Health inspection·September 17, 2025

42 CFR §483.25 Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and (d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22CCR §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 8/2/2025, the California Department of Public Health (CDPH) received a complaint of alleged neglect or elder abuse against Resident 1. The complaint indicated Resident 1 was seen in the emergency department for persistent ankle pain that began three weeks prior. The x-ray indicated an ankle fracture. On 8/5/2025, CDPH conducted an unannounced visit to the facility to investigate the allegation. The facility failed to: 1. Ensure Certified Nursing Assistant (CNA ) 1 and CNA 2 used proper transfer technique or an appropriate assistive device such as a Hoyer lift (a mechanical device used to safely transfer people with mobility limitations) to transfer Resident 1 from a wheelchair to a bed, as indicated on the resident's care plan titled "At risk for impairment to skin integrity r/t use of Hoyer lift". 2. Implement Resident 1's care plan (CP) interventions titled, "At risk for impairment to skin integrity related to use of Hoyer lift", which indicated Resident 1 would be free from injury. As a result, Resident 1 sustained two fractures at the right medial malleolus (bone on the inner side of the ankle) and lateral malleolus (bone on the outer side of the ankle), was admitted to a general acute care hospital (GACH) from 8/2/2025 to 8/6/2025 (a total of 4 days), for evaluation and treatment. Resident 1 was an 88-year-old male admitted to the facility on 10/10/2011 with diagnoses including hemiplegia (total paralysis to one side of body), muscle wasting (condition where muscles lose size and strength, and hemiparesis (weakness on one side of the body). A review of Resident 1's care plan, titled "At risk for impairment to skin integrity related to use of Hoyer lift", dated 2/01/2025, indicated Resident 1 had abnormalities of gait and mobility. The care plan goal indicated Resident 1 will be free from injury. The interventions indicated the facility would use caution during transfers and bed mobility to prevent striking arms, legs, and hands against sharp or hard surface. A review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool), dated 4/21/2025, indicated Resident 1 was able to express ideas and usually able to understand others. The MDS indicated Resident 1 required substantial/maximal assist (helper did more than half the effort) from sitting to lying, was not able to stand or walk 10 feet, and was dependent (helper does all the effort) on staff to transfer from chair to bed. A review of Resident 1's Occupational Therapy Progress Report from 5/26/2025 through 6/22/2025, indicated staff used a Hoyer lift (a machine that a caregiver uses to lift and move a person who cannot move on their own) for Resident 1's transfers. A review of Resident 1's Physical Therapy Progress Report from 5/26/2025 through 6/22/2025, indicated Resident 1 was "mostly bedbound and occasionally up in her wheelchair via Hoyer lift". The report further indicated Resident 1 needed maximum assistance with bed mobility and was non-ambulatory for a long time. Resident 1's baseline was total dependence with bed mobility. A review of Resident 1's Transfer Level notes in an un-named and undated binder, indicated Resident 1 required a Hoyer lift for transfer. A review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), indicated from July 1st -July 15th, Resident 1 received 50 mg (a medication used to treat moderate pain in adults) for four out of fifteen days. The MAR indicated Resident 1, indicated Resident 1 received Tramadol 50 mg from July 16th-July 31st, fourteen out of sixteen days. A review of Resident 1's e-MAR Medication Administration notes, dated 7/16/2025, at 2:43 p.m. (date of transfer incident), indicated Resident 1 was given Tramadol 50 mg for complaint of body pain rated at seven out of 10 on a 0-10 pain scale (0-3 =, 7-10=, where seven indicated strong/severe pain). A review of Resident 1's Nursing Note, dated 7/31/2025 (two weeks after Resident 1 screamed out in pain), indicated the family member (FM) was concerned about swelling to Resident 1's ankle and requested an x-ray (photographic or digital image of the internal part of the body) to be sure, and Resident 1's Medical Doctor (MD 1) ordered a STAT (immediate) x-ray to both ankles." A review of Resident 1's Radiology Results Report, dated 7/31/2025, indicated Resident 1 had a mildly displaced fracture of the right medial malleolus (bone on the inner side of the ankle) and a nondisplaced fracture of the lateral malleolus (bone on the outer side of the ankle). A review of Resident 1's Change in Condition (COC) evaluation, dated 8/1/2025, indicated the FM reported, after going to a doctor's appointment on 7/16/2025 with Resident 1, the FM (she) was outside Resident 1's room when nurses attempted to put Resident 1 back to bed, and the FM heard Resident 1 scream. The COC indicated FM 1 entered the room and asked Resident 1 what happened, and Resident 1 stated her leg "hurts so bad". The FM stated Resident 1 complained of pain since that time. The COC indicated Resident 1 had fractures of the medial and lateral malleolus and was ordered to be transferred to the GACH. A review of Resident 1's GACH Progress Notes indicated Resident 1 was admitted to the GACH on 8/2/2025 at 10:09 am for right ankle pain. The progress notes indicated Resident 1 had diagnosis including a right Trimalleolar fracture (ankle fracture) and elder abuse. Resident 1 underwent an open reduction and internal fixation (ORIF- a surgical procedure used to treat a bone fracture) of the right ankle on 8/3/2025. A review of Resident 1's GACH x-ray results dated 8/2/2025 indicated Resident 1 had fractures of the distal fibula (lower end of the leg bone) and medial malleolus (inner side of the ankle) bones. A review of Resident 1's GACH Discharge Summary (DS) dated 8/6/2025, The DS indicated Resident 1 was transferred back to the facility status post right ankle ORIF and pain management. During an interview, on 8/5/2025, at 11:53 a.m., with the FM, the FM stated on 7/16/2025 Resident 1 went to a doctor's appointment. The FM stated Resident 1 was bedbound (being confined to a bed due to illness or physical limitations) and was supposed to be transferred with a Hoyer lift. The FM stated she stepped out of the room while Two CNAs transferred Resident 1 from a wheelchair to bed. The FM stated she heard Resident 1 scream, "You broke my foot!" and she rushed into the room and observed Resident 1 in bed, crying, and asking for pain medication. FM 1 stated there was no Hoyer lift at the bedside and staff transferred Resident 1 without using a Hoyer Lift. The FM stated she asked CNA 1 what happened, and CNA 1 just shrugged his shoulders and left the room without responding. The FM stated on 7/31/2025 she noticed Resident 1's right leg was swollen; she reported it to the nurse and requested an x-ray be done. The FM stated the next day, he/she was notified Resident 1's the x-ray revealed Resident 1 had two right ankle fractures. During an interview, on 8/6/2025, at 10:50 a.m., CNA 1 stated on 7/16/2025, he assisted transferring Resident 1 to the bed using a 2-person assist. CNA 1 stated he and CNA 2 placed an arm under Resident 1's armpit and held her waistline, then transferred Resident 1 to his bed. CNA 1 stated they did not use a Hoyer Lift. CNA 1 stated failure to use the right technique or equipment to transfer a resident, can cause injury to the resident. During an interview, on 8/6/2025, at 1:43 p.m., with the Registered Nurse (RN) 1, RN 1 stated on 7/31/2025, Resident 1 complained of soreness when the right ankle was touched, and an x-ray was done. RN 1 stated Resident 1's X-ray results indicated Resident 1 had two right ankle fracture2. RN 1 stated she notified the FM that Resident 1 had an ankle fracture. RN 1 stated the FM told she (RN 1), on 7/16/2025, when staff were placing Resident 1 back to bed, the FM heard Resident 1 scream, "my leg is hurting". RN 1 stated the FM stated Resident 1 had been complaining of pain since that day. During a concurrent observation and interview, on 8/7/2025, at 11:55 a.m., Resident 1 was in bed with a splint to the right lower leg/ankle. Resident 1 stated on the date of incident (7/16/2025), two staff members (a male and a female) were transferring her from a wheelchair to bed. Resident stated CNA 1 grabbed her (Resident 1's) feet and a lady (CNA 2) grabbed her shoulders. Resident 1 stated when CNA 1 "grabbed" her feet during the transfer she screamed and cried because "he hurt my foot." Resident 1 stated staff have not transferred her like that before. Resident 1 stated staff sometimes used a Hoyer lift to transfer her. Resident 1 stated after the incident, she was in pain all night. During an interview, on 8/7/2025, at 1:40 p.m., the Director of Staff Development (DSD) stated the proper technique for a 2-person transfer from wheelchair to bed was to have a staff member on both sides of the resident holding the resident under the arms, so the resident's weight was evenly distributed. The DSD stated after holding the resident under the arm, have the resident stand and pivot in one or two steps to move to the bed. The DSD CNA 1 and 2 should not have transferred Resident 1 by grabbing the resident's feet and shoulders, because this method could not properly transfer the resident to bed. The DSD stated staff used the wrong transfer technique and Resident 1 was injured. The DSD stated Resident 1 should be transferred using a 2-person assistance technique or using a Hoyer lift. The DSD stated Resident 1 was bedbound, did not stand, or walk and it was not typical to get an ankle fracture. The DSD stated it was not okay for Resident 1 to be injured by staff during care. The facility failed to: 1. Ensure Certified Nursing Assistant (CNA ) 1 and CNA 2 used proper transfer technique or an appropriate assistive device such as a Hoyer lift (a mechanical device used to safely transfer people with mobility limitations) to transfer Resident 1 from a wheelchair to a bed, as indicate on the resident's care plan titled "At risk for impairment to skin integrity r/t use of Hoyer lift". 2. Implement Resident 1's care plan (CP) interventions titled, "At risk for impairment to skin integrity related to use of Hoyer lift", which indicated Resident 1 would be free from injury. As a result, Resident 1 sustained two fractures at the right medial malleolus (bone on the inner side of the ankle) and lateral malleolus (bone on the outer side of the ankle), was admitted to a general acute care hospital (GACH) from 8/2/2025 to 8/6/2025 (a total of 4 days), for evaluation and treatment. This violation had a direct relationship to the health, safety, or security of the residents.