Health inspection·October 22, 2025

§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 10/7/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident about a resident fracture (broken bone). The facility failed to provide an environment that was free from accidents and hazards for Resident 2 when on 9/27/2025 at 3:30 p.m. Certified Nursing Assistant (CNA) 1 transferred Resident 2, who required two-person assistance due to severely impaired cognitive skills (are significant difficulties with thinking, remembering, and learning that prevent a person from living independently and carrying out daily tasks) and right hemiplegia (paralysis of the right side of the body), onto the shower bed, and from Resident 2’s room to the shower room while on the shower bed, without a second staff assisting. As CNA 1 was pushing Resident 2 on the shower bed, Resident 2’s right toe made a direct impact with the door handle, causing a mechanical tear and avulsion fracture between Resident 2’s right first and second toes.   As a result, on 9/27/2025 at 9:57 p.m. Resident 2 was transferred to the General Acute Care Hospital (GACH) 1 per order from the Medical Doctor (MD) for wound stitching and where Resident 2 was diagnosed with an open toe fracture (break or crack in a bone) and laceration (a rough, jagged tear or cut in the skin that goes through more than one layer of skin and causes bleeding). A review of Resident 2’s Admission Record indicated the facility admitted Resident 2, a 58-year-old male, on 8/20/2016 and was readmitted on 7/5/2025 with diagnoses including encephalopathy (any illness, injury, or substance that damages or alters the brain's function or structure), type 2 diabetes mellitus (DM – a chronic condition characterized by high blood sugar levels that occur when the body does not produce enough insulin [hormone that regulates the amount of sugar in the blood] or does not use insulin effectively), long term (current) use of anticoagulants (medications that prevent blood from clotting), chronic respiratory failure (a long-term lung condition where your body cannot get enough oxygen into the blood or get carbon dioxide out of it), and had a tracheostomy (a surgical procedure that creates an opening in the trachea (windpipe) to provide a direct airway for breathing).   A review of Resident 2’s Care plan, initiated on 8/20/2016, indicated Resident 2 with self-care deficits and the level of assistance needed in each activity of daily living (ADL – activities such as bathing, dressing, and toileting a person performs daily) is total for bed mobility, transfer, and bathing. The care plan interventions indicated to provide two or more persons to assist Resident 2 with transfer.   A review of Resident 2’s History and Physical (H&P- a doctor's comprehensive process of gathering information about a resident’s health by asking about their past medical issues and current symptoms and then performing a hands-on physical examination to check their overall body for signs of illness), dated 8/23/2025, indicated the resident’s level of consciousness was severely impaired as demonstrated by the resident’s status as awake, not oriented, not responding to yes or no questions appropriately, and was nonverbal (nonspeaking). In addition, the resident demonstrated right hemiplegia.   A review of Resident 2’s Minimum Data Set (MDS - a resident assessment tool), dated 8/7/2025, indicated Resident 2’s cognitive skills for daily decision making was severely impaired (never/rarely made decisions). Resident 2 was totally dependent (helper does all of the effort) with eating, oral hygiene, toileting, showering, upper and lower body dressing, and putting on and taking of shoes and personal hygiene.    A review of Resident 2’s Change of Condition (COC) Assessment, dated 9/27/2025 at 3:30 p.m., indicated a tear between Resident 2’s right first and second toes. CNA 1 reported at 4 p.m. that around 3:30 p.m. CNA 1 was bringing Resident 2 to the shower room and was moving the shower bed (with Resident 2 on it) through the hallway and Resident 2’s right toe hit the fire exit door handle. At 4:12 p.m. Resident 2 was assessed and was noted with a tear between his (Resident 2) right first and second toes. At 5:04 p.m. MD ordered to transfer Resident 2 to GACH 1 for wound stitching (Resident 2 was transferred to GACH 1 on 9/27/2025 at 9:57 p.m.).   A review of Resident 2’s GACH 1 Diagnostic Imaging Report, dated 9/27/2025, indicated an intra-articular avulsion fracture (a type of injury where a strong pulling force from a tendon [a fibrous connective tissue that attaches muscle to bone] or ligament [tough, fibrous bands of connective tissue in your body] tears a small piece of bone away from the main bone, and this break extends into a joint) at the base of the great toe proximal phalanx (bone of a finger or toe that is closest to the hand or foot) extending to the first metatarsophalangeal joint (the large "ball and socket" joint that connects the longest bone in your foot to the first bone of your big toe).   A review of Resident 2’s GACH 1 Patient Visit Information, dated 9/27/2025 at 9:57 p.m., indicated Resident 2 was seen for laceration and open toe fracture. Resident 2 had an open fracture underlying the laceration in the webspace of the first great toe on the right side.   During an interview on 10/7/2025 at 2:54 p.m. with CNA 1, CNA 1 stated on 9/27/2025 when he (CNA 1) was transferring Resident 2 to the shower room, Resident 2’s foot hit the fire exit door. CNA 1 stated Resident 2 was being transferred to the shower room with no assistance from other staff and that Resident 2 required two staff members for transfers. He (CNA 1) had been educated that Resident 2 needs to have two people during transfers. CNA 1 stated because he (CNA 1) transferred Resident 2 to the shower by himself (CNA 1) Resident 2 got hurt. CNA 1 stated there should be two persons when transferring Resident 2.   During an interview on 10/7/2025 at 3:36 p.m. with Registered Nurse (RN) 4, RN 4 stated on 9/27/2025 at around 4 p.m. RN 4 was notified by another nurse (name not identified) that Resident 2 had an injury during CNA 1 transferring Resident 2 from the bedroom to the shower room. RN 4 went to assess Resident 2, and he (Resident 2) had a deep wound between the first and second toes but was no longer bleeding. RN 4 notified the medical doctor (MD) who requested Resident 2 to be transferred out to the hospital for sutures. RN 4 stated CNA 1 usually likes to work on his (CNA 1) own, is very independent, and performs care to Resident 2 alone. Resident 2 requires two staff for transfers to ensure resident safety. CNA 1 should have another staff helping with transferring Resident 2 to the shower room. RN 4 stated this injury was avoidable if two staff had been transporting Resident 2.   During an interview on 10/7/2025 at 4:33 p.m. with the Director of Nursing (DON), the DON stated Resident 2 is a two-person assist for showers. CNA 1, by himself, was transferring Resident 2 . The DON stated the potential for CNA 1 transferring Resident 2 who was a two-person transfer with only CNA 1 is that during the transfer there was a risk for accidents and Resident 2 did get injured.   A review of the facility’s Policy and Procedure (P&P) titled, “Accidents and Incidents, Investigating and Reporting,” last reviewed on 4/24/2025, indicated the facility is compliant with current rules and regulations governing accidents and or incidents.   A review of the facility’s P&P titled, “Safety and Supervision of Residents,” last reviewed on 4/24/2025, indicated the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Resident supervision is a core component of the system approach to safety. The facility failed to provide an environment that was free from accidents and hazards for Resident 2 when on 9/27/2025 at 3:30 p.m. CNA 1 transferred Resident 2, who required two-person assistance due to severely impaired cognitive skills and right hemiplegia, onto the shower bed, and from Resident 2’s room to the shower room while on the shower bed, without a second staff assisting. As CNA 1 was pushing Resident 2 on the shower bed, Resident 2’s right toe made a direct impact with the door handle, causing a mechanical tear and avulsion fracture between Resident 2’s right first and second toes.   As a result, on 9/27/2025 at 9:57 p.m. Resident 2 was transferred to the GACH 1 per order from the MD for wound stitching and where Resident 2 was diagnosed with an open toe fracture and laceration. The above violations jointly, separately, or in any combination, 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.