Health inspection·September 3, 2025

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. 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 7/15/25, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding resident care. The Department determined the facility failed to use safe lifting techniques to move Resident 1 from the wheelchair to the bed and conduct a thorough assessment of the impact after Resident 1 had an assisted fall (a situation where a resident begins to fall but is supported or guided by another person to minimize the impact of the fall) to the ground on 7/5/25. This failure resulted in Resident 1 sustaining a left distal femoral fracture (broken bone in the lower part of the left thigh bone near the knee) and experienced pain associated with the fracture. Review of Resident 1's "ADMISSION RECORD," indicated Resident 1 was admitted to the facility with diagnosis of dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and repeated falls. Review of Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool), dated 5/9/25, indicated Resident 1 scored 3 of 15 points total. A score of 3 indicated that Resident 1 had severe cognitive impairment (when a person is likely to experience significant difficulties with mental tasks and may require substantial assistance with daily activities). Review of Resident 1's "Progress Notes," dated 7/5/25, indicated, "...Resident was not like himself this shift, wasn't talking and looking weak. When CNA [certified nursing assistant] went to get him ready she alerted writer that his left leg was at an [sic] weird angle and his knees were stuck together and it was hard hold them apart without resident screaming in pain. Sent out to [name of emergency department] around 1645 [4:45 p.m.]..." Review of Resident 1's "Progress Notes," dated 7/6/25, indicated, Licensed Nurse (LN) 2 received a call from the emergency room staff who informed her that Resident 1 "...has been admitted [to the hospital] and that he has a shattered knee..." A review of Resident 1's hospital record titled, "History and Physical/Admission Notes," dated 7/6/25, indicated the following: Resident 1 was admitted to the hospital on 7/6/25 and a Computed Tomography (CT) scan (a special x-ray that takes detailed pictures inside your body) of Resident 1's left knee was conducted, with the following reported assessment and findings, "... he complained of left knee pain for the last few days and it is suspected that he had a ground-level fall at some point recently...Displaced fracture centered at the distal femoral metaphysis, with intra-articular extension at the level of the anterior medial femoral condyle [a broken bone near the bottom of the thighbone (femur), close to the knee joint. The pieces of bone are out of place (displaced), and the break goes into the knee joint itself] ...Left leg shortened compared to contralateral side [opposite side of body] TTP [ Tenderness to palpation; pain or discomfort experienced by a patient when a healthcare provider applies pressure (palpates) to a specific area of the body] and swelling about the left knee... #right arm swelling... Noted by PT [Physiotherapist] today during evaluation and treatment today. Pt [patient] had fall prior to hospital stay..." During a concurrent observation and interview on 7/15/25, at 2:04 PM, the Restorative Nursing Aide (RNA) stated that on 7/5/25 between 1 PM to 1:30 PM, she offered Resident 1 to attend the RNA Program and Resident 1 agreed. The RNA explained, at that time, she assisted Resident 1 to sit on the edge of the bed, however, Resident 1 was unable to stand like he used to and began sliding off the bed. The RNA stated she then sought assistance from CNA 1, who happened to be inside Resident 1's room. The RNA stated, both herself and CNA 1 were unable to help Resident 1 to stand. The RNA stated they then assisted Resident 1 "slowly to the floor." The RNA stated, once Resident 1 was on the floor, CNA 1 and herself transferred Resident 1 to the wheelchair using a gait belt (a safety device used by caregivers to assist patients with mobility and transfers, such as walking or rising from a chair) while supporting Resident 1 under both armpits. The RNA explained, from the wheelchair, they transferred Resident 1 back to the bed using a towel transfer technique. The RNA explained and demonstrated that she placed a towel behind Resident 1's leg, just above the backs of his knees. The RNA stated CNA 1 and herself then positioned themselves on each side of the resident. The RNA further explained, with one arm, each of them supported Resident 1 under his armpits while holding the gait belt; with the other arm, each held one end of the towel. The RNA stated they then lifted and swung Resident 1 back onto the bed. The RNA stated that she taught CNA 1 how to execute the towel transfer on 7/5/25, at the time of said towel transfer. The RNA stated that at around 2:30 PM she went to see Resident 1 just to say hello when Resident 1 stated, "I think you broke my leg..." The RNA stated that she did not document the incident because she had told the nurse in-charge of Resident 1 on that day about what happened. The RNA stated Family Member (FM) 1 went to the facility on 7/6/25 and was able to speak with her regarding what happened. During an interview on 7/15/25 at 4:06 PM, the RNA stated that on 7/5/25, she did not think of using a mechanical lift (a device used to safely transfer individuals who cannot bear weight or have limited mobility, from one place to another) or requesting assistance from a physical therapist (a person qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise) to assist Resident 1 off the ground. The RNA stated she used the towel transfer technique and manually transferred Resident 1 from the wheelchair to the bed. The RNA stated that she believed a therapy order was required to use the mechanical lift. During an interview with the Director of Nursing (DON) and Administrator (ADM) on 7/15/25 at 4:50 PM, the DON stated when a resident was heavy or considered "dead weight" or unable to assist during transfers, the expected practice was to use a mechanical lift. When asked about the use of the towel transfer technique, the DON stated that the facility primarily uses gait belts and mechanical lifts but depending on the situation, the facility would use what was appropriate for a safe resident transfer. During the interview, the ADM contacted the RNA by phone to confirm how the towel transfer had been performed. The RNA explained that Resident 1 had been sliding off the edge of bed. She asked CNA 1 for help repositioning him, but they were unable to move him back up. As a result, they laid him down on the floor. The RNA stated that she and CNA 1 then used a gait belt - holding Resident 1 by the gait belt and under each armpit, to lift him up from the floor into the wheelchair. From the wheelchair they transferred Resident 1 to the bed by lifting him into the air - ensuring he did not touch the floor - using a towel placed under the back of his legs and holding by each arm, swinging him onto the bed. During an interview on 7/15/25, at 12:42 PM, the DON stated Resident 1 was transferred to the emergency room on 7/5/25 due to an "Altered baseline" and was admitted to the hospital due to a shattered knee. The DON explained that Resident 1 used to be talkative. The DON explained, on 7/5/25, although Resident 1 was not confused, he was notably quiet. The DON stated Resident 1 complained of left leg pain during repositioning by a CNA and that his knees "were together" and staff were unable to separate them due to his pain. The DON stated Resident 1 did not fall on 7/5/25; rather, Resident 1 was assisted by both the RNA and CNA 1 to the floor sometime between 1 PM and 1:30 PM. The DON stated it was unclear what happened because Resident 1 was a one-person assist with transfers (movement from one place to another) according to the therapy department (a group of healthcare professionals who help residents perform physical movements). During an interview on 7/15/25 at 1:26 PM, FM 1 stated he was notified by a facility staff around 5 PM on 7/5/25 that Resident 1 had been sent to the hospital. FM 1 stated he was told that Resident 1's leg appeared crooked. FM 1 stated, the next day, on 7/6/25, he visited the facility because he wanted to find out what happened to Resident 1. FM 1 stated he spoke with the RNA who informed him that Resident 1 began to fall but facility staff were able to assist Resident 1 to the floor, facility staff then used a towel to pick up Resident 1, and Resident 1 said, "it hurts," and his leg appeared crooked. FM 1 stated he was also told by the RNA that Resident 1 was put back to bed and refused lunch. FM 1 stated the RNA told him that Resident 1 told her, "I think you broke my leg." During an interview on 7/15/25 at 1:54 PM, the Director of Staff Development (DSD) stated that Resident 1's RNA program (a range of treatments and approaches aimed at helping residents regain, maintain, or improve their physical functioning) was ordered three times per week, although the specific days were inconsistent. The DSD also stated that Resident 1 had never refused the RNA program and, although he could not walk, he could stand up and pivot (to turn or rotate on the foot) with the assistance of one person. During an interview on 7/15/25 at 2:25 PM, LN 1 stated that she was the nurse assigned to Resident 1 on 7/5/25 and was also the one who arranged his transfer to the hospital. LN 1 stated, although Resident 1 was alert, she transferred him out to the hospital because, Resident 1 did not seem like himself and was a bit different from his normal. LN 1 further explained that CNA 2 had alerted her to check on Resident 1's left leg. LN 1 stated, upon assessment, LN 1 observed that Resident 1's left knee was swollen, Resident 1 was complaining of pain, and Resident 1's left leg appeared misaligned or not straight. LN 1 stated that she was not aware of any fall involving Resident 1 but had heard that he had been "lowered to the floor." During an interview on 7/15/25 at 3:33PM, CNA 2 stated that she was the CNA in charge of Resident 1 on 7/5/25 and that she was very familiar with him. CNA 2 stated she took Resident 1's vital signs and observed that he was "non-verbal" and appeared as though he was dying, noting that his eyes looked sleepy. CNA 2 stated after reporting her concerns regarding Resident 1 to LN 1, LN 1 decided to transfer Resident 1 to the hospital. CNA 2 stated before the transfer, CNA 2 intended to change Resident 1's briefs to ensure he was clean and dry. CNA 2 stated when she removed Resident 1's blanket, she noticed that his left leg appeared crooked. CNA 2 stated that when she attempted to reposition Resident 1, he screamed in pain. During an interview on 7/15/25 at 4:02 PM, the DSD stated that the facility's protocol for transferring a heavy or non-weight bearing (one who should not put any weight at all on the injured leg, foot or ankle) resident was to use a mechanical lift. The DSD clarified that they did not require an order to use the mechanical lift. The DSD stated that her expectation was for all resident transfers to be conducted safely and without causing pain. During an interview on 7/17/25 at 9:03AM, the RNA explained that the facility did not provide training on the towel transfer technique. The RNA explained she learned the towel transfer method through years of experience and from working at other facilities. The RNA stated the towel should be placed under the resident's leg - not under the buttocks or hips - According to the RNA, she was holding one side of the towel, which was placed on the resident's leg just above the knee. With her other arm, she was supporting one side of the resident's armpit. The RNA added that placing an arm under the armpit also "allows you to hold the gait belt." CNA 1 was positioned on the other side of the resident, using the same technique. When asked whether there were any medical conditions that would make the towel transfer inappropriate, the RNA said she did not know. During an interview on 7/17/25 at 9:15 AM, the Physical Therapist (PT) stated that the facility did not offer the towel transfer technique (also known as, towel lift transfer or towel lift) training. The PT stated the facility recommended the following lifting transfer methods: Stand and Pivot Transfers (Helping one move from seated position to another by assisting them to stand up, turn and then sit down again), slide board transfers (Way to move a person with limited mobility from one sitting surface to another), use of a Hoyer lift (A special machine to help move someone who cannot get up or move on their own, safely and gently), and use of a Stand-up Hoyer Lift (A special machine that helps a person stand up from sitting position when they cannot do it on their own but still have some strength in legs and can hold on). The PT explained that the towel transfer technique was not typically used at the facility, though it may be considered depending on the specific case. The PT explained that she found it safer not to use a towel transfer technique. The PT explained, with the towel transfer technique, the towel was placed around the buttock/low waist to gain control of the pelvis (hips). The PT stated the towel lift technique was not appropriate for certain residents including residents without lower body strength, residents with general weakness, and residents with neurological conditions (a problem with the brain, spinal cord, or nerves that affect how your body moves, feels, or functions) due to lack of lower extremity control and stability. The PT stated that a resident must be stable before considering a towel lift transfer. During a phone interview with the DON and LN 3 on 7/17/25 at 10:43 a.m., the DON confirmed that LN 3 was the assigned nurse for Resident 1 during the m