Health inspection·February 27, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review, the facility failed to prevent an injury to one of one sampled resident (Resident 1) when Resident 1 hit her head during the transfer from the wheelchair to the bed. The facility failure resulted to resident to experience severe pain and sustain a bump on the back of her head. Findings: A review of the face sheet indicated Resident 1 was admitted with diagnoses including left ankle wound, congestive heart failure (when the heart does not pump as strong as it should) and osteopenia (weakened bones). A review of the Minimum Data Set (MDS, a standard assessment tool) dated 3/30/23, Brief interview of mental status (BIMS, a brief memory test to help determine cognitive functioning [thinking, learning, and decision- making abilities]) score of 5 indicated severe cognitive impairment (rarely/never make decisions). Resident 1 required extensive assistance with one-person physical assist to perform activities of daily living including bed mobility, transfer, personal hygiene, and toilet use. Resident 1 was non ambulatory (unable to walk). During an interview on 11/14/23, at 2:36 PM, Certified Nurse Assistant (CNA, care giver) 1 stated that with CNA 2, they attempted to transfer Resident 1 back to bed. The resident was sitting on the wheelchair with the sling underneath. The wheelchair was on the left side of the bed facing the foot of the bed and in front of the hoyer lift. During an interview on 2/27/24, at 2:52 PM, CNA 2 stated that CNA 1 was operating the hoyer lift and had started raising the resident from the wheelchair but unable to roll the hoyer lift due the wound vacuum tubing on the floor blocking the hoyer lift's wheels to roll. CNA 2 stated she left the resident side and went to the right side and under the bed to move the wound vacuum tubing out of the hoyer lift's wheels way. CNA 2 also stated, The resident (Resident 1) panic, screamed, moved backwards, and she flipped. (CNA 2 gestured, and with her left hand down and right hand up moved them to the left hand up and right-hand down position). She (Resident 1) was hanging on the lift. CNA 2 continued that Resident 1, with the lower part of the sling placed under and over between the legs/thighs kept Resident 1 off the floor. CNA 2 further stated, The back of the sling doesn't give enough support. The sling was thrown away. During an interview on 2/27/24, at 3:02 PM, Occupational Therapist (OT, she responded after hearing Page 1 of 4 555856 555856 02/27/2024 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0689 a scream and saw Resident 1 upside down, hanging from the hoyer lift. Level of Harm - Minimal harm or potential for actual harm During an interview on 2/27/24, at 3:06 Vocational Nurse (LVN) 1 stated, I was called to the resident's room. The OT was already there, and the resident was already lowered on the floor. LVN further stated that after completing assessment to Resident 1, he decided that Resident 1 can be transferred to bed. Residents Affected - Few A review of the nurses' notes, dated 4/11/23, indicated, .resident (patient) complained of pain on the back of her head. Resident rated pain as 10/10 (severe pain) .while being transferred was noted to have hit her head. Resident also noted with a small bump on her head .Notified Director of Nursing (DON) and Assistant DON (ADON) of current situation and upon assessment ordered to send the resident out . A review of the nurses' notes, a late entry, dated 4/12/23, indicated, .Resident hit her head on the base of the hoyer lift during transfer .resident was given tramadol (used to relieve moderate to severe pain). Prior to sending resident out, this writer (LVN 2) assessed the resident .A bump at the back of the head was noted . A review of the Policy and Procedure titled, Safe Lifting and Movement of Residents dated 7/2017, indicated, .In order to protect the safety and well-being of the staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents .Nursing staff, in conjunction with the rehabilitation staff, shall assess individual resident' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan . A review of the facility policy titled, Lifting Machine, using a Mechanical dated 7/2017, indicated, .Before using a lifting device, assess the resident's current condition including: .Can the resident understand and follow instructions? Does the resident express fear or appear anxious about the use of the lift? Is the resident agitated, resistant or combative? . Check the resident's comfort by observing for signs of pinching or pulling of the skin. Slowly lift the resident. Only lift the resident as high as necessary to complete the transfer. Gently support the resident as he or she is moved . 555856 Page 2 of 4 555856 02/27/2024 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview and record review, the facility failed to ensure that a Registered Nurse (RN) completed an assessment to 4 of 4 sampled residents (Resident 1, 2, 3, and 4) when the residents had a change in condition. The deficient practice had the potential for harm on the resident's safety and well-being. Findings: A review of the face sheet indicated Resident 1 was admitted with diagnoses including left ankle wound, congestive heart failure (when the heart does not pump as strong as it should) and osteopenia (weakened bones). During an interview on 2/27/24, at 3:02 PM, Occupational Therapist (OT, help people recover from injuries to regain abilities to perform daily activities) she responded after hearing a scream and saw Resident 1 upside down, hanging from the hoyer lift. During an interview on 2/27/24, at 3:06 Vocational Nurse (LVN) 1 stated, I was called to the resident's room. The OT was already there, and the resident was already lowered on the floor. LVN further stated that after completing assessment to Resident 1, he decided that Resident 1 can be transferred to bed. A review of the nurses' notes, dated 4/11/23, indicated, .resident (patient) complained of pain on the back of her head. Resident rated pain as 10/10 (severe pain) .while being transferred was noted to have hit her head. Resident also noted with a small bump on her head . A review of the nurses' notes, a late entry, dated 4/12/23, indicated, .Resident hit her head on the base of the hoyer lift during transfer .resident was given tramadol (used to relieve moderate to severe pain). Prior to sending resident out, this writer (LVN 2) assessed the resident . A review of the nurses' notes dated 4/12/23, indicated, Resident 1 returned to the facility from the emergency department with a diagnosis of neck fracture (broken) on the second cervical vertebra . b. A review of the face sheet indicated Resident 2 was admitted with diagnoses including sepsis (generalized infection), diabetes (Abnormally high blood sugar level), and heart failure (when the heart does not pump as strong as it normally does). A review of the nurses' notes dated 2/8/24, indicated Resident 2 had an unwitnessed fall. There was no assessment completed by a Registered Nurse. c. A review of the face sheet indicated Resident 3 was admitted with diagnoses including fracture (break, broken) femur (thigh bone), hypertension (abnormally high blood pressure) and osteomyelitis (inflammation[swelling] of the bones). A review of the nurses' notes dated 2/28/24, indicated Resident 3 had a fall incident. There was no assessment completed by an RN. 555856 Page 3 of 4 555856 02/27/2024 Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some d. A review of the face sheet indicated Resident 4 was admitted with diagnoses including osteoarthritis of the knee (pain and inflammation of the bones), atrial fibrillation (abnormal heartbeat) and fibromyalgia (general body pain). A review of the nurse notes dated 2/6/24, indicated Resident 4 had a fall, where Resident 1 was found lying on the floor on his left side. There was no assessment completed by an RN. During an interview on 3/5/24, at 11:15 AM, the Director of Nursing stated the LVN's performs assessment on residents with changes in conditions. A review of the faciity Job Description for the LVN dated 11/2018, indicated, The purpose of the job position is to provide direct nursing care to the resident and to supervise the day-to-day nursing activities performed by nursing assistants . Administer professional services such as catheterization, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy, and drainage bags, taking blood, giving massages and range of motion exercises, care for dead/dying .obtain sputum, urine, and other specimens for lab tests .Take and record TPR's, blood pressures . The job description for LVN did not include performing resident assessments. 555856 Page 4 of 4