Health inspection·December 2, 2025

Complaint Incident # 2654688 and 2655949. Survey Event ID: 1DA51B-H1 State Citation A was written Code of Federal Regulations, Title 42, Section 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 residents' choices, including but not limited to the following: Code of Federal Regulations, Title 42, Section 483.25(d). Accidents. 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 10/30/24, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate two complaints regarding resident care. The facility failed to ensure Certified Nursing Assistant (CNA) 1 implemented two-persons assist, in accordance with the facility's policy and procedure (P&P), when CNA 1 attempted to use a mechanical lift (a medical device used to safely lift and move a resident) to transfer (moving from one place to another) Resident 1. As a result, on 10/25/25, this deficient practice led to Resident 1 sustaining a fall to the floor from the mechanical lift. Resident 1 was transferred to a General Acute Care Hospital (GACH) on 10/25/25 for further evaluation and suffered an intramuscular hematoma (collection of blood within a muscle) to the right pectoralis (chest muscle) and minimally displaced fractures of the right proximal tibia and fibula (small cracks or breaks near the top of the right lower leg bones). Review of Resident 1's "ADMISSION RECORD," indicated Resident 1 was admitted to the facility with diagnoses which included hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (a condition where blood flow to the brain is interrupted, also known as a stroke), and aphasia (speech or language problems as a result of a stroke). Review of Resident 1's clinical record titled, "Minimum Data Set," (MDS - an assessment tool used by nursing homes to collect information about each resident's health, abilities, and care needs) dated 11/03/24, by the MDS Coordinator (MC 1), indicated under Section GG0170 - Mobility, item FF (Tub/shower transfer) that Resident 1 was coded on the assessment tool as 01 - Dependent on nursing staff for transferring. Per the MDS scoring definition, a score of 01 indicated that the helper (a nursing assistant) performed all the effort, and the assistance of two or more nursing staff members was required for Resident 1 to complete the transfer activity. During a concurrent interview and record review on 10/30/25 at 1:21 p.m., with MC 1, Resident 1's MDS assessment records were reviewed. MC 1 verified that Resident 1's assessment indicated that Resident 1 was dependent on two or more CNAs for assistance with showering and transferring. MC 1 further stated that Resident 1 required a mechanical lift device for all transfers and stated that Resident 1 had not experienced any mobility improvements since his admission. During an interview on 10/30/25 at 2:26 p.m., Licensed Nurse (LN) 1 stated that he witnessed the post-fall event with Resident 1 on 10/25/25. LN 1 stated that he witnessed Resident 1 on the floor in a prone position (lying flat on the stomach, face down) with CNA 1 next to Resident 1. LN 1 stated that he interviewed CNA 1 and CNA 1 told LN 1 that she tried to transfer Resident 1 from bed to the shower chair by herself, and that Resident 1 slipped from the sling (a device that attaches to a mechanical lift device that allows a resident to be lifted and transferred with minimal physical effort) and then fell to the ground. LN 1 stated that two CNAs were required to assist when Resident 1 was transferred using the mechanical lift device. LN 1 further stated that the expectation was for two CNAs to assist when the mechanical lift device was used. LN 1 stated that Resident 1's fall could have been prevented if CNA 1 had followed the facility's expectations. During a phone interview on 10/30/25 at 3:17 p.m., CNA 1 admitted that she made a mistake when she transferred Resident 1 with the mechanical lift device without assistance from another CNA. CNA 1 acknowledged that she did not follow the facility's policy and procedure when she transferred Resident 1 independently with the use of a mechanical lift device. CNA 1 stated this failure contributed to Resident 1's fall and injury. CNA 1 also stated that the fall could have been prevented if she had asked for help from another CNA. Review of Resident 1's facility progress note, with an effective date of 10/25/25 (20:00), indicated, "Writer was called into the pts [patient's] room at 1930 as the pt [Patient] had a fall. When writer entered the room the pt was noted on the ground with head towards foot of the bed laying on her L [left] side... The Pt was being transferred from the bed to the Shower chair via Hoyer lift and fell from the sling... Pt is nonverbal, unable to communicate pain. She is grimacing when the RUE is moved around. She does have hemiplegia... Writer and CN [Charge Nurse] assisted the cna [CAN] with getting pt back up into bed using the Hoyer lift... There is a discoloration noted to the L breast... pt was sent out to [hospital name] given the nature of the fall and pt inability to communicate with staff. Communication was sent to Dr. [Doctor] Pham [Pharmacist] and the CN communicated with Pts RP's [Responsible Parties]." Review of Resident 1's [HOSPITAL NAME] clinical record titled, "TRAUMA/ACUTE CARE SURGERY PROGRESS NOTE", dated 10/31/25, indicated that Resident 1 was admitted to hospital on 10/25/25 following a fall from four feet from a mechanical lift. Medical documentation indicated Resident 1 sustained a large intramuscular hematoma to the right pectoralis with areas of active bleeding (ongoing blood loss), and minimally displaced fractures of the right proximal tibia and fibula (small cracks or breaks near the top of the right lower leg bones). During a concurrent interview, record review, and P&P review on 10/31/25 at 10:56 a.m., with the Director of Nursing (DON), Resident 1's [HOSPITAL NAME] records, the facility's P&P titled, "Lifting Machine, Using a Mechanical," revised 7/17, and the facility's P&P titled, "Safety Precautions, Nursing Services," revised 12/09 were reviewed. The P&P titled, "Lifting Machine, Using a Mechanical," indicated, "...The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device... 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift...". The P&P titled, "Safety Precautions, Nursing Services," indicated, "...The following safety precautions have been established for all personnel to follow when providing nursing care/services...21. Follow proper lifting procedures when lifting resident or heavy objects...". The DON verified that CNA 1 did not follow the facility's P&Ps when she transferred Resident 1 independently while using the mechanical lift. The DON acknowledged that this failure resulted in Resident 1's fall and injury. The DON also acknowledged that the injuries sustained by Resident 1 were acquired due to the fall incident that occurred on 10/25/25. Therefore, the Department determined the facility failed to ensure CNA 1 implemented two-persons assist, in accordance with the facility's P&P, when CNA 1 attempted to use a mechanical lift to transfer Resident 1 from bed to shower chair. As a result, on 10/25/25, this deficient practice led to Resident 1 sustaining a fall to the floor from the mechanical lift. Resident 1 was transferred to a GACH on 10/25/25 and suffered an intramuscular hematoma to the right pectoralis and minimally displaced fractures of the right proximal tibia and fibula. These violations of the aforementioned statutes and regulations presented imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would occur, and constitute an A citation.