Health inspection·December 12, 2025

F689 Citation A §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. Cal. Code Regs. Tit. 22, § 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 9/9/25, an unannounced visit was conducted at the facility for an abbreviated survey regarding a complaint investigation. The facility failed to ensure resident safety to prevent accidents resulting in a fall for one of three residents (Resident 1) when the facility van's wheelchair securement system (a safety device installed in accessible vehicles used to keep a wheelchair in place during transport and also secure the wheelchair user with safety straps) used to transport Resident 1 did not meet Code of Federal regulations, Title 49, Part 38 (49 CFR § 38.23(d)(7), Americans with Disabilities Act [ADA] Accessibility Specifications for Transportation Vehicles), and the facility used three staff members (maintenance supervisor [MS], central supply staff [CSS], and the maintenance assistant [MA]) that were not qualified and/or were not trained to transport residents using the facility van such as: -The facility van lacked the required seat belt or safety belt, specifically the shoulder harness (strap that goes diagonally over the shoulder, across the chest, down to the lap) to secure a wheelchair user; The maintenance supervisor (MS), central supply staff (CSS), and the maintenance assistant (MA) transported residents in the facility van without a certified nursing assistant certification, a requirement for a van driver; - The MA did not complete the Facility Vehicle Driver Training Program and did not conduct and complete a Pre-Trip Inspection Report prior to transporting Resident 1 using the facility van. The failures of transporting residents in the facility van without necessary safety belts resulted in Resident 1's fall in the facility van on 8/23/25, sustaining a skin tear and head injury, and had the potential to result in other residents' falls and injuries. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious physical harm would result. Findings: Review of Resident 1's face sheet (a summary document containing a resident's personal and demographic information, including contact details and medical history), dated 8/27/25 indicated she was admitted to the facility with diagnoses including dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney or kidneys have failed) and difficulty in walking. Review of Resident 1's physician order indicated an order, dated 8/23/25, "Dialysis schedule on Saturday 8/23/25 at [dialysis facility] in Watsonville. [The facility] will provide W/C [wheelchair] transport to dialysis with pick up at 10:30 AM." Review of Resident 1's Change of Condition progress note, dated 8/23/25 indicated, "Per in house transport driver, resident fell during transportation going to dialysis ... Resident noted with 3 cm [centimeter, unit of measurement] x 2cm x 0.5cm Right shin skin tear." Review of Resident 1's IDT note, dated 8/25/25, indicated, "On 8/23/2025, [Resident 1] returned to facility following scheduled dialysis appointment. Per in-house transport driver, resident experienced a fall incident [in the facility van] during transportation to dialysis, reportedly due to a seat malfunction within the transport vehicle. Incident occurred prior to arrival at dialysis facility. Upon return to facility, resident was assessed immediately by licensed nurse (LN) ... MD ordered to send resident out to ER for further evaluation ... Driver stated that the resident fell from the transport chair due to an apparent seat malfunction. Resident verbalized she was 'okay' at the time of the incident and expressed that she was comfortable proceeding with dialysis ..." Review of Resident 1's Emergency Department (ED) Physician Notes, dated 8/23/25 indicated, "[Resident 1] is an 81-year old F [female] who had a mechanical fall while being transported to dialysis. She sustained a small skin tear to one of her lower extremities and struck her head ... Physical Examination ... Head: Moderate tenderness to palpation [examination of the body by using touch] in the left forehead area ... she does note moderate to severe pain in the area.. Neck: Patient is complaining of diffuse neck pain and on physical exam had midline neck pain so could not be clinically cleared and was placed in a soft collar ..." The ED Physician Notes also indicated Resident 1's diagnosis was a closed head injury [traumatic brain injury caused by a blow to the head with no break in the skull]. Review of Resident 1's Discharge Instructions Document, dated 8/23/25 indicated, "You were seen in the emergency department after a head injury ... It is possible that you have a concussion ... There is no imaging ... that makes this diagnosis. The diagnosis is based on symptoms. Typical symptoms include headache, dizziness, and/or nausea/vomiting ..." Review of Resident 1's Nurse's Note, dated 8/26/25 indicated Resident 1 complained of headache, was given Tylenol (pain medication) 325 milligrams (mg, unit of measurement) two tablets. Review of Resident 1's Medication Administration Record for August 2025 indicated Resident 1 received Acetaminophen 325 mg two tablets as needed for mild/generalized body pain on 8/24/25 at 5:07 p.m., 8/25/25 at 8:52 a.m., and 8/27/25 at 9:36 a.m. During an interview on 9/9/25 at 2:43 p.m., the administrator (ADM) stated another driver, not the regular facility van driver, drove Resident 1 to the dialysis center on 8/23/25. The ADM stated the facility had two staff members that could drive the facility van. During an interview on 9/11/25 at 2:14 p.m., the director of nursing (DON) stated the drivers just drive and do not have experience in patient care or assessment. She stated if the driver did not know what to do at that time, the driver should have called 911. The DON also stated that after a resident falls, another option for the driver would be to call the facility or speak to a nurse. During an interview on 10/1/25 at 12:26 p.m., licensed vocational nurse A (LVN A) stated he did not remember the name of the staff member driving the van. LVN A stated the staff member driving the van informed him that on their way to dialysis on 8/23/25, Resident 1 fell onto the floor of the van and hit her head. LVN A stated the staff member driving the van informed LVN A that he asked Resident 1 if she was okay, Resident 1 replied that she was fine, and they continued to the Resident 1's dialysis facility. LVN A stated when Resident 1 got back to the facility after having dialysis, she had a skin tear on her knee and was given pain medication. He stated because Resident 1 had a head injury, she was sent to a hospital emergency department. LVN A stated the staff member driving the van was not a healthcare provider and was not qualified to make the determination whether the resident was okay to go to dialysis. He stated the staff member driving the van should have at least informed the dialysis facility about Resident 1's fall on 8/23/25. During an interview and concurrent document review on 10/2/25 at 1:54 p.m., the maintenance aide (MA) stated he was asked to transport Resident 1 in the facility van. Review of MA's text message from the marketing director (MD) dated 8/22/25 at 1:04 p.m. indicated, "Please take [Resident 1] tomorrow Saturday to dialysis. Drop off and pick up ... [The ADM] told me to let you [the MA] know." The MA stated he was not comfortable driving the resident because he had no experience transporting residents before and he was not trained to drive. The MA stated he felt forced to do it because he was told transporting residents would be added to his job description. He stated he was told if he did not drive Resident 1, they would find someone else to do his job. The MA stated on 8/23/25 he did his best to strap Resident 1 down with the straps they had in the van. He stated when he was driving on the highway, he looked back and saw Resident 1's wheelchair "doing a wheelie" on its back wheels. The MA stated he realized he did not have her strapped down the correct way. The MA stated when he stopped the van along the way to the dialysis facility, Resident 1 came out of the wheelchair, fell forward, and bumped her head against the fire extinguisher. The MA stated he panicked and asked if she was okay, but there was a language barrier because he did not speak the language Resident 1 spoke. He stated he only secured the back wheels and did not have Resident 1 strapped with a lap belt (belt stretched across the passenger's lap and secure them in their seat). He further stated after dropping off Resident 1 at dialysis, he called the facility to inform the nurse about Resident 1's fall. The MA stated the nurse told him he would assess Resident 1 when she gets back to the facility from dialysis. The MA stated after Resident 1's fall, the facility had shoulder straps on the side of the van installed. He said prior to Resident 1's fall, the van did not have the strap that goes up and across a resident's chest. During an interview on 10/3/25 at 10:40 a.m., the MA stated he did not perform an inspection or complete a form prior to transporting Resident 1 on 8/23/25. The MA also stated after Resident 1's fall, he completed the driver training and was trained by the former director of staff development (FDSD). He stated he did not complete any other driver training from another staff member or DSD prior to driving the van on 8/23/25. During an interview on 10/15/25 at 2:35 p.m. the ADM stated he could not find the Pre-Inspection Report for Resident 1's trip to dialysis on 8/23/25. During an interview and concurrent record review on 10/29/25 at 1:14 p.m. with the contracted installer (CI) from a mobility equipment service company, the CI stated he installed equipment for the facility's van on 9/8/25. Review of the facility's invoice, dated 9/8/25 indicated three items were installed, including a three-point kit belt system (seat belt that secures a person with straps across the chest and across the lap at three anchor points, one above the shoulder and two at the hips). He stated prior to installing the three-point harness, the facility van's securement system "did not meet the regulations." The CI stated the van only had a lap belt and did not have a shoulder belt. He stated vans require that the person using the wheelchair is secured with a lap belt and an over-the-shoulder belt. He also stated that just having a lap belt is not as safe as having a lap belt and shoulder belt. During an interview and concurrent record review on 10/29/25 at 3:21 p.m. the former director of staff development (FDSD) stated she had experience driving a van for another facility. The FDSD stated all drivers should be trained prior to driving residents in the facility van. She stated the driver needs to inspect the van and complete a form each time the van is used. The FDSD stated the resident's wheelchair needs to be secured at four points. She stated the resident also needs to be secured by straps over the shoulder and lap, like a seat belt. The FDSD reviewed the Facility Vehicle Driver Training Program forms for MS, CSS, and MA. She confirmed the Facility Vehicle Driver Training Program forms for MS and CSS were undated. The FDSD stated she trained the MS and CSS, but she did not remember the date. She stated she conducted a driver training and all three staff (MS, CSS, and MA) were present on that day. The FDSD confirmed Facility Vehicle Driver Training Program form for MA was dated 9/4/25. She stated that she did not train the MA prior to that date. During an interview on 11/4/25 at 9:45 am, the Payroll/Human Resources staff (PHRS) stated the Van Driver job description indicated the staff should be certified nursing assistants (CNA). The PHR confirmed MS, CS, and MA were not CNAs. She also stated the MA's termination date was 10/9/25. During an interview on 11/4/25 at 1:24 p.m. the charge nurse (CN) from Resident 1's dialysis facility (CN) stated dialysis staff was not informed of Resident 1's fall prior to dialysis on 8/23/25. The CN stated if dialysis staff was informed of a fall they would assess them and monitor for orientation, pupil dilation, etc. She also stated dialysis staff would have assessed Resident 1 to determine if they should call 911 for further evaluation. The CN stated if Resident 1 fell and hit her head, she would have sent her to the hospital via 911 right away. During an interview on 11/4/25 at 4:02 p.m., the CN stated she reviewed Resident 1's dialysis flowsheet and progress notes and confirmed there was no documentation that indicated dialysis staff was informed regarding Resident 1's fall prior to dialysis on 8/23/25. Review of the facility's Job Description for "Van Driver," dated 8/2018 indicated an essential duty was to ensure the safe transportation of residents to scheduled medical appointments or other approved activities, resident outing, etc. The van driver job description also indicated, "Must have successfully completed CNA training and maintain all CE [continuing education] to maintain certification." Review of the facility's Vehicle Safety Manual, revised 12/1/17 contained the following documents: Facility Vehicle Driver New Hire Checklist, Facility Vehicle Driver Training Program, and Pre-Trip Inspection Report. Review of the Facility Vehicle Driver New Hire Checklist (undated) indicated the following are required for facility vehicle drivers and must be completed BEFORE driving facility vehicle: Must be a Certified Nursing Assistant; must be CPR Certified; required Facility Vehicle Training Program must be completed. Review of the Facility Vehicle Driver Training Program (undated) indicated, "In order to become a certified facility vehicle driver you must complete the Facility Vehicle Driver Training Program which includes the following: ... - Vehicle Occupant Protection and Wheelchair Securement - Facility Driver Safety Policy ... - Accident Procedures - Vehicle Maintenance Procedures and Pre-Trip Inspection Report - First Aid/Personal Protective Equipment for Facility Vehicle." Review of the facility's Pre-Trip Inspection Report indicated, "This report is to be completed before each usage of facility vehicle and signed below after vehicle is returned to facility." Review of the "AMF Bruns America Protektor Installation Manual" (wheelchair securement system), dated 10/2022 indicated, "All persons who will install, use and/or maintain this product must read, understand and follow all warnings and instructions provided in this manual ... However nothing in this manual, and none of the safety devices installed on the product, substitute for proper training, careful operation and common sense." The manual indicated a common wheelchair securement and occupant restraint system contains the following and are to be used as a complete system: retractor tie downs (securement strap that automatically tighten to secure the wheelchair in place), occupant lap belt, occupant shoulder belt, user instructions. Review of the AMF Bruns America User Manual, dated 3/2025 indicated specific items should be inspected carefully on a daily basis, including the functionality of the restraint system and floor and sidewall anchorages (fixed points installed directly on the floor or interior walls of the vehicle. The manual also indicated the wheelchair has rear securement points (where straps to secure the wheelchair should be attached) and front securement points. It indicated, "Once you have four straps attached, release the brakes on the wheelchair and check for movement. Once secured the wheelchair should not move more than two (2) inches front-to-back or side-to-side. Reapply the brakes." The manual indicated, "This product is not designed