Health inspection·February 26, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure needed care or services were provided for one of three sampled residents (Resident 1) when Resident 1's use of postoperative boot (designed to protect and support the foot while healing from injuries) after a fall for right ankle sprain (a soft tissue injury that occurs when ligaments are stretched or torn) was not monitored and evaluated. Residents Affected - Few This failure decreased the facility's ability to evaluate Resident 1's response to intervention and had the potential to result in Resident 1's increased risk for skin breakdown related to the use of the boot. Findings: During a review of Resident 1's admission records, the records indicated Resident 1 was admitted to the facility in December 2023 with diagnoses that included morbid obesity ( having too much body fat), muscle weakness, fibromyalgia (pain and tenderness throughout the body), and difficulty in walking. Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 1 had moderate cognitive impairment. During a review of Resident 1's MDS Section GG - Functional Abilities, dated 1/2/25, the section indicated Resident 1 was dependent on staff with toileting hygiene and showering, indicating Resident 1 put no effort to complete the activities and needed the assistance of two or more staff to complete the activities. During a review of Resident 1's Fall Risk Observation/Assessment, dated 1/2/25, the assessment indicated Resident 1 scored 16 which indicated Resident 1 was at high risk for falls. During a review of Resident 1's Change in Condition (CIC) evaluation, dated 2/11/25, the evaluation indicated Resident had a fall in the morning of 2/11/25. The evaluation further indicated Resident 1 had 8 out of 10 level of pain [severe pain] on the back due to the fall and the primary clinician recommended to do x-ray (imaging of the body parts) and to send Resident 1 to the hospital. During a review of Resident 1's imaging results, dated 2/11/25, the results indicated, XR [Xray] ANKLE 3 OR MORE VIEWS RIGHT .CLINICAL INDICATION: Injury. Pain status post [after] fall .FINDINGS: 3 views of the right ankle and 4 views of the right foot .IMPRESSION: Possible avulsion fracture of the lateral talar process [a small break in the ankle bone where it attaches to a ligament or tendon] . During a review of Resident 1's Emergency Department Note, dated 2/11/25, the note indicated, Page 1 of 6 555219 555219 02/26/2025 Auburn Oaks Care Center 3400 Bell Road Auburn, CA 95603

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few [Resident 1] presents after mechanical fall .Describes discomfort near her ankle. May have a tiny avulsion fracture of the talus but no other need for orthopedic emergent intervention. Placed in a postoperative boot and will be prescribed pain medication . During a concurrent observation and interview on 2/26/25 at 10:57 a.m. with Resident 1 in her room, Resident 1 was observed alert, calm, lying in bed, and wearing a boot on her right foot. Resident 1 stated, I did have a fall, I was in that lift .the whole machine tripped .my back and my foot hurts .I have a little boot thing on my right foot .It still hurts . During a concurrent observation and interview on 2/26/25 at 2:46 p.m. with the Assistant Director of Nursing (ADON) in Resident 1's room, Resident 1 was observed lying in bed with eyes closed, wearing a boot on right foot. The ADON confirmed the observation. During a concurrent interview and record review on 2/26/25 at 2:49 p.m. with the ADON, the ADON confirmed Resident 1's xray indicated possible avulsion fracture on ankle and new diagnosis from the hospital indicated right ankle sprain. The ADON stated she cannot find any documentation about Resident 1's use of the boot and stated, Expectation is staff should be aware about it, make sure no skin breakdown and good circulation. The ADON verified there were no physician orders and no monitoring for Resident 1's use of boot in the clinical record. The ADON stated, If it's in the discharge orders, it should be carried out. The ADON confirmed there were no treatment notes nor care plans in place for the use of the boot and stated, Every intervention should be care planned. During a concurrent interview and record review on 2/26/25 at 3:04 p.m. with Licensed Nurse 1 (LN 1), LN 1 stated she was aware that Resident 1 was wearing a boot on the right foot. LN 1 confirmed there was no order for the boot in the clinical record and stated, .supposed to have one .to monitor boots, if legs need to be evaluated, we monitor for skin integrity and circulation . During a concurrent interview and record review on 2/26/25 at 3:26 p.m. with the ADON and the Director of Rehabilitation (DOR), the DOR confirmed Resident 1 came back from the hospital on 2/11/25 with the boot on the right foot for right ankle sprain. The ADON and the DOR verified there was no order for the boot and no care plan in place specific to the use of boot in Resident 1's clinical record. The ADON stated the boot should be checked by the wound nurse and confirmed that Resident 1 was not seen by the wound care team because Resident 1 had no active wound. During a review of the facility's policy and procedure (P&P) titled Safety and Supervision of Residents, revised 10/2023, the P&P indicated, Individualized, Resident-Centered Approach to Safety .3. Implementing interventions to reduce accident risks and hazards may include the following .d. Ensuring that interventions are implemented .e. Documenting interventions .f. Modifying or replacing interventions as needed .g. Evaluating the effectiveness of new or revised interventions . 555219 Page 2 of 6 555219 02/26/2025 Auburn Oaks Care Center 3400 Bell Road Auburn, CA 95603

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 observation, interview and record review, the facility failed to provide safe supervision and assistance to prevent accidents for one of three sampled residents (Resident 1) when Resident 1 fell on the ground while being transferred from bed to shower chair by 2 Certified Nursing Assistants (CNA 1 and CNA 2) who failed to follow the proper maneuvering and operation of a Hoyer lift (a mechanical device used to lift and/or transfer a person from one surface to another) during the transfer and when CNA 2 was behind the shower chair away from the Hoyer lift. This failure resulted in Resident 1 sustaining a right ankle sprain (a soft tissue injury that occurs when ligaments are stretched or torn), back pain, and developed fear of being moved out of bed using a lift. Findings: During a review of Resident 1's admission records, the records indicated Resident 1 was admitted to the facility in December 2023 with diagnoses that included morbid obesity (having too much body fat), muscle weakness, fibromyalgia (pain and tenderness throughout the body), and difficulty in walking. Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 1 had moderate cognitive impairment. A review of Resident 1's MDS Section GG - Functional Abilities, dated 1/2/25, indicated Resident 1 was dependent on staff with toileting hygiene, transfers and showering which indicated Resident 1 put no effort to complete the activities, and needed the assistance of two or more staff to complete the activities. During a review of Resident 1's Fall Risk Observation/Assessment, dated 1/2/25, the assessment indicated Resident 1 scored 16 which indicated Resident 1 was at high risk for falls. During a review of Resident 1's undated Care Plan, the care plan indicated, Falls: [Resident 1] is at risk for falls with or without injury related to .in need of assistance with ADLs [Activities of Daily Living], decreased mobility, difficulty walking, generalized muscle weakness .Will minimize risk for falls to extent possible .Will not experience a fall related to risk factors .2/12/25: IDT [Interdisciplinary Team is a group of professionals who collaborate and plan resident care] recommends room change once available to accommodate for bariatric bed [big bed that supports overweight clients], belongings and maneuvering Hoyer [lift] in the room with ease to minimize risk for unsafe transfer technique thus minimizing risk for falls . During a review of Resident 1's Change in Condition (CIC) evaluation, dated 2/11/25, the evaluation indicated Resident 1 had a fall in the morning of 2/11/25. The evaluation further indicated Resident 1 had 8 out of 10 level of pain [severe pain on a numeric pain scale of zero to 10, zero being no pain and 10 being the worst pain possible, classified as mild 1-3, moderate 4-6 and severe 7-10] on the back due to the fall and the primary clinician recommended to perform x-ray (imaging of the body parts) and to send Resident 1 to the hospital. During a review of Resident 1's imaging results, dated 2/11/25, the results indicated, XR [Xray] ANKLE 3 OR MORE VIEWS RIGHT .CLINICAL INDICATION: Injury. Pain status post [after] fall .FINDINGS: 3 views of the right ankle and 4 views of the right foot .IMPRESSION: Possible avulsion fracture of the 555219 Page 3 of 6 555219 02/26/2025 Auburn Oaks Care Center 3400 Bell Road Auburn, CA 95603

F 0689 lateral talar process [a small break in the ankle bone where it attaches to a ligament or tendon] . Level of Harm - Actual harm During a review of Resident 1's Emergency Department Note, dated 2/11/25, the note indicated, .[Resident 1] presents after mechanical fall [fall associated to an external cause e.g. an object or force] .Describes discomfort near her ankle. May have a tiny avulsion fracture of the talus but no other need for orthopedic [medical specialty that deals with treatment of bones, joints, muscles, ligaments and tendons] emergent intervention. Placed in a postoperative boot [designed to protect and support the foot while healing from injuries) and will be prescribed pain medication . Residents Affected - Few During a review of Resident 1's IDT (Interdisciplinary team is a group of health care professionals who coordinate and plans patient care) Notes, dated 2/12/25, the notes indicated, .Per nursing note Writer was notified by staff that [Resident 1] had sustained a fall while attempting to transfer [Resident 1] to the shower chair for her shower. Upon initial entry of [Resident 1's] room, [Resident 1] was found on her bottom right next to her bed. Hoyer lift was on standby next to her. Resident showing non verbal signs of pain such as grimacing and rapid breathing. Pain assessment performed and pain was noted to be worse at her ankle .Asked CNAs [Certified Nursing Assistants] how [Resident 1] fell and said that the lift had tipped over while they were attempting to get [Resident 1] into the shower chair. NP [Nurse Practitioner] informed and ordered xray to ankle. Later on during the shift [Resident 1] started reporting she was experiencing back pain. Asked [Resident 1] to rate the pain and [Resident 1] rated the pain to be 8/10 [8 out of 10, severe pain] NP informed and added lower back xray. [Resident 1] also experiencing bad pain when moving and elevating head of bed .Suspected root cause: .During the process of moving the [Resident 1] from bed to shower chair the lift tilting laterally leading to [Resident 1] making contact with the ground . During a review of Resident 1's Nurse Practitioner Note,dated 2/12/25, the note indicated, On 2/11/25, nurse assigned reported that [Resident 1] had sustained a fall [on 2/11/25] while attempting to transfer [Resident 1] to the shower chair for her shower. [Resident 1] was found on her bottom right next to her bed and Hoyer lift was on standby next to her. Upon assessment, [Resident 1] complained of pain in the back and most on the right ankle and in tears when telling me that [Resident 1] is in pain .Hours later, [Resident 1] informed the nurse assigned that [Resident 1's] pain is 8/10 and wanted to be sent to hospital for further evaluation and management. Late at night, [Resident 1] came back with new diagnosis of right ankle sprain .I went to see [Resident 1] today, [Resident 1's] right leg elevated on the pillow and has complaints of pain on the right ankle. [Resident 1] is in pain . During a review of Resident 1's Care Conference Meeting notes, dated 2/20/25, the notes indicated, DOR [Director of Rehabilitation] explained how [Resident 1] fell in the most recent fall [on 2/11/25], and that inservicing [in-service is training given to employees] was completed with the staff following the fall regarding use of the hoyer [lift] .and recommendation for a potential room change when a room becomes available. [Resident 1's family members] expressed concerns of [Resident 1] feeling now fearful of the lift d/t [due to] the falls .[Resident 1] expressed she has been having back spasms and is having difficulty sitting up to eat, writer informed NP .of the back pain. During a concurrent observation and interview on 2/26/25 at 10:57 a.m. with Resident 1 in her room, Resident 1 was observed alert, calm, lying in bed, and wearing a boot on her right foot. Resident 1 stated, I did have a fall, I was in that lift .the whole machine tripped .my back and my foot hurts .I have a little boot thing on my right foot .It still hurts .I don't like the lift, no more lift .Feels safe [in the facility] except for the lift and I will not use it anymore. 555219 Page 4 of 6 555219 02/26/2025 Auburn Oaks Care Center 3400 Bell Road Auburn, CA 95603

F 0689 Level of Harm - Actual harm Residents Affected - Few During an interview on 2/26/25 at 11:30 a.m. with CNA 1, CNA 1 stated she was one of the CNAs assisting Resident 1 when the incident happened on 2/11/25. CNA 1 stated, I was transferring [Resident 1] to the shower chair .now [Resident 1] won't [use the lift] because she's afraid .I was by the feet .The other CNA [CNA 2] was at the back of the shower chair .[CNA 2] was away from the lift .[CNA 2] should have been closer . During an interview on 2/26/25 at 11:47 a.m. with the Director of Staff Development (DSD), the DSD stated, Expectation for safe transfer would be to make sure staff follow proper transferring techniques, both for resident and staff safety .We don't want the resident or the staff to get hurt. During an interview on 2/26/25 at 12:09 p.m. with CNA 2, CNA 2 stated, I was asked by [CNA 1] to assist with a lift, I went with [CNA 1] .[CNA 1] was guiding [Resident 1] to the shower chair .the lift was not maneuvered properly by [CNA 1] that's why it tipped .there was no pivot, she went to the left side of it [the lift] instead of pivoting it .[CNA 1] moved the Hoyer sideways instead of backwards . CNA 2 further stated Resident 1 fell on the ground followed by the Hoyer lift and the lift fell on Resident 1's right ankle. CNA 2 added that instead of opening the base of the lift, and pivoting and then moving forward, CNA 1 came to the side of the lift and held the left side handle and the hydraulic pump (part of the lift that creates the power to lift). CNA 2 stated, .not both handles . CNA 2 stated Resident 1's back hit the foot of the bed, and the tip of the lift hit Resident 1 on her right ankle. CNA 2 further stated, The legs of the Hoyer were not open or extended, if it was open, it would have been more stable .according to what was taught to us, it was not the proper maneuvering of the Hoyer [lift]. During an interview on 2/26/25 at 12:29 p.m. with the Maintenance Director (MTD), the MTD stated, .To get it [the lift] to where it's going, the staff should hold both handles, lock the wheels, and spread the feet [base of the lift] .If not done, the biggest problem is stability, it can slide either way .it could tip to one side . During an interview on 2/26/25 at 1:15 p.m. with the Assistant Director of Nursing (ADON), the ADON stated, From what I was told, it could be something that happened with the equipment [lift] .If the lift was not maneuvered correctly, it can cause the lift to fall .[Staff] should be holding both handles . The ADON stated staff should not be holding the hydraulic pump and should be holding both handles because the lift might not be balanced. The ADON further stated, Expectation is to do two-person transfer and follow right protocol .and use the appropriate lift too .follow correct usage and maneuvering . During an interview on 2/26/25 at 1:37 p.m. with the Director of Rehabilitation (DOR), the DOR stated, .[Resident 1] should not be falling and not be fearful .Staff should hold both handles, stay as close as you can [to the resident], the other person guide the resident to the desired position .The legs should be open so it can have a wider base support . During a review of the Hoyer lift's operation manual, dated 12/2019, the manual indicated, .Transfer from a Bed or Stretcher .11) Move the [brand name of Hoyer lift] into position .Open the base to its widest position .14) Leaving the caster brakes [packing brakes] unlocked, lift the patient about 2 inches off of the bed or stretcher and back the [brand name of Hoyer lift] away. Leaving the brakes unlocked will allow the lift to walk forward to center itself over the patient's center of gravity as it raises. This increases the stability of the lift. The only time the brakes should be locked is if the patient is being lifted from a ramp or some other sloping surface .15) When the patient is away from the bed or stretcher, lower the patient so his or her feet are at the top of the base of 555219 Page 5 of 6 555219 02/26/2025 Auburn Oaks Care Center 3400 Bell Road Auburn, CA 95603

F 0689 the lift and, slowly turning the lift, move the patient to the desired location . Level of Harm - Actual harm During a review of the facility's policy and procedure (P&P) titled Safety and Supervision of Residents, revised 10/2023, the P&P indicated, Our facility strives to make the environment as free from accident hazards as practicable as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Systems Approach to Safety .1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly .Resident Risks and Environmental Hazards .1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards may include .b. Safe Lifting and Movement of Residents; c. Falls . Residents Affected - Few During a review of the facility's P&P titled Lifting Machine, Using a Mechanical, revised 7/2022, the P&P indicated, General Guidelines .1. The nursing assistant will assist to safely move a resident with a mechanical lift. 2. Mechanical lifts may be used for tasks that require: .b. Transferring a resident from bed to chair .d. Toileting or bathing .Steps in the Procedure .4. Make sure the lift is stable and locked . 555219 Page 6 of 6