Health inspection·March 25, 2025

F689 Title 42 Code of Federal Regulations §483.25(d) Accidents. The facility must ensure that – (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. Title 22 Code of California Regulations §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. Title 22 Code of California Regulations §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 2/6/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility-reported incident (FRI) regarding a resident fracture (broken bone). The facility failed to ensure Resident 3, who was assessed as high risk for falls, had intermittent (not happening regularly or continuously) confusion, was dependent upon staff for all forms of transfers, and required two-person staff assistance at all times was free from falls and injury in accordance with Resident 3's care plan (a document that outlines the specific healthcare and support needs of a resident, along with strategies and interventions to address those needs), by failing to: 1. Provide Resident 3 with the required two-person staff assistance for the use of a mechanical lift (a device used to assist with transfers of residents who require support for mobility) when on 1/24/2025, at 9:30 a.m., Certified Nursing Assistant (CNA) 1 transferred Resident 3, by himself, from the wheelchair to the shower bench. 2. Ensure CNA 1 did not move Resident 3 after the witnessed fall, from the shower room floor to the wheelchair before a registered nurse (RN) had assessed Resident 3 for injuries. As a result, on 1/24/2025 at 9:30 a.m., Resident 3 fell from the wheelchair and hit her (Resident 3) right knee on the shower bench. Resident 3 sustained a mild displaced avulsion fracture (when a small piece of bone attached to a tendon [a strong, flexible cord of strong fibrous tissue attaching a muscle to the bone] or ligament [a band of tough tissue that connects two bones or holds together a joint] gets pulled away from the main part of the bone) that involved the tibial tuberosity (the top of the tibia [shinbone] where the patellar [kneecap] tendon connects). Resident 3 was given pain medication and was transferred to General Acute Care Hospital (GACH) 1 on 1/25/2025 for further evaluation and treatment. A record review of Resident 3's Admission Record indicated the facility admitted Resident 3, a 97-year-old female, on 2/9/2020, with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and age-related osteoporosis (a disease that causes bones to become weak and brittle, making them more likely to break) without current pathological fracture (a broken bone in an area weakened by another disease, not by an injury). A record review of Resident 3's Physician Order, dated 6/14/2024, indicated Resident 3 may use a mechanical device (mechanical lift) for transfers. A record review of Resident 3's Fall Risk Assessment, dated 11/19/2024, indicated Resident 3 had a total score of 16 (a total score of above ten represents a high risk for falls). A record review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 11/20/2024, indicated Resident 3's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were moderately impaired. The MDS indicated Resident 3 had a functional limitation in range of motion (ROM - extent of movement of a joint) on both sides of the upper extremity (shoulder, elbow, wrist, and hand) and the lower extremity (hip, knee, ankle, and foot). The MDS indicated Resident 3 was completely dependent (resident does none of the effort to complete the activity or the assistance of two or more helpers [staff] were required for the resident to complete the activity) on facility staff with mobility (movement) such as sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or the side of the bed), chair or bed-to-chair transfer (the ability to transfer to and from bed or chair to a chair or wheelchair), toilet transfers, and shower transfers. A record review of Resident 3's Physician Order, dated 12/6/2024, indicated Tylenol (a brand name for acetaminophen [medication used to relieve mild to moderate pain]) 325 milligrams (mg - unit of measurement) two tablets every four hours as needed for mild pain or general discomfort. A record review of Resident 3's Activities of Daily Living (ADLs - refers to everyday tasks that individuals need to care for our bodies and maintain overall well-being) Hygiene Task section, dated 1/24/2025, indicated Resident 3 was provided a shower on 1/24/2025. A record review of Resident 3's ADL Transfer Task section, dated 1/24/2025, indicated Resident 3 was dependent on facility staff for shower transfers. The ADL Transfer Task indicated there was no mechanical device used in Resident 3's transfers on 1/24/2025. A record review of Resident 3's Registered Nurse (RN) / Licensed Vocational Nurse (LVN) Progress Notes, dated 1/24/2025, indicated that on 1/24/2025 at 9:30 a.m., CNA 1 (with no assistance from any other facility staff) was inside the shower room with Resident 3, when Resident 3 became agitated and pushed CNA 1 during transfer of Resident 3 from the wheelchair to the shower bench. The RN/LVN Progress Notes further indicated Resident 3's knee (side not specified in the progress notes) hit the shower bench and swelling was observed. The RN/LVN Progress Notes indicated Resident 3 received Tylenol for facial grimacing (a distorted, pained facial expression). The RN/LVN Progress Notes indicated on 1/24/2025, at 6:30 p.m., Resident 3's right lower leg had skin discoloration (a change in the skin's natural skin tone), swelling, and a nine out of ten pain (a numeric scale used to describe the pain with zero as no pain and ten as the worst pain). The RN/LVN Progress Notes indicated Resident 3's physician was notified and ordered for stat (immediately and without delay) X-ray (a medical imaging procedure that captures images of the structures inside the body). A record review of Resident 3's Physician Order, dated 1/24/2025, indicated stat X-ray of the right tibia and fibula (the two bones in the lower leg), two views due to right leg pain. A record review of Resident 3's X-ray results of the right tibia and fibula, dated 1/24/2025, indicated Resident 3 had acute (recent onset) oblique coronal fracture (an angled break in a bone that occurs on a plane that cuts across the bone like a slice) through the base of the tibial tuberosity with approximately 7.8 millimeter (mm - unit of measurement) diastases (an abnormal separation of parts normally joined together). The X-ray indicated Resident 3 had joint subluxation (a partial dislocation of a joint). A record review of Resident 3's X-ray results, dated 1/24/2025, indicated Resident 3 had acute to subacute (rather recent onset or rapid change) mild displaced avulsion fracture involving the tibial tuberosity. A record review of Resident 3's Physician Order, dated 1/24/2025, indicated to transfer Resident 3 to GACH 1 for further evaluation. A record review of Resident 3's Interdisciplinary Team (IDT, a team of healthcare professionals from different professional disciplines who work together to address and manage the needs of the resident) Care Conference Review, dated 1/24/2025, indicated that on 1/24/2025, during the shower transfer, Resident 3 became agitated, pushed CNA 1, and her (Resident 3’s) right knee hit the shower bench that resulted to Resident 3's right knee swelling. The IDT Care Conference Review indicated an ice pack was placed on Resident 3's right knee for 15 minutes every six hours and Resident 3 was given Tylenol for facial grimacing. The IDT Care Conference Review indicated on 1/24/2025, at 6:30 p.m., Resident 3 had skin discoloration and swelling on the right lower leg. Resident 3 had an X-ray of the right tibia and fibula done. Resident 3 had nine out of ten on the pain scale when Resident 3's right leg was moved. Resident 3's physician was notified and ordered to send Resident 3 to GACH 1 for further evaluation and treatment. During an interview on 2/7/2025 at 10:19 a.m., CNA 1 stated that on 1/24/2025, at around 9:30 a.m., Resident 3 had an aggressive behavior. CNA 1 stated Resident 3 required two-person staff assistance with transfers. CNA 1 stated on 1/24/2025 between 9 a.m. to 10 a.m., he (CNA 1) transferred Resident 3 from the resident's bed to the resident's wheelchair without the use of a mechanical device for transfers. CNA 1 stated he (CNA 1) brought Resident 3 to the shower room utilizing a wheelchair. CNA 1 stated he (CNA 1) stood in front of Resident 3, locked the wheelchair wheels and placed his (CNA 1) arms under Resident 3's arms to transfer Resident 3 from the wheelchair to the shower bench. CNA 1 stated Resident 3 became agitated and pushed CNA 1. CNA 1 stated he (CNA 1) lost grip on Resident 3. Resident 3's right knee hit the shower bench before Resident 3's right knee landed on the floor. CNA 1 stated he sat Resident 3 on the shower room floor. CNA 1 stated he assisted Resident 3 back to the wheelchair without the use of a mechanical device for transfer and before a licensed nurse had assessed Resident 3. CNA 1 stated he brought Resident 3 (resident was on a wheelchair) to the nurse station and informed Licensed Vocational Nurse (LVN) 4 and RN 1 about Resident 3's fall inside the shower room. CNA 1 stated if there were two staff that assisted Resident 3 on transfers, the fall would have been prevented. CNA 1 stated Resident 3 had the potential for more injury because Resident 3 was moved before RN 1 assessed Resident 3. During a concurrent interview and record review on 2/7/2025, at 11:22 a.m., with LVN 4, Resident 3's care plan on Functional Abilities of Everyday Activities dated 12/22/2023, was reviewed. The care plan on Functional Abilities of Everyday Activities, dated 12/22/2023, indicated a goal for the resident to be transferred safely as evidenced by no fall through the target date of 3/4/2025. The care plan intervention indicated to transfer Resident 3 in and out of bed or wheelchair daily as needed using a mechanical lift and provide two-person physical assist. The care plan intervention indicated Resident 3 required two-person physical assist as needed when bathing or showering. LVN 4 stated Resident 3's care plan was not followed and resulted in Resident 3's fall with injury on 1/24/2025. LVN 4 stated on 1/24/2025, after the fall incident, Resident 3 was observed with facial grimace. LVN 4 stated she (LVN 4) gave Resident 3 Tylenol 325 mg two tablets for pain. During a concurrent interview and record review on 2/7/2025, at 12:25 p.m., with the Director of Nursing (DON), Resident 3's care plan on Functional Abilities of Everyday Activities dated 12/22/2023 was reviewed. The DON stated Resident 3 had a fall on 1/24/2025 and sustained a right leg fracture (break or crack in the bone). The DON stated Resident 3 should have been assisted by two facility staff during transfers and mobility as required in Resident 3's care plan. The DON stated CNA 1 should have not moved Resident 3 before RN 1 and the Physical Therapist (a health professional trained to evaluate and treat residents who have conditions or injuries that limit their ability to move and do physical activities) assessed Resident 3 for injuries. The DON stated moving Resident 3 before RN 1's assessment had the potential to cause more injury. The DON stated Resident 3's care plan was not followed and resulted to Resident 3's fracture. The DON stated the facility failed to follow the fall prevention interventions, Resident 3's care plan interventions, and Resident 3's physician order dated 6/14/2024 to use a mechanical device (mechanical lift) for transfers. During a concurrent interview and record review on 2/7/2025, at 1:56 p.m., with LVN 4, Resident 3's RN/LVN Progress Notes, IDT Care Conference Review, and care plans from 1/1/2025 to 1/23/2025 were reviewed. LVN 4 stated there was no documented evidence found regarding Resident 3's agitation (a condition in which a person is unable to relax and be still) and aggressive (actions or conduct that are intended to cause harm, intimidate others) behavior in Resident 3's RN/LVN Progress Notes, IDT Care Conference Review, and care plans. During a follow up interview on 2/7/2025, at 2:19 p.m., the DON stated Resident 3's agitated and aggressive behavior should be documented for every occurrence and a plan of care should have been created to address Resident 3's aggression and agitation. The DON stated Resident 3's behaviors that were not communicated to Resident 3's care givers had the potential to affect the care provided for Resident 3. A record review of the current facility-provided policy and procedure (PnP) titled, "Fall Management Program," last reviewed on 1/27/2025, indicated the facility will provide the highest quality in the safest environment for the residents residing in the facility. The PnP indicated upon completion of the resident care assessment upon admission, quarterly, with significant change in condition, and as needed, MDS nurse will assess how many persons are needed to assist each resident. The PnP indicated that based on the information gathered from the history and assessment of the resident, the nursing staff ... will identify and implement interventions to reduce the risk of falls. A record review of the current facility-provided PnP titled, "Care Planning," last reviewed on 1/27/2025, indicated the purpose to ensure a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs. The PnP indicated each resident's comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial (relating to the interrelation of social factors and individual thought and behavior) well-being. A record review of the current facility-provided PnP titled, "Transfer of Residents," last reviewed on 1/27/2025, indicated the purpose to provide the form of transfer best suited to each resident's needs and to maintain resident safety during the procedure. The PnP indicated a licensed nurse, or the Director of Rehabilitation services is to assess and determine lifting and transfer requirements, and the procedure used for each resident. The procedure is recorded in the resident's care plan. The PnP indicated residents must be lifted or transferred according to the determined procedure. A record review of the current facility-provided PnP titled, "Response to Falls," last reviewed on 1/27/2025, indicated upon witnessing a fall or finding a resident in a position indicating a fall, staff are to stay with the resident and send another staff member to notify a licensed nurse if the first responder is not a licensed personnel. The PnP indicated to not move the resident until after an assessment has been completed. The PnP indicated to call for assistance. The facility failed to ensure Resident 3, who was assessed as high risk for falls, had intermittent confusion, was dependent upon staff for all forms of transfers, and required two-person staff assistance at all times was free from falls and injury in accordance with Resident 3's care plan, along with its own PnPs, by failing to: 1. Provide Resident 3 with the required two-person staff assistance for the use of a mechanical lift when on 1/24/2025, at 9:30 a.m., CNA 1 transferred Resident 3, by himse