Health inspection·October 3, 2025

Code of Federal Regulations, Title 42, Section 483.25(d). Accidents. (d) 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. California Code of Regulations, Title 22, Section 72311. Nursing Service--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. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 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 8/26/25 at 8 a.m., the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to conduct a recertification survey and to investigate a facility reported incident regarding resident safety. The Department determined the facility failed to provide adequate supervision and ensure an accident-free environment for Resident 103 when, Resident 103 fell partially off of the gurney while left unattended and partially secured in the gurney, in a transportation vehicle during transportation to a dialysis clinic (outpatient facility that provides dialysis treatment to residents with end-stage renal disease (ESRD) or chronic kidney failure, helping to clean their blood of waste and excess fluid when their kidneys cannot) on 7/3/25. This failure resulted in Resident 103 sustaining a mild compression fracture (when the bone is crushed or compressed but not completely broken) in the third lumbar spine (L3; the third lumbar vertebra (bone) in the spine located in the lower back that supports body weight). A review of Resident 103's "ADMISSION RECORD," indicated Resident 103 was admitted to the facility in 2021 with diagnoses which included chronic pain, hemiplegia and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction (a medical condition where blood flow to the brain is interrupted, leading to tissue damage or death) affecting the left non-dominant side, dependence on renal dialysis (a person's life relies on regular dialysis treatments to sustain life because their kidneys have lost most or all of their function), functional quadriplegia (a person is unable to move all four limbs due to severe disability or frailty, but without any underlying physical injury or damage to the spinal cord), and aphasia (a language disorder that affects a person's ability to communicate effectively due to damage to the area in the brain responsible for language processing). A review of Resident 103's nursing care plan, "...ADLS [Activities of Daily Living; tasks necessary for basic personal care and independent living ]..." dated 10/21/21, indicated, "...Focus: Resident has self-care deficit d/t [due to] left sided weakness...Requires 1-2-person dependent assistance [require total physical assistance from another person]...Goal: Will be assisted by staff in performing ADLs which cannot be met by resident...Interventions: Monitor for any decline in ADL function..." A review of Resident 103's nursing care plan, dated 6/15/25, indicated, "...Focus: Resident requires safe and coordinated transport to/from medical appointments...Goal: Resident will be transported safely with no injury or adverse event...Interventions: Provide safety belts, positioning devices, and blankets as needed..." A review of Resident 103's Progress Notes with the following dates and times indicated the following: 1. 7/3/25, at 1 p.m., "...VS WNL [vital signs such as blood pressure, heart rate, respiratory rate and temperature are within normal limits]. No new skin changes noted. Resident left to dialysis..." 2. 7/3/25, at 2:03 p.m., "...Received call from dialysis that resident was sent to [name of hospital] due to resident having a fall in van and running a fever of 105..." 3. 7/3/25, at 6:36 p.m., "...resident in hospital..." 4. 7/4/25, at 1:54 a.m., "...Spoke to ER [emergency room] nurse...as per nurse resident on ATB [antibiotic; a medication used to fight off bad bacteria] for UTI [urinary tract infection; an infection in any part of the urinary system which includes the kidneys, ureters, bladder and urethra]..." 5. 7/6/25 at 8:16 a.m. "...hospitalized..." 6. 7/7/25, at 1:28 p.m., "...[General Manager (TRM 2)] expressed his plan of correction and apologized for the driver not following protocol...[name of transportation company] informed that the driver will be terminated [fired] and not following procedure of securing resident in the transport van..." 7. 7/18/25, at 7:14 p.m., "Resident arrived at the facility around 16:22 [4:22 p.m.] via Stretcher from [hospital]...DX [diagnosis] of UTI with sepsis [a serious condition in which the body responds improperly to an infection]..." 8. 7/22/25, at 7:48 p.m., "...Results received via fax. Resident is noted [with] mild compression [fracture] in L3..." A review of Resident 103's emergency department (ED) records titled, "ED Note - Physician," dated 7/3/25, indicated, "...CHIEF COMPLAINT: BIBA [brought in from ambulance] from [name redacted] dialysis center. Pt [patient] resides at [name of skilled nursing facility]. Fever. HISTORY OF PRESENT ILLNESS: Patient...with history of chronic kidney disease on dialysis, nonverbal from previous CVA [cerebral vascular accident; also known as a stroke which is a medical condition where blood flow to the brain is disrupted, causing brain tissue damage] brought in by ambulance from [name of skilled nursing facility] for evaluation of fever, per report from EMS [Emergency Medical Services] patient had a maximum temperature of 102 at the facility...Patient unable to give adequate history because she is nonverbal [unable to speak] from previous CVA..." There was no mention of Resident 103's fall from the gurney in the ED Note. A review of Resident 103's clinical record written by Resident 103's primary physician titled, "Office Visit," dated 7/22/25, indicated "...Family requesting Xray...Recent gurney [a medical stretcher on wheels for transporting residents] fall to ground patient complaining of increase pain in hip knee...Plan of care...Xray ordered..." A review of Resident 103's clinical record titled, "Radiology [specializes in the use of imaging techniques to diagnose and treat diseases] Interpretation," dated 7/22/25, indicated "...LUMBER SPINE 2-3 View [an X-ray (imaging that takes pictures of the inside of your body) study of the lower back that includes two to three different images taken from specific angles]: Mild compression fracture in L3..." Review of Resident 103's "Nurses Note," dated 7/23/25, the record indicated, "...Resident was seen by MD [medical doctor] on 7/22. X-ray reviewed, resident was noted w/ [with] compression fx [fracture] on L3...MD instructed writer to f/u [follow-up] w/ [name of doctor redacted, Resident 103's primary physician] on treatment secondary to L3 compression fx findings..." During an interview on 7/27/25, at 11:29 a.m., Certified Nursing Assistant (CNA) 5 stated Resident 103 was on total care (resident reliant on staff to meet all needs) on 7/3/25. CNA 5 stated during the transport to the dialysis clinic on 7/3/25, Resident 103 was secured on the gurney with two out of three safety belts. CNA 5 explained, Resident 103 was secured by two safety belts; one was around the hip and the second one around the legs. CNA 5 stated Resident 103 was not secured by the safety belt around the chest area. CNA 5 stated she did not know if Resident 103 needed to have a safety belt secured in place around the chest area. CNA 5 stated instead of sitting in the back seat of the transportation van she sat in the front seat next to the driver. CNA 5 stated during transportation inside the transportation van, Resident 103 was sitting upright in the gurney with her head elevated. CNA 5 stated on the way to the dialysis clinic, when the van made a left turn, she heard a sound. CNA 5 stated she turned around to look at the back of the van and saw Resident 103's upper body was out of the gurney while Resident 103's leg was still secured in the gurney. CNA 5 stated Resident 103 had rolled halfway from the gurney to the van floor. CNA 5 stated the driver of the transportation van stopped the vehicle and both the driver and CNA 5 went to the back of the van and put Resident 103 back in the gurney. CNA 5 stated when she placed Resident 103 back in the gurney, Resident 103 had no safety belt secured around her chest area. CNA 5 further stated that upon arrival at the dialysis clinic, she notified Licensed Nurse (LN) 9 (nurse whom worked at the dialysis clinic) that Resident 103 fell from the gurney inside the transportation van on the way to the dialysis clinic. CNA 5 stated LN 9 took Resident 103's temperature and notified CNA 5 that Resident 103 had to go to the emergency room due to a high temperature and the fall from the gurney. CNA 5 stated she should have checked that Resident 103 had a safety belt secured in the chest area. CNA 5 stated since she sat in front of the transportation van, she did not have direct visual of Resident 103. CNA 5 stated she should have had visual of Resident 103 the whole-time during transportation. CNA stated the risk of not checking that the safety belts were fastened resulted in Resident 103 falling from the gurney. CNA 5 stated Resident 103 could have injured her head from the fall. During an interview on 8/27/25, at 12:07 p.m., the Staffing Coordinator (SC) stated CNA 5 had notified her that Resident 103 fell out of the gurney inside the transportation van during transportation to dialysis clinic on 7/3/25. The SC stated she had transported residents on a gurney in the past and there was a seat in the back of the van next to the gurney for the staff to sit. The SC stated she had sat in the back seat of the van next to the gurney to make sure residents were safe during transportation. The SC stated she had made sure that all safety belts were properly fastened around the resident and prevented residents from falling. The SC stated in the past she would have a licensed nurse check with her that all safety belts were fastened. During an interview on 8/27/25, at 12:48 p.m., Transportation Driver (TR, from a contracted transportation company) 1 stated the nurses did a safety check before he took residents out for appointments in the transportation van. During a phone interview on 8/27/25, at 1:31 p.m., Responsible Party (RP) 1 stated the facility notified him that Resident 103 had a back fracture from a fall that happened during transfer to Dialysis Clinic on 7/3/25. RP 1 stated Resident 103 was in pain and crying and grimacing more after the fall. RP 1 stated the expectation that all the safety belts were safely secured in the gurney during Resident 103's transportation in the van. RP 1 stated he felt frustrated that a staff member was not sitting next to Resident 103 during transfer since Resident 103 was immobile. RP 1 stated if all safety belts were fastened and a staff member sat next to Resident 103 then she would not have fallen and got injured. During an interview on 8/28/25, at 8:49 a.m., LN 7 stated before a resident left for appointments the LN took residents' vital signs and made sure all three safety belts were properly secured. LN 7 stated the CNA assisted with transferring residents to the gurney from their bed. LN 7 stated there were three safety belts on the gurney, one for the chest area, one for the hip and the third for the leg. LN 7 stated she did not let the residents transport in the van if one of the safety belts was missing. LN 7 stated the resident could fall and get injured if one of the three safety belts was not secured. LN 7 stated the Director of Nursing (DON) had given in-service to staff to take precautions and safe transfer of residents for appointments. During an interview on 8/28/25, at 9:08 p.m., LN 6 stated the LN and CNA transferred residents from their bed to the wheelchair or gurney. LN 6 stated the LN made sure that all three safety belts were properly secured before a resident left the facility for an appointment. LN 6 stated there were three safety belts on the gurney, one for chest, one for hip area and one for legs. LN 6 stated residents could fall and get injured if safety belts were missing or not properly secured. During a phone interview on 8/28/25, at 10:05 a.m., the Office Manager (TRM, from a contracted transportation company) 1 stated the transportation van that was used to transfer Resident 103 had a gurney with three safety belts, one for the chest area, one for the hip and one for the legs. TRM 1 stated the transportation van driver was trained to safely secure all three safety belts when transferring residents on a gurney. TRM 1 stated the risk of not having all safety belts secured is that the resident could fall and get injured. During a phone interview on 8/28/25, at 10:46 a.m., the General Manager (TRM, from a contracted transportation company) 2 stated the driver of the transportation van was fired because the driver did not make sure the aide (CNA 5) sat in the back seat of the van with Resident 103. TRM 2 stated there was a seat at the back of the transport van for a staff member to sit close to Resident 103 for safety. TRM 2 stated CNA 5 sat in the front passenger seat next to the driver of the van during transportation. TRM 2 stated the camera from the van showed when the van made a left turn, Resident 103 rolled from the gurney over to her left side and landed on the floor. TRM 2 stated the driver of the van should have insisted CNA 5 to sit in the back seat with Resident 103 to make sure Resident 103 was safe and secured and did not fall. During an interview on 8/28/25, at 1:23 p.m., TR (from a contracted transportation company) 2 stated facility staff always checked and made sure residents were secured in their wheelchair before they were picked up for appointments. During an interview on 8/28/25, at 1:26 p.m., LN 4 stated before a resident left for appointment, the LN made sure all three safety belts on the gurney were fully secured. LN 4 stated there were three safety belts, one on the chest, one on the hip and one on the leg. LN 4 stated the LN stayed with the resident until the resident got into the transportation van. LN 4 stated a CNA accompanied residents for the appointments to make sure residents were taken care of. LN 4 stated residents could fall when safety belt was not secured. During an interview on 8/28/25, at 1:26 p.m. and 2:22 p.m., CNA 6 stated she had gone to appointments in a transportation van with a resident who was on a gurney. CNA 6 stated she made sure that all three safety belts on the gurney were secured. CNA stated there were three safety belts, one for the chest area, one for the hip and one for the leg. CNA 6 stated to make sure residents did not fall she sat on the back seat in the transportation van so she could visually see the resident during transportation. During an interview on 8/29/25, at 8:42 a.m., the Social Services Director (SSD) stated CNA 5 had gone to an appointment with Resident 103 in a transportation v