Health inspection·September 9, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who was assessed as a high risk for falls and required assistance from staff during transfers, was provided with safe and appropriate transfer assistance to avoid a fall for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Certified Nurse Assistant (CNA) 1 utilized a gait belt ([transfer belt] a device placed on a resident who has mobility issues to aid in safe movement for the resident) upon transferring Resident 1. 2. Ensure Resident 1 ' s Care Plan included specific interventions indicating the requirement for two-person assistance when transferring Resident 1, in compliance with the facility ' s procedure Transfer from a Bed to a Wheelchair. These deficient practices resulted in Resident 1 falling to the ground on 8/30/2024 which had the potential to cause Resident 1 serious physical and psychosocial harm. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses including mood disorder (mental condition where there are long periods of sadness, elation or depression), neuralgia (nerve pain which feels like a burning, sharp or stabbing sensation), neuritis (inflammation of the nerves), and chronic pain syndrome (pain that lasts longer than three months) . During a review of Resident 1 ' s Minimum Data Set ([MDS]) a standardized assessment and care screening tool), dated 7/22/2024, the MDS indicated Resident 1 ' s cognitive skills (thinking process) for daily decision-making were intact and had the ability to understand and be understood by others. The MDS indicated Resident 1 had functional limitations in range of motion on one side which affected her upper and lower extremities. The MDS indicated Resident 1 required substantial/maximum assistance (helper does more than half the effort) during sit to stand (ability to come to a standing position from sitting in a chair, wheelchair, or on site of the bed). The MDS indicated Resident 1 required partial/moderate assistance (helper lifts, holds, or supports trunk or limbs but provides less than half the effort) during bed to chair transfers (ability to transfer to and from a bed to a wheelchair). The MDS indicated Resident 1 presented with hemiplegia (a condition which causes weakness on one side of the body) or hemiparesis (inability to move on one side of the body). During a review of Resident 1 ' s Fall Risk Assessment (assessment tool indicating a resident ' s Page 1 of 4 055952 055952 09/09/2024 Torrance Care Center West, Inc 4333 Torrance Blvd Torrance, CA 90503

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few likelihood of falling), dated 7/26/2024, the Fall Risk Assessment indicated Resident 1 ' s fall risk score was 13 (a score of 10 and above indicates a resident is a high fall risk). During a review of Resident 1 ' s Clinical Record (Care Plan section), dated 7/22/2024, the Care Plan indicated Resident 1 was admitted with left above the knee amputation ([AKA] a surgical procedure removing the leg above the knee) related to trauma, had impaired physical mobility, and was at risk for pain, ineffective pain management, and fall. The Care Plan indicated the following goals and re-evaluation date of 10/24/2024 included: 1. Resident 1 will show/verbalize no pain for 90 days. 2. Resident 1 will be able to participate in Activities of Daily Living ([ADL] grooming, dressing, hygiene) every day for 90 days. 3. Resident 1 will verbalize understanding of the individual, situation, treatment regimen and safety measures every day for 90 days. The Care Plan interventions indicated, to assess for pain, and to provide medications and interventions as needed. During a continued review of Resident 1 ' s Clinical Record (Care Plan section), dated 7/26/2024, the Care Plan indicated Resident 1 was at risk for falls and injuries related to incontinence, unsteady gait, chronic and acute condition which makes resident unstable. The Care plan goals indicated the facility will minimize the risk for falls and will decrease significant injury as a result from a fall in the next 3 months with a re-evaluation date of 10/24/2024. The Care Plan indicated the following approaches (interventions) included assess, anticipate, and intervene for factors causing prior falls (e.g. mobility problem, standing, and transferring). The Care plan approaches further indicated to evaluate current fall prevention interventions and use appropriate device as needed. During a review of Resident 1 ' s Change of Condition (COC) dated 8/30/2024, the COC indicated on 8/30/2024, CNA 1 was transferring Resident 1 from the bed to wheelchair and was unable to hold Resident 1 ' s body weight so CNA 1 lowered Resident 1 to the floor. The COC indicated Resident 1 complained of right foot pain rated 3 out of 10 based on the numeric pain scale (11-point numeric scale, ranging from 0 indicating no pain to 10 indicating worse pain imaginable). During an interview on 9/9/2024 at 12:07 p.m., Certified Nurse Assistant (CNA) 1 stated Resident 1 required assistance from staff during transfers from the bed to the wheelchair and bed and vice versa. CNA 1 stated, some CNAs will transfer Resident 1 alone and some CNAs will ask for a second person to help during assistance. CNA 1 stated, it is up to the person transferring Resident 1 on what they feel they can physically handle. CNA 1 stated most petite CNAs will ask for a second person but not always. CNA 1 stated staff do not use a gait belt during transfers with Resident 1. During an interview on 9/9/2024 at 1p.m., CNA 2 stated on 8/30/2024 at approximately 9:30 a.m., she heard someone call for help in Resident 1 ' s room. CNA 2 stated when she walked into the room, she saw Resident 1 kneeled on her right knee while CNA 3 was holding Resident 1 by the pants. CNA 2 stated Resident 1 can require one or two-persons to assist depending on the strength of the CNA. 055952 Page 2 of 4 055952 09/09/2024 Torrance Care Center West, Inc 4333 Torrance Blvd Torrance, CA 90503

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a record review of the facility ' s Investigative Interview dated 8/30/2024, the Investigative Interview indicated the on 8/30/2024, CNA 3 was asked by Resident 1 to assist in transferring her from her bed to her wheelchair. CNA 3 attempted to request assistance from another staff member to help with transfer but none were available. Resident 1 then instructed CNA 3 to hold Resident 3 by the back of the pants and place her in the wheelchair while Resident 1 used the side table and wheelchair to transfer herself to the wheelchair. Upon transfer, CNA 3 indicated she was unable to hold Resident 1 ' s body weight during the transfer so decided to lower Resident 1 to the floor and call for help. During an interview on 9/9/2024 at 2 p.m., the Director of Staff (DSD) stated it is her role to train CNAs to transfer residents safely. The DSD stated Resident 1 ' s Care Plan did not indicate the need for one or two-person assistance for transfer. The DSD stated, the Care Plan should have reflected two-persons assistance to ensure the safety of Resident 1 and the staff. The DSD stated, Resident 1 had a left AKA and could only transfer on the right leg. The DSD stated per procedure, Resident 1 should have been transferred with two staff members. During a concurrent interview and record review on 9/9/2024 at 2:10 p.m. with the DSD, the facility ' s undated procedure titled, Transfer from a Bed to a Wheelchair was reviewed. The procedure indicated transferring patients from a bed to a wheelchair requires the understanding the patient ' s needs, oneperson assist may be performed if the patient can bear weight on both lower extremities and predictably take small steps, if these criteria are not met, a two-person transfer, or mechanical lift may be necessary to transfer the patient safely. The procedure further indicated, if transferring a patient from a bed to the wheelchair, sit the patient on the side of the bed with the legs off the bed and the feet squarely on the floor and if necessary, attach a gait belt or walking belt around the patient ' s waist. The DSD stated the CNA 3 did not follow the proper procedure when she transferred Resident 1 from the bed to the wheelchair. The DSD stated, there should have been two- persons assisting in Resident 1 ' s transfer and CNA 3 should have used a gait belt to ensure safely and not Resident 1 ' s pants. During an interview on 9/9/2024 at 3 p.m., the Director of Nursing (DON) stated, on 8/30/2024 at approximately 9:30 a.m., she was called to Resident 1 ' s room. The DON stated upon her arrival she observed Resident 1 sitting with her right knee touching the floor, while CNA 3 was standing behind Resident 1 holding Resident 1 ' s pants. The DON stated, Resident 1 should have been transferred with two-persons and CNA 3 should have used a gait belt instead of holding on to Resident 1 ' s pants. The DON stated a gait belt should have been used with Resident 1 due to her limited mobility and high risk for falls. The DON stated gait belts are used to provide a point of contact and a secure hold for caregivers to help residents regain their balance during a possible fall, such as the case for Resident 1 who seemed to lose her footing, on her one leg. The DON stated by failing to provide appropriate staff during Resident 1 ' s transfer and failing to use a gait belt, the facility placed Resident 1 at risk for serious injury. During a review of the facility ' s undated P/P titled Fall Prevention Program, the P/P indicated, each resident will be assessed for fall risk and receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The P/P indicated the facility will provide additional interventions as directed by the resident ' s assessment, including but not limited to assistive devices, family/caregiver or resident education, and scheduled ambulation or toileting assistance. The P/P indicated each resident ' s risk factors and environmental hazards will be evaluated when developing the resident ' s comprehensive plan of care. 055952 Page 3 of 4 055952 09/09/2024 Torrance Care Center West, Inc 4333 Torrance Blvd Torrance, CA 90503

F 0689 Level of Harm - Minimal harm or potential for actual harm During a review of the facility ' s undated P/P titled Use of Gait Belt Policy, P/P indicated it is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety. Residents Affected - Few 055952 Page 4 of 4