Health inspection·October 31, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to implement two persons assist when mechanical lift (a medical device used to safely lift and move a resident) was used to transfer (moving from one place to another) Resident 1.These deficient practices led to Resident 1 sustaining a fall that resulted in intramuscular hematoma (collection of blood within a muscle) to the right pectoralis (chest muscle) and a broken right leg.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 of the effort, and the assistance of two or more nursing staff members were 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. with the Licensed Nurse (LN 1), 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 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. with CNA 1, 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 Page 1 of 2 555190 555190 10/31/2025 English Oaks Convalescent & Rehabilitation Hospita 2633 West Rumble Rd Modesto, CA 95350

F 0689 Level of Harm - Actual harm Residents Affected - Few had asked for help from another CNA.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 NAME] following a fall from four feet from a mechanical lift. Medical documentation indicated Resident 1 sustained a large intramuscular hematoma (collection of blood under the skin) to the right pectoralis (chest muscle) 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 policy and procedure (P&P) review on 11/07/25 at 12:53 p.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. 555190 Page 2 of 2