3:55 p.m., the SBAR indicated on 8/2/2024, at 3:50PM, Resident 1 slid off the Hoyer lift on to her right leg, when the lift ' s sling snapped (broke). The SBAR indicated Resident 1 ' s right leg was noted with slight swelling and the resident reported a level of 10 out of 10 pain. 055519 Page 4 of 7 055519 08/13/2024 Downey Post Acute 13007 S. Paramount Blvd. Downey, CA 90242

F 0689 During a review of Resident 1 ' s Order Summary, dated 8/2/2024, the order summary indicated X-ray (a photographic image of a part of the body) of the right knee, and right hip. Level of Harm - Actual harm Residents Affected - Few During a review of Resident 1 ' s X-ray result dated 8/2/2024, the X- ray result indicated acute (sudden) comminuted supracondylar (broken bone into more than two pieces) fracture of the right distal femur. During a review of Resident 1 ' s Progress Note dated 8/3/2024 timed at 9:30 a.m., the progress note indicated Resident 1 was transferred to the GACH for further evaluation and treatment due to a fall. During a review of Resident 1 ' s GACH admission Record, dated 8/3/2024, the GACH admission record indicated Resident 1 was admitted to the GACH on 8/3/2024 with a diagnosis of acute right femoral fracture. During a review of Resident 1 ' s GACH Computed Tomography ([CT] a procedure that uses a computer linked to a machine to make a series of detailed picture of areas inside the body) Report, dated 8/3/2024 timed 4:05 p.m., the CT report indicated comminuted fracture of the right distal femur. During a review of Resident 1 ' s GACH Physician Daily Progress Note dated 8/5/2024, the GACH physician daily progress note indicated Resident 1 had an ORIF surgery for right distal femur fracture. During a review of Resident 1 ' s GACH Discharge Note, dated 8/8/2024, the discharge note indicated Resident 1 was discharged back to the facility. During a review of Resident 1 ' s Progress Note dated 8/8/2024 timed 3:07 p.m., the progress note indicated Resident 1 returned to the facility from the GACH with a diagnoses of status post (after) right knee ORIF. During an interview on 8/12/2024 at 3:00 p.m., with CNA 3, CNA 3 stated, on 8/2/2024 around 3:30 p.m., the Director of Nursing (DON) notified her that Resident 1 fell from the Hoyer lift, was on the floor, and the DON needed assistance to transfer Resident 1 back to bed. CNA 3 stated she went to Resident 1 ' s room and observed Resident 1 on the floor. CNA 3 stated the Hoyer lift strap was broken. CNA 3 stated the laundry aid ([LA] person who works in a facility washing and folding laundry) was responsible for checking the Hoyer lift straps for torn pieces and tears every wash. CNA 3 stated CNAs were responsible for checking the Hoyer lift prior to use. During an interview on 8/12/2024 at 3:38 p.m., with LA 1, LA 1 stated she was responsible for checking the Hoyer lift sling for any damages prior to washing and before folding. LA 1 stated after the sling was checked and good for use, she signed and initialed the facility ' s sling log. LA 1 stated reported to the maintenance supervisor ([MS] person responsible for repairs and keeping the facility safe and functional) for damaged and broken slings. LA 1 stated the MS was responsible for replacing damaged the slings. During a concurrent interview and record review on 8/12/2024 at 4:10 p.m., with MS 1, the facility ' s sling log dated 7/2024, and 8/2024 was reviewed. MS 1 stated the sling log indicated there was no entry on the log from 7/31/2024 through 8/8/2024. MS 1 stated he and other laundry staff were supposed to check the slings daily to ensure it was in good condition. MS 1 stated he was also responsible for the Hoyer lift ' s maintenance and replacement when damaged. MS 1 stated the facility ' s 055519 Page 5 of 7 055519 08/13/2024 Downey Post Acute 13007 S. Paramount Blvd. Downey, CA 90242

F 0689 staff failed to check the sling and placed residents at risk for falls and injuries. Level of Harm - Actual harm During an interview on 8/12/2024 at 4:25 p.m., with the DON, the DON stated on 8/2/2024 at 3:30 p.m., CNA 1 notified her that while CNA 1 was transferring Resident 1 from the wheelchair to the bed with the Hoyer lift, the Hoyer lift ' s sling strap broke. The DON stated she immediately went to Resident 1 ' s room and observed Resident 1 on the floor next to her bed. The DON stated she (DON) and six other staff assisted Resident 1 into bed. The DON stated Resident 1 complained of right leg pain. The DON stated Resident 1 was dependent and required two persons assist for transfer. The DON stated CNA 1 should have asked for assistance from another staff to transfer Resident 1 via the Hoyer lift. The DON stated CNAs were responsible for checking the Hoyer lift sling for tears and torn pieces prior to resident use. Residents Affected - Few During an interview on 8/12/2024 at 4:35 p.m., with the Director of Staff Development (DSD), the DSD stated there should have been a two person physical assist when operating the Hoyer lift. The DSD stated staff should assess the Hoyer lift sling(s) prior to each use for the residents ' safety and to prevent falls and injuries. During an interview on 8/13/2024 at 10:53 a.m., with CNA 1, CNA 1 stated on 8/2/2024 around 3:15 p.m., she was assisting Resident 1 with a Hoyer lift transfer from the wheelchair to bed. CNA 1 stated Resident 1 was seated in the wheelchair and the Hoyer lift sling was under Resident 1. CNA 1 stated there were four straps, two in front of Resident 1 and two on the back of Resident 1. CNA 1 stated she attached the four sling straps to the Hoyer lift. CNA 1 stated she was standing behind Resident 1 and while she started to lift Resident 1 with the Hoyer lift from the wheelchair, she (CNA 1) heard a loud noise. CNA 1 stated Resident 1 immediately fell to the floor. CNA 1 stated she noted that the right front sling strap was broken. CNA 1 stated she notified the DON right way. CNA 1 stated she was aware that Resident 1 was a two persons physical assist for transfer, and she should have asked another staff for assistance before transferring Resident 1 with the Hoyer lift. CNA 1 stated she was busy rushing to get her other assigned residents ' care done, did not ask for assistance, and did not assess the Hoyer lift prior to use. CNA 1 stated Resident 1 ' s fall could had been avoided if she asked for assistance and assessed the Hoyer lift prior to use. During a concurrent observation and interview on 8/13/2014 at 11:31 a.m., with the Administrator (ADM), in the ADM ' s office, the Hoyer lift sling used during Resident 1 ' s transfer on 8/2/2024 was observed. The ADM stated the front right strap of the sling was broken, and the other three straps (front left side, and two on the back side) were torn, worn, and ragged. The ADM stated the sling was unsafe for use and should have been thrown out. During a review of the facility ' s policy and procedure (P&P) tilted Fall Management System, revised 12/2023, the P&P indicated the facility will provide an environment free of accident hazards. The P&P indicated the facility will provide each resident with appropriate assessment and interventions to prevent falls. During a review of an undated Manufacturer ' s User Manual titled Invacare ([Invacare] manufacture of long-term care medical products), Manual/Electric Portable Patient Lift, the manual indicated staff will read the manual before using the Lift. The manual indicated a recommendation to use two persons assist for lifting and transferring procedures. The manual also indicated a one-person assist could be used based on the evaluation of the health care professional for each individual case. During a review of an undated Manufacturer ' s Operations and Maintenance Manual titled, Patient 055519 Page 6 of 7 055519 08/13/2024 Downey Post Acute 13007 S. Paramount Blvd. Downey, CA 90242

F 0689 Level of Harm - Actual harm Slings, the manual indicated staff will read the manual before using the slings. The manual indicated staff will inspect the sling(s) for wear, tears, loose stitching, or broken sling(s)and immediately discard any damaged slings to prevent injury. Residents Affected - Few 055519 Page 7 of 7