Health inspection·June 13, 2025

42 CFR §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: (2) Implementing of 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 4/28/2025, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) indicating on 4/19/2025 a resident (Resident 2) requested to be transferred to a shower chair, lost control of her upper extremities and abruptly leaned forward and was assisted to the floor by two staff members. The FRI indicated on 4/24/2025 Resident 2 complained of left knee pain, and an X-ray was ordered. The results of the X-ray indicated Resident 2 sustained a minimally displaced impacted fracture (a broken bone where the bone fragments are compressed together but the degree they are out of alignment is small) of the distal (away from the center of the body) left femur (thigh bone). On 4/28/2025 CDPH conducted an unannounced visit at the facility to investigate the FRI. Upon investigation, CDPH determined Resident 2, who had a diagnosis of paraplegia (loss of movement and/or sensation, to some degree, of the legs), and was assessed as high risk for falls, was manually transferred without the use of a mechanical lift by two staff members from her bed to a shower chair, which resulted in Resident 2 falling and sustaining a minimally displaced fracture of the distal left femur. This deficient practice places residents at high risk of injuries including death, as evidenced by the actual injury suffered by Resident 2. The facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 4 and Restorative Nursing Assistant (RNA) 1 used a mechanical lift to transfer Resident 2 from a bed to a shower chair, as recommended by the Physical Therapy (PT) department. 2. Develop and implement a care plan for Resident 2's mode of transfer between surfaces with interventions to prevent the resident's injury. 3. Ensure staff followed the facility's policy and procedure (P/P) titled, "Total Mechanical Lift" dated 9/29/2016, which indicated "a mechanical lift is used to appropriately facilitate transfers of residents." 4. Ensure staff followed facility's P/P titled, "Falls Prevention Program" revised 2/2025, which indicated "staff from all departments will be expected to contribute to the efforts of fall prevention for their residents." As a result of these deficient practices Resident 2 sustained an acute (severe and sudden in onset) minimally displaced impacted fracture of the distal left femur when she had an assisted fall (a fall in which a staff member was with the resident and attempted to minimize the impact of a fall by slowing by slowing the resident's descent) while being manually transferred from a bed to a shower chair by CNA 4 and RNA 1 without using a mechanical lift. A review of Resident 2's Admission Record (Face Sheet) indicated Resident 2, a 69-year-old female, was originally admitted to the facility on 11/14/2014 and readmitted on 4/15/2025 with a diagnosis of paraplegia. A review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool), dated 4/22/2025, indicated Resident 2 had no cognitive (thought process) impairment. The MDS indicated Resident 2's functional abilities to both her lower extremities (legs) were impaired, and she was dependent (helper does all of the effort, resident does none of the effort to complete the activity or, the assistance of two or more helpers is required for the resident to complete the activity) for toileting hygiene, shower/bathe and chair/bed to chair transfers. A review of Resident 2's History and Physical (H&P), dated 4/15/2025, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's PT Evaluation and Plan of Treatment, dated 4/16/2025, indicated Resident 2 presented with balance deficits, decreased dynamic balance (the ability to maintain a stable posture and control movements while the body is in motion), decreased static balance (the ability to maintain an upright posture and keep the center of gravity within the limits of the base of support while standing or sitting still), gross motor (physical abilities involving large muscle groups and body movements, such as walking, running, jumping, and climbing) coordination deficits, pain, strength impairment, deficits in judgment and limitations in range of motion ([ROM] the direction a joint can move to its full potential). The PT Evaluation and Plan of Treatment indicated Resident 2 was totally dependent on transfers and with bed mobility. The PT Evaluation and Plan of Treatment indicated a recommendation for Resident 2 to use a mechanical lift during transfers. A review of Resident 2's Occupational Therapy ([OT] a healthcare profession that helps people participate in meaningful activities in their daily lives) Evaluation and Plan of Treatment, dated 4/16/2025, indicated Resident 2 presented with a decrease in activity tolerance affecting her ability to safely perform and complete self-care activities safely with her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily) due to decreased activity tolerance, decrease strength, and decrease sitting tolerance. A review of Resident 2's Change of Condition (COC) form, dated 4/19/2025, indicated Resident 2 was observed sitting on the floor following an assisted fall. The COC form indicated Resident 2 complained of pain to her left breast rated six out of 10 on a pain scale (an 11 eleven-point scale where pain is rated from zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain). The COC indicated Resident 2 was medicated with Acetaminophen Extra Strength 500 milligram (mg) for moderate pain. A review of Resident 2's Skin Assessment dated 4/24/2025, indicated Resident 2 had slight swelling to her left knee and her left knee was warm to touch. A review of Resident 2's COC form dated 4/24/2025, indicated Resident 2 complained of pain rated at five out of 10 to her left knee. The COC form indicated Resident 2's physician was notified and an order for an X-Ray to Resident 2's left knee was given. A review of Resident 2's Physician's Order dated 4/24/2025, indicated to obtain an X-ray of Resident 2's left knee due to pain and swelling. A review of Resident 2's Radiology Report dated 4/24/2025, indicated Resident 2 sustained an acute minimally displaced impacted fracture to her distal left femur. During an interview on 4/30/2025 at 10:36 a.m., Registered Nurse Supervisor (RNS) 2 stated, CNA 4 reported that Resident 2 had an assisted fall on 4/19/2025. RNS 2 stated on 4/19/2025, when she (RNS 2) entered Resident 2's room she found Resident 2 sitting on the floor. RNS 2 stated CNA 4 reported that she (CNA 4) and RNA 1 attempted to manually transfer Resident 2 from her bed to a shower chair without using a mechanical lift. RNS 2 stated she was not aware that Resident 2 refused to be transferred using the mechanical lift. RNS 2 stated CNA 4 and RNA 1 should have used a mechanical lift to transfer Resident 2. During a telephone interview on 4/30/2025 at 10:57 a.m., CNA 4 stated on 4/19/2025, Resident 2 requested to be transferred from her bed to a shower chair using a mechanical lift. CNA 4 stated she had to look for a mechanical lift and sling (a flexible strap or belt used in the form of a loop to support or raise a weight), but Resident 2 did not want to wait and insisted on being transferred without using a mechanical lift. CNA 4 stated she asked RNA 1 to assist with Resident 2's transfer. CNA 4 stated when they attempted to transfer Resident 2, they (CNA 4 and RNA 1) realized Resident 1 was too heavy, and they assisted the resident to the floor. CNA 4 stated for safety Resident 2 should have been transferred using a mechanical lift. During an interview on 4/30/2025 at 11:59 a.m., Resident 2 stated staff would usually transfer her by using a mechanical lift but on 4/19/2025 she insisted that CNA 4 transfer her from her bed to a shower chair without it because the sling hurts her back and she did not want to use the mechanical lift. Resident 2 stated during the transfer RNA 1 placed his (RNA 1) hand under her (Resident 2) left arm and at the same time put pressure on her left breast causing her pain. Resident 2 stated she screamed "put me down, put me down!" and she was assisted to the floor by CNA 4 and RNA 1. Resident 2 stated when she was on the floor, she noticed her left leg was twisted backwards and asked CNA 4 to place her leg forward. During an interview on 4/30/2025 at 12:48 p.m., RNA 1 stated on 4/19/2024 CNA 4 asked him to assist her with Resident 2's transfer from her bed to a shower chair. RNA 1 stated, during the transfer Resident 2 started leaning forward and they (CNA 4 and RNA 1) could not hold her up, so they sat her on the floor and requested help. RNA 1 stated he knew Resident 2 used a mechanical lift for transfers, but Resident 2 was in a hurry and insisted they not use the mechanical lift. RNA 1 stated if given the opportunity to redo the transfer he would have used the mechanical lift for the safety of the resident. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 3 on 4/30/2025 at 1:16 p.m., LVN 3 stated on 4/19/2025 CNA 4 called her and RNS 2 to Resident 2's room and they (LVN 3 and RNS 2) both found Resident 2 sitting on the floor. LVN 3 stated Resident 2 should have been transferred using a mechanical lift and if Resident 2 refused to be transferred using the mechanical lift, CNA 4 and RNA 1 should have notified her (LVN 3) and/or RNS 2. During an interview on 5/1/2025 at 9:25 a.m., the Director of Nursing (DON) stated because of Resident 2's diagnosis of paraplegia, a Care Plan did not have to be created with an intervention to use a mechanical lift when transferring Resident 2. The DON stated the recommendation from the Rehabilitation Department to use a mechanical lift when transferring Resident 2 should have been enough. The staff and the nurses should have followed PT's recommendation to use the mechanical lift to prevent Resident 2 from falling and sustaining an injury. During a concurrent interview and record review with the Director of Rehabilitation (DOR) on 5/1/2025 at 12:10 p.m., Resident 2's OT/PT Evaluation and a Plan of Treatment dated 4/16/2025 was reviewed. The OT/PT Evaluation and Plan of Treatment indicated Resident 2 was placed on the high risk for falls list and based on the evaluation and plan of treatment Resident 2 was required to be transferred using a mechanical lift. The DOR stated the nursing staff should have followed the recommendation from the OT/PT to use a mechanical lift when transferring Resident 2 to prevent Resident 2 from falling. The DOR stated the rehabilitation department communicates the residents' needs verbally and via their OT/PT evaluation to the nursing staff and they should have been aware of the recommendation to transfer Resident 2 using a mechanical lift. A review of the facility's P/P, titled, "Falls Prevention Program" revised 2/2025, indicated staff from all departments will be expected to contribute to the efforts of fall prevention for their residents. A review of the facility's P/P, titled, "Total Mechanical Lift" dated 9/29/2016, indicated that a mechanical lift is used to appropriately facilitate transfers of residents. The facility failed to: 1. Ensure CNA 4 and RNA 1 used a mechanical lift to transfer Resident 2 from a bed to a shower chair, as recommended by the PT department. 2. Develop and implement a care plan for Resident 2's mode of transfer between surfaces with interventions to prevent the resident's injury. 3. Ensure staff followed the facility's P/P titled, "Total Mechanical Lift" dated 9/29/2016, which indicated "a mechanical lift is used to appropriately facilitate transfers of residents." 4. Ensure staff followed facility's P/P titled, "Falls Prevention Program" revised 2/2025, which indicated "staff from all departments will be expected to contribute to the efforts of fall prevention for their residents." As a result of these deficient practices Resident 2 sustained an acute minimally displaced impacted fracture of the distal left femur when she had an assisted fall while being transferred from a bed to a shower chair by CNA 4 and RNA 1 without using a mechanical lift. 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 to Resident 2.