Other·May 26, 2026

This citation includes F689 based on a distinct violation of a specific regulatory requirement and supported by evidence demonstrating the facility's failure to meet that requirement. 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 resident's choices... 22 CCR 72311 (a) Nursing service shall include, but not be limited to, the following: (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 (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. Based on observation, interview, medical record review, facility document review, and facility P&P (Policy and Procedure) review, the facility failed to ensure Patient 179 remained free from accident hazards. * The facility failed to ensure Patient 179 was safely transferred from her bed to her wheelchair. This failure resulted in Patient 179 hitting her leg on a wheelchair and sustained a 10-cm (centimeters) abrasion and large hematoma (a collection of clotted blood outside blood vessels, caused by trauma or injury, leading to swelling, pain, and skin discoloration) on her right anterior (situated at or toward the front of the body) shin. Findings: 1. Review of the facility's P&P titled Safe Patient Handling/Transfers dated 12/19/22, showed it is the policy of the facility to ensure that Patients are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the Patient while keeping the employees safe in accordance with current standards and guidelines. All Patients require safe handling when transferred to prevent or minimize the risk for injury. Medical record review for Patient 179 was initiated on 4/20/26. Review of Patient 179's Facesheet (quick access to essential patient information, including demographics, insurance, allergies, current medications, and key medical history) dated 4/22/26, Patient 179 was admitted to the facility on 2/9/26. Review of Patient 179's MDS (Minimum Data Set - a standardized assessment tool) dated 1/30/26, showed Patient 179's had a BIMS (Brief Interview of Mental Status - a tool used to assess the Patient cognitive (the mental processes involved in gaining knowledge, understanding, and comprehension, including thinking, memory, reasoning, and learning) status) score of "14" (cognitively intact). Review of Patient 179's Care Plan Report showed the care plan focus problem to address the following: - ADL (Activities of Daily Living - basic skills necessary for individuals to independently care for themselves, such as eating, bathing and mobility) self-care performance deficit related to impaired function and mobility, due to spinal stenosis (narrowing of the spinal canal, which compresses the spinal cord and nerves, usually caused by age-related wear and tear), scoliosis (abnormal, sideways curvature of the spine), and osteoporosis (a disease that weakens bones, making them fragile and prone to fractures) initiated on 2/10/26; - at risk for falls related to impaired function and mobility initiated on 1/26/26. The care plan goal was for Patient 179 not to sustain serious injury. The care plan interventions included Patient 179 needed to be supplied with appropriate adaptive equipment (devices designed to enhance independence, functionality, and participation for individuals with physical, cognitive, or sensory disabilities) or devices as needed, revised on 2/10/26; and - potential for skin tear of bilateral upper and lower extremities initiated on 1/26/26. The care plan interventions included use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. Review of Patient 179's Nurses Progress Note dated 4/1/26 at 0812 hours, showed Patient 179 sustained a skin tear to her right shin during transfer to her wheelchair. Review of Patient 179's Skin Check note dated 4/1/26 at 0959 hours, showed Patient 179 sustained a skin tear to her right leg with moderate bleeding and a hematoma noted. A skin flap was placed back and Steri-Strips (sterile, breathable, adhesive skin closures) were applied. Review of Patient 179's Daily Skilled Services note dated 4/1/26 1550 hours, showed earlier in the day Patient 179 reported an injury to her right lower extremity. Nursing was aware and recommended to avoid out of bed activities and to keep right lower extremity elevated to reduce inflammation. Strengthening of the left lower extremity in supine position (lying flat on the back) in all possible ranges of motion, avoiding right lower extremity. Review of Patient 179's Physician Progress Note dated 4/1/26 at 2121 hours, showed while transferring Patient 179 into her wheelchair this morning, Patient 179's leg got stuck/caught in the wheelchair, causing a large 10-cm abrasion and large hematoma on her right anterior shin. Review of Patient 179's Nurses Progress Note dated 4/1/26 at 2141 hours, showed Patient 179 was on monitoring for a skin tear on the front of her right lower leg and Patient 179 complained of pain level of six out of 10 (in a pain scale of 0-10, 0 = no pain and 10 = severe pain) to her lower right leg. Review of Patient 179's Skin Check dated 4/17/26 at 1036 hours, showed a physician examined Patient 179 who ordered to wrap Patient 179's right lower leg with an ace bandage (a stretchable wrap used to provide compression) for one week, with a follow up scheduled for next week for possible incision (to cut into with a sharp instrument) and drainage. On 4/20/26 at 1249 hours, an observation and concurrent interview was conducted with Patient 179. Patient 179 was observed lying in her bed with a bandage wrapped around her right lower leg. Patient 179 was asked if she had sustained an injury to her right leg. Patient 179 stated approximately three weeks ago, she sustained an injury while RNA (Restorative Nursing Assistant) 1 was transferring her from her bed to her wheelchair. Patient 179 stated RNA 1 failed to utilize the gait belt (a durable belt worn around a Patient's waist to provide caregivers a secure, safe, and comfortable grip for assisting with walking, standing, or transferring) while transferring her and her leg got caught on a piece of metal on the front side of her wheelchair where the footrest would be attached, as a result her right lower leg was injured. Patient 179 stated after her leg hit the wheelchair she yelled for RNA 1 to stop; however, RNA 1 could not control her momentum, which caused the skin to tear off the front of her leg. Patient 179 stated the trauma from her leg hitting the wheelchair caused her leg to bleed and at the time of the injury she suffered a lot of pain. Patient 179 stated she was upset when the staff failed to transfer her properly and she was injured as a result. Patient 179 stated she had weakness in her lower extremities due to injuries to her back and staff would need to use the gait belt when transferring her from her bed to her wheelchair. Patient 179 stated the use of the gait belt offered her more stability and made her feel safe. Patient 179 stated the facility's rehabilitation staff would always utilize the gait belt when transferring her from her bed to the wheelchair; however, the CNAs (Certified Nursing Assistant) and RNAs assigned to the floor did not always utilize the gait belt when transferring her from her bed to her wheelchair. Patient 179 stated after she sustained the injury the facility staff took a photograph of her injury and reported the incident to her family. Patient 179 stated her leg had yet to heal completely and remained swollen. Patient 179 stated the treatment nurse informed her the physician may incise and drain the swollen area to promote healing. Patient 179 stated her goal was to be discharged home with her family and hopefully her leg would heal soon. On 4/22/26 at 1002 hours, a telephone interview was conducted with RNA 1. RNA 1 stated on 4/1/26, during the morning shift, she was assigned to provide care for Patient 179. RNA 1 stated she had cared for Patient 179 once before on 3/31/26. RNA 1 was asked to describe how Patient 179 sustained the injury to her right lower leg during the transfer from her bed to her wheelchair on 4/1/26. RNA 1 stated Patient 179 had an appointment on the morning of 4/1/26. RNA 1 stated she needed to transfer Patient 179 from her bed to the wheelchair. RNA 1 stated she independently transferred Patient 179 from her bed to her wheelchair. RNA 1 stated while she was transferring Patient 179 from her bed to the wheelchair, Patient 179 had difficulty bending her knees, which made it difficult for her to transfer Patient 179 to her wheelchair. RNA 1 further stated the previous morning Patient 179 was able to bend her knees. RNA 1 stated she believed Patient 179 sustained the injury to her right lower leg when Patient 179's right leg hit the metal on the front of the wheelchair where the footrest would be attached. RNA 1 was asked if she utilized a gait belt during the transfer, to which RNA 1 replied, she had not. RNA 1 stated she was not informed Patient 179 needed a gait belt during transfers from her bed to the wheelchair. RNA 1 further stated she was not familiar with Patient 179, having been assigned to care for Patient 179 only on two occasions. On 4/22/26 at 1420 hours, an interview and concurrent medical record review for Patient 179 was conducted with the Director of Rehabilitation. Review of Patient 179's Physical Therapy Treatment Encounter notes dated 3/23/26, showed for transfers (sit to stand), Patient 179 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort). The Director of Rehabilitation stated substantial/maximal assistance meant the staff would provide 75 to 80 percent assistance during the sit-to-stand transfers for Patient 179. The Director of Rehabilitation stated the facility protocol was for the staff to always utilize a gait belt when independently transferring the Patients from their beds to their wheelchairs. The Director of Rehabilitation stated the facility RNAs and CNAs (Certified Nursing Assistant) were trained to utilize the gait belts when independently transferring the Patients from their beds to their wheelchairs, regardless of the level of assistance the Patients would require. On 4/23/26 at 1101 hours, an interview and concurrent facility document review for Patient 179 was conducted with the DON (Director of Nursing). The DON stated the facility conducted a risk management investigation specific to Patient 179's injury sustained on 4/1/26, during the transfer from her bed to her wheelchair. The DON stated interviews with Patient 179 and the facility staff were conducted. The DON stated according to Patient 179, on the morning of 4/1/26, while being transferred from her bed to her wheelchair, she scraped her leg against her wheelchair. The DON stated the facility also interviewed RNA 1 who performed the transfer of Patient 179 from her bed to her wheelchair. The DON stated according to RNA 1, during the transfer, Patient 179 was seated at the edge of the bed and Patient 179 was unable to stand up completely. RNA 1 stated she could not place Patient 179 back into bed due to Patient 179's low air loss mattress (a specialized medical support surface designed to prevent and treat pressure injuries by providing, through a blower, constant airflow to manage moisture and heat). RNA 1 then proceeded to transfer Patient 179 to the wheelchair at which time she sustained an injury to her right lower leg. The DON was asked to describe the facility's investigative conclusion. The DON stated RNA 1 failed to secure Patient 179 during the transfer and RNA 1 should have utilized a gait belt to help stabilize Patient 179 during the transfer. The DON stated the facility practice was to utilize the gait belts when the staff independently transfer the Patients from their beds to their wheelchairs, regardless of the level of assistance the Patients would require. The DON stated the staff would receive this training upon hire and annually.