Health inspection·August 26, 2025

The following reflects the findings of the California Department of Public Health during an investigation of a facility reported incident # 965347/2516021. 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 # 965347/2516021 at F-Tag 689-G. F689 §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. 22 CCR §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 each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR § 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 6/4/25, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding Resident 1 who fell and sustained injury. Resident 1 is a 65-year-old male who was admitted to the facility on 1/3/25 and has diagnoses of paraplegia (loss of impairment of motor (movement of body parts) and sensory (sensation) functions in the lower half of the body), neuralgia (nerve pain) and neuritis (inflammation of a nerve), and congestive heart failure (heart does not pump blood well). Based on interview and record review, the facility failed to ensure the staff used the Hoyer lift (mechanical device designed to assist individuals with limited mobility in safely transferring from one place to another) properly when the legs (base) of the Hoyer lift were not open during a transfer for one of three sampled residents (Resident 1). This failure resulted in the Hoyer lift tilting over causing Resident 1 to fall to the floor, sustaining a mild displaced (bone fragments are no longer together) distal (away from the point of attachment) coccygeal (tailbone) segment (completely detached from surrounding bone) fracture (break in a bone). Findings: During a review of Resident 1's "Admission Record (AR)," dated 6/10/25, the AR indicated, Resident 1 was admitted to the facility on 1/3/25 with diagnoses including paraplegia (loss of impairment of motor (movement of body parts) and sensory (sensation) functions in the lower half of the body), neuralgia (nerve pain) and neuritis (inflammation of a nerve), congestive heart failure (heart does not pump blood well). During a review of Resident 1's "Minimum Data Set (MDS - comprehensive assessment tool)," dated 5/23/25, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS- an assessment of cognition, how well a person thinks, remembers, and learns) score of 13 out of 15 (score of 13-15 indicated cognitively intact). The MDS indicated under section GG (an assessment of the level a care a resident required), Resident 1 was dependent on staff for transferring from bed to chair/chair to bed. During a review of Resident 1's "Fall Risk Observation/Assessment" (FROA) dated 5/18/25, the FROA indicated, "Score 22 [score of 16-42 means high risk for falls]." During a review of Resident 1's "Progress Notes (PN)," dated 5/31/25 at 3:50 p.m., the PN indicated, "Staff reported this writer that the resident had a fall during a transfer from bed to wheelchair using a Hoyer lift. Upon arrival, res [Resident 1] was found on the floor in between Hoyer lift and closet, having landed on buttocks with sling underneath. An incident occurred when staff attempted to move the res with Hoyer lift legs in the closed position and turned the resident, causing the lift to tip and res to fall. . .Resident c/o [complained of] pain right wrist." During a review of Resident 1's "SBAR (Situation Background Appearance Review and Notify- a communication tool used between healthcare professionals i.e. between the nurse and physician) Communication Form," dated 5/31/25, the SBAR indicated, "Witnessed fall. . .Recommendations of Primary Clinicians. . .X-ray [medical imaging technique that uses radiation to create a picture of the inside of the body] Sacrum [triangular bone in the lower back] bone & Coccyx [tailbone] Bilateral Hips X-ray right wrist ." During a review of Resident 1's PN dated 5/31/25 at 10:26 p.m., the PN indicated, "[physician's name] notified of. . .mild displaced distal coccygeal segment fracture. . .MD (Medical Doctor) confirmed of res [Resident 1] to already have Norco [strong pain medication] and Tylenol [pain medication] ordered. NNO [no new orders] at this time." During a review of Resident 1's "Radiology Interpretation (RI)," dated 5/31/25, the RI indicated, "mild displaced distal coccygeal segment fracture [broken tailbone]." During an interview on 6/4/25 at 12:35 p.m. with Resident 1, Resident 1 stated, "When CNAs Certified Nursing Assistants (CNA 1 and CNA 2) were transferring me with the Hoyer lift on 5/31/25, they got me in the air with the sling and was over there by the wood dresser and I was up in the air. Then boom hit the ground and the rubber cap on the Hoyer where the hook came in and hit me in the head and stunned me and felt a jolt when I hit my elbow, and my hand and elbow were hurting really bad, having spasms in back of shoulder and have to lay on a pillow. I am paralyzed [being unable to move or feel part of the body due to nerve damage or illness] from the navel down, can't move legs or toes and now when lifting and lower right leg feel a click in front of the pelvis [large bony structure near the base of the spine/backbone to which the back limbs or legs are attached] where the femur [thigh bone] and acetabulum [structure located on the hip bone] meet, thank God I can't feel anything." Resident 1 stated CNA 1 apologized 20-30 times and said he should have opened the base (legs) of the Hoyer lift. During an interview on 6/4/25 at 2:44 p.m. with CNA 2, CNA 2 stated on 5/31/25 she was assisting CNA 1 with transferring Resident 1 with the Hoyer lift from the bed to the wheelchair. CNA 2 stated she was guiding Resident 1 in the air as CNA 1 was raising him up and she did not notice the legs of the lift were not open. CNA 2 stated while she was guiding Resident 1 out from over the bed, Resident 1 fell. CNA 2 stated the legs of the Hoyer lift were closed and the legs should have been open to help stabilize the Hoyer lift to prevent it from tipping over. During an interview on 6/4/25 at 3:10 p.m. with Director of Staff Development (DSD), DSD stated after Resident 1 fell on 5/31/25, she investigated the cause of the fall. DSD stated when CNA 1 and CNA 2 were transferring Resident 1 the legs of the Hoyer lift were not open causing the Hoyer lift to tip over and Resident 1 to fall to the floor. DSD stated both CNA 1 and CNA 2 had received transfer training with a Hoyer lift before the fall incident, and it was very important to open the legs of the Hoyer lift to prevent the Hoyer lift from tilting over. During an interview on 6/5/25 at 2:42 p.m. with CNA 1, CNA 1 stated on 5/31/25, CNA 1 and CNA 2 were transferring Resident 1 from the bed to the wheelchair. CNA 1 stated when he was operating the Hoyer lift, he placed the legs of the Hoyer lift under the bed closed and after Resident 1 was in the sling he pulled the legs out from under the bed closed and when he began turning the Hoyer lift with Resident 1, the Hoyer lift tipped over causing Resident 1 to fall to the floor. CNA 1 stated Resident 1 fell straight on his tailbone and grunted out in pain. CNA 1 stated he did not open the legs of the Hoyer lift due to the clutter in the room. CNA 1 stated he should have opened the legs of the Hoyer lift to stabilize it. During a concurrent interview and record review, on 7/3/25 at 2:20 p.m. with Director of Nursing (DON), Resident 1's care plans were reviewed. There was no care plan indicating how Resident 1 was to be transferred at the time of the fall. DON stated she could not find a care plan on how to transfer Resident 1 and there should have been one created at the time of admission (1/3/25). During a review of the facility's "Vander-Lift II Transfer Procedure (VLTP-manufacturer user manual)," dated 12/2019, the VLTP indicated, "Transfer from a bed or stretcher. Make sure there is enough room in the patient's room to do the transfer. Open the base to its widest position." During a review of the facility's policy and procedure (P&P) titled, "Lifting Machine, using a Mechanical" dated 7/2017, the P&P indicated, "Prepare the environment. . .clear an unobstructed path for the lift machine. Make sure the lift is stable and locked." In violation of the above cited standards, the facility failed to ensure the staff used the Hoyer lift properly according to manufacturer user manual when the legs (base) of the Hoyer lift were not open during a transfer of Resident 1. This failure resulted in the Hoyer lift tilting over causing Resident 1 to fall to the floor, sustaining a mild displaced distal coccygeal segment fracture. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and represents a class "A" citation.