Health inspection·April 22, 2025

The following reflects the findings of the California Department of Public Health during the investigation of facility reported incident number 941454. The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility. A deficiency was written for facility reported incident #941454 at F-tag 689/G. 42 Code of Federal Regulations part §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. Based on observation, interview, and record review, the facility failed to prevent an avoidable fall (move downward, typically rapidly and freely without control from a higher to a lower level) for one of three sampled residents (Resident 1) when Certified Nursing Assistant (CNA 1) and CNA 2 failed to implement the care plan (CP- a document that outlines a resident's needs, treatment, and expected outcomes) to use a Hoyer lift (a mechanical device that helps move people with limited mobility) in transferring Resident 1 from the bed to the wheelchair. This failure resulted in Resident 1 sustaining a fall and experiencing pain to the left foot. Resident 1 was transferred to the acute hospital where the resident was found to have varus deformity (a condition characterized by an inward angulation or bending of a bone or joint) of the second metatarsophalangeal (the joints connecting the long bones of the foot and bones of the toes) joint. A nondisplaced (a break in the bone where the original bones remain in their original position) proximal phalangeal (the toe bones closest to the ankle and metatarsals [the five long bones in the foot]) fracture (a break in the bone) cannot be entirely excluded. On 1/29/25, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding a resident fall with resulting pain to the left foot and nondisplaced proximal phalangeal fracture cannot be entirely excluded. Resident 1 is a 62-year-old female who was admitted to the facility on 5/21/2024 and has a diagnosis history of repeated falls, difficulty in walking, spinal stenosis (a narrowing of the spinal column (backbone) that occurs over time and can put pressure on the spinal cord [a tube-shaped bundle of nerves that runs from the brain to the lower back]) lumbar region (lower back) with neurogenic claudication (a condition that causes pain, weakness, or numbness in the legs while walking or standing), and need for assistance with personal care. During a review of Resident 1's "ADMISSION RECORD (AR)," dated 1/29/25, the AR indicated, Resident 1 was admitted to the facility on 3/29/24. The AR indicated, Resident 1 diagnoses including repeated falls, difficulty in walking, spinal stenosis (a narrowing of the spinal column (backbone) that occurs over time and can put pressure on the spinal cord [a tube-shaped bundle of nerves that runs from the brain to the lower back]) lumbar region (lower back) with neurogenic claudication (a condition that causes pain, weakness, or numbness in the legs while walking or standing), and need for assistance with personal care. During a review of Resident 1's quarterly Minimum Data Set (MDS- an assessment tool) dated 1/10/25, under the section Brief Interview for Mental Status (BIMS- an assessment of cognition [how well a person thinks, remembers, and learns])," the BIMS indicated, Resident 1 had a score of 13 (cognition [how well a person thinks, remembers, and learns] intact). The MDS under the section "GG (an assessment of the level a care a resident required)," indicated, Resident 1 was dependent on staff for transferring from bed to chair/chair to bed. During a review of Resident 1's Care Plan dated 6/23/24, the CP indicated, Resident 1 had self-care performance issues secondary to impaired balance, limited mobility, and limited ROM (range of motion- how far you can move a joint [where two or more bones connect] in your body). CP intervention indicated under transfer to use a Hoyer lift with two staff members for any transfers Resident 1 required. During an observation and interview on 1/29/25 at 12:16 p.m. with Resident 1, in Resident 1's room, Resident 1 was sitting in her wheelchair and stated on 1/16/25, Certified Nursing Assistant (CNA 1) and CNA 2 attempted to transfer her from the bed to the wheelchair. Resident 1 stated she was not able to bear weight (to support or withstand the weight of the body) in her legs. Resident 1 stated, "They (CNA 1 and CNA 2) picked me up (using a bath towel) and they (CNA 1 and CNA 2) dropped me, they used a (bath) towel to pick me up not the Hoyer lift." Resident 1 stated she experienced left foot pain (no detailed information about the pain) after the fall incident. During a review of Resident 1's "Progress Notes (PN)," dated 1/16/25, the PN indicated the following: a. At 12:30 p.m.- "Nursing observations, evaluation, and recommendations . . . Staff (not indicated who) reported resident (1) had an assisted fall. When resident (1) was asked, she stated that staff (not indicated who) dropped her on the floor while being transferred. She also stated that she fell on both her knees. Spoke to staff (not indicated who) and one of the CNA (not indicated who) stated that her partner lost grip of the towel under resident's (1) legs, and she had to be assisted to the floor." b. At 4:15 p.m.- "On time of fall (no indicated time), no swelling noted to left great toe. At approximately (4:20 p.m.), redness, and swelling to left great toe was noted." During a review of Resident 1's "Nursing- Pain Evaluation (NPE)," dated 1/16/25, the NPE indicated, Resident 1 complained of pain after her fall to the floor on a scale of five out of 10 (moderate pain, distracting or interfering with activities) . . .to the left great toe. During a review of Resident 1's "Interdisciplinary Post Event Note (IDT- Interdisciplinary Team- group of professionals who assess, coordinate, and manage each resident's comprehensive needs)," dated 1/20/25, the IDT indicated, Resident 1 had an x-ray (medical imaging technique that uses radiation to create a picture of the inside of the body) of the left foot (on 1/17/25). The x-ray results indicated Resident 1 had a possible fracture (break) in her left great toe. The IDT indicated Resident 1 had an order for Norco (a narcotic medication for pain) 5/325 mg (milligram- a unit of measurement) every eight hours for pain (routinely given). During a review of Resident 1's Physician Orders (PO), dated 1/21/25, the PO indicated, Resident 1 was to be sent out to the hospital to confirm a possible fracture to the left great toe. During a review of the acute hospital "Emergency Department Notes (EDN)," dated 1/21/25, the CN indicated, Resident 1 was sent to the acute hospital with a left great toe injury after a fall. The EDN indicated a left foot x-ray was performed, and Resident 1 was found to have a nondisplaced fracture (a break in the bone where the original bones remain in their original position) of the proximal phalangeal (the toe bones closest to the ankle and metatarsals [the five long bones in the foot]). During an interview on 1/29/25 at 1:48 p.m. with Director of Nursing (DON), DON stated on 1/16/25 Resident 1 fell to the floor while being transferred by CNA 1 and CNA 2 from the bed to the wheelchair using a (bath) towel. DON stated Resident 1 was to be transferred from the bed to the wheelchair using a Hoyer lift, but CNA 1 and CNA 2 did not use the Hoyer lift. During an interview on 2/5/25 at 2:31 p.m. with CNA 1, CNA 1 stated on 1/16/25 at approximately 11 a.m. she asked CNA 2 to assist her with transferring Resident 1 from the bed to the wheelchair. CNA 1 stated she and CNA 2 did not use the Hoyer lift to transfer Resident 1. CNA 1 stated she and CNA 2 used a bath towel underneath Resident 1's legs to lift her up to transfer from the bed to the wheelchair. CNA 1 stated she and CNA 2 lost control of the bath towel and Resident 1 fell to the floor. CNA 1 stated after the fall incident Resident 1 started complaining of pain to her left foot. CNA 1 stated no staff trained her to use a bath towel to transfer Resident 1 and it was dangerous to do so. CNA 1 stated she used a bath towel in the past (no dates given) to transfer Resident 1. CNA 1 stated she was aware she should use the Hoyer lift (as indicated in the CP). During an interview on 2/5/25 at 3:20 p.m. with CNA 2, CNA 2 stated on 1/16/25 at approximately 11 a.m. she and CNA 1 transferred Resident 1 from the bed to the wheelchair using a bath towel. CNA 2 stated she and CNA 1 lost control of the bath towel and Resident 1 fell to the floor. CNA 2 stated Resident 1 was dead weight (when a person is unable to assist with movement and their full weight is felt by the persons assisting) and had fallen into a position in which her foot (left) was possibly crushed by her weight. CNA 2 stated Resident 1 was visibly upset (could not describe what this meant other than upset) and yelling at them (CNA 1 and CNA 2) about the fall incident. CNA 2 stated, "She (Resident 1) required a Hoyer lift . . . we (CNA 1 and CNA 2) did not use it." During a review of the facility's policy and procedure (P&P) titled, "Comprehensive Care Plans," dated 11/2024, the P&P indicated, "It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. . .The comprehensive care plan will describe, at a minimum, the following . . .The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being." During a review of the facility's P&P titled, "Safe Resident Handling/Transfers," dated 11/2024, the P&P indicated, "It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. . . All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used. . .Mechanical lifting equipment or other approved transferring aids will be used based on the resident's needs to prevent manual lifting except in medical emergencies. . .Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment. . .Resident lifting and transferring will be performed according to the resident's individual plan of care." This violation had a direct or immediate relationship to the health, safety, or security of patients or residents and constitutes a class "B" citation.