Health inspection·April 24, 2025

42 CFR § 483.25 Quality of care (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. 22 CCR §72311. Nursing Service- General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (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 3/10/2025, the California Department of Public Health (CDPH) conducted an unannounced annual recertification survey at the facility. The facility failed to ensure: 1. Certified Nursing Assistant (CNA) 4 used a two-person assist when performing perineal care ([peri care] the washing of the genitals and anal area) and repositioning while caring for Resident 23. 2. Implement its policy and procedure (P&P) titled, “Safety and Supervision of Residents” which indicated the facility would strive to make the environment as free from accident hazards as possible. As a result, on 12/31/2024 Resident 23 fell from the bed and sustained bilateral femur fractures (broken thighbone, a serious injury, often requiring surgery and extensive rehabilitation, and is typically caused by high-impact trauma like car accidents or falls) and hypovolemic shock (a life-threatening condition that occurs when there is a significant loss of blood or fluids in the body, leading to inadequate blood circulation and oxygen delivery to organs) due to third-spacing, which required surgical intervention at a general acute care hospital (GACH) and three blood transfusions. Resident 23 was a 77 year-old female, originally admitted to the facility on 8/12/2019 and readmitted on 1/20/2025 with diagnoses including morbid obesity (a severe form of obesity characterized by an excessive amount of body fat that significantly impacts health and well-being), contracture of muscle multiple sites (a permanent or prolonged shortening of muscles, tendons, or other soft tissues that results in limited range of motion and stiffness), functional quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), neuromuscular dysfunction of the bladder (poor bladder control), dementia (a progressive state of decline in mental abilities), and anxiety (a feeling of uneasiness). A review of Resident 23’s Minimum Data Set ([MDS], a resident assessment tool), dated 12/29/2024, indicated Resident 23’s cognitive skills (ability to think and reason) for daily decision making was moderately impaired. The MDS indicated Resident 23 had an impairment on both sides of her lower extremities. The MDS indicated Resident 23 was dependent on staff for toileting hygiene, showering or bathing, upper and lower body dressing, and performing personal hygiene. The MDS indicated Resident 23 required substantial or maximal assistance for rolling to the left and right side of the bed. A review of Resident 23’s Physical Therapy Discharge Summary, dated 12/29/2022, indicated Resident 23 was assessed as “total dependence with attempts to initiate” for bed mobility. A review of Resident 23’s Fall Risk Assessment, dated 12/27/2024, indicated Resident 23 was “at risk” for falls. A review of Resident 23’s CNA Task Flowsheet, dated December 2024, indicated Resident 23 was assessed as “dependent” for the task of rolling to the left and right side of the bed, on the 7 a.m. to 3 p.m., shift, for 21 out of the 31 days in the month of December 2024. The flowsheet indicated Resident 23 was assessed as “dependent” for the task of toileting hygiene, on the 7 a.m. to 3 p.m. shift, for 24 out of the 31 days in the month of December 2024. A review of Resident 23’s Change of Condition Note, dated 12/31/2024, timed at 9:30 a.m., indicated on 12/31/2024 at 9:30 a.m., while CNA 4 was changing Resident 23, CNA 4 turned Resident 23 to the right side. Resident 23 reached and grabbed on to the call light slid off the bed and landed on her back. A review of Resident 23’s Situation, Background, Assessment, Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents), dated 12/31/2024 (untimed), indicated on 12/31/2024 at 9:30 a.m., Resident 23 fell. The SBAR indicated Registered Nurse (RN) 1 assessed Resident 23 on the floor. The SBAR indicated Resident 23’s Physician ordered a STAT (without delay) right hip and right femur x-rays (imaging that creates pictures of the inside of your body), and for Resident 23 to be transferred to a GACH. A review of Resident 23’s Physician Progress Note, dated 12/31/2024, timed at 12:42 p.m., indicated Resident 23 had a right anterior (the front or front surface of a structure or body part) thigh deformity (part of the body not having the normal or natural shape or form) with concern for a fracture. The note indicated Resident 23 complained of left hip and right leg pain. A review of Resident 23’s Radiology Results Report, dated 12/31/2024, timed at 12:53 p.m., indicated the following: 1. Left hip x-ray indicated Resident 23 sustained a displaced (occurs when a broken bone snaps into two or more pieces and the ends are no longer aligned) acute fracture to the proximal (situated nearest the center of the body) femur. 2. Left femur x-ray indicated Resident 23 sustained a displaced acute subtrochanteric (a break in the femur that occurs below the lesser trochanter, a bony prominence located at the top of the femur) fracture. 3. Right femur x-ray indicated the presence of a fracture to the mid shaft femur. A review of the GACH Internal Medicine History and Physical Note, dated 12/31/2024, timed at 9:27 p.m., indicated Resident 23’s blood pressure was 53/39 millimeters of mercury ([MM HG]- unit of measurement that describes the amount of force blood uses to get through the vessels of the body [normal range of 120–129 [top number] and 80–84 [bottom number]). The note indicated Resident 23’s oxygen saturation (the percentage of oxygen in a person's blood) was 88 percent (%) (normal range 93-100%) on room air. The note indicated Resident 23’s x-ray of the bilateral femurs and bilateral hips indicated Resident 23 sustained the following: 1. A comminuted (a fracture where a bone is broken into multiple pieces or fragments) medial angulated fracture (a fracture that results when one piece of the bone points in an inward direction) of the right femur mid shaft (a break in the middle portion of the femur) with 3.5 centimeter (cm- a unit of measurement) overlap of fracture fragments. 2. A comminuted, mildly medically displaced fracture of the left femoral proximal shaft (the upper, long part of the femur bone) with extension into the lesser trochanter (a small, bony prominence located on the inner side of the femur). A review of the GACH Operating Room Note, dated 1/2/2025, timed at 9:29 a.m., indicated Resident 23 underwent a right and left femur open reduction internal fixation surgery (a surgical procedure used to treat severe fractures or dislocations by realigning the broken bones and stabilizing them with internal hardware, such as screws, plates, or rods). A review of the facility’s Post Fall Review, dated 1/9/2025, timed at 10:30 a.m., indicated on 12/31/2024, Resident 23 suffered an “assisted fall” and slid off the bed while being changed and turned. A review of the GACH Principal Discharge Diagnosis with Brief Summary Note, dated 1/16/2025, timed at 12:50 p.m., indicated Resident 23 was admitted to the GACH on 12/31/2024 for hypovolemic shock due to blood loss and bilateral thigh hematomas (a localized collection of blood outside of blood vessels that forms due to injury or trauma) secondary to bilateral femoral fractures while receiving anticoagulation (blood thinning) medication. The GACH Note indicated Resident 23 received three units of blood. During a concurrent observation and interview on 3/10/2025 at 10:10 a.m. with Resident 23, in Resident 23’s room, Resident 23 was observed lying on her back in bed. Resident 23’s eyebrows were furrowed as the resident stated, “I just wish I could be repositioned more often.” During an interview on 3/11/2025 at 12:19 p.m., Resident 23’s family member (FM) 1 stated on 12/31/2024, Resident 23 fell and sustained a fracture to both of her femurs and right hip while CNA 4 cleaned Resident 23 in bed. During an interview on 3/11/2025 at 12:20 p.m. with Resident 23, in Resident 23’s room, Resident 23 stated on 12/31/2024, while being changed she suggested CNA 4 grab another nurse for help because she felt CNA 4 could not change her alone. Resident 23 stated CNA 4 replied “no” and proceeded to clean Resident 23. Resident 23 stated CNA 4 rolled her to her side and she (Resident 23) fell off the bed to the ground. Resident 23 stated after the fall, she suffered “excruciating pain all over” Resident 23 stated she did not recall reaching for a call light. During an interview on 3/11/2025 at 2:40 p.m., Registered Nurse (RN) 2 stated on 12/31/2024 at 9:30 a.m., CNA 4 informed her that Resident 23 fell. RN 2 stated she (RN 2) observed Resident 23 on the floor to the right side of the bed. RN 2 stated Resident 23 was able to hold onto the “grab bars” on her bed during repositioning and peri care. RN 2 stated Resident 23 had “poor core strength” when assisting with repositioning or turning in bed. RN 2 stated Resident 23 had broken her leg after seeing a large deformity to the resident’s right leg. RN 1 stated CNA 4 reported that while cleaning Resident 23, CNA 4 repositioned the resident away from her (CNA 4’s) body. RN 1 stated CNA 4 stated that Resident 23 tried to grab the call light to break her fall as the resident slipped off the air mattress. RN 1 stated CNA 4 should have had a second nurse assist with repositioning and cleaning Resident 23 to maintain safety and to prevent falls. During an interview on 3/11/2025 at 3:20 p.m., CNA 4 stated on 12/31/2024 she was the assigned CNA for Resident 23 for the 7 a.m. to 3 p.m. shift. CNA 4 stated on 12/31/2024, at approximately 9:00 a.m., she provided peri care for Resident 23 and positioned the resident on her right side in preparation for Resident 23’s wound treatment. CNA 4 stated the wound nurse was at the door and she (CNA 4) did not intend on leaving Resident 23 on her right side for a long time. CNA 4 stated Resident 23 attempted to grab “an area of the bed” to hold on to. CNA 4 stated Resident 23’s legs fell first off, the bed, and the rest of the resident’s body followed. CNA 4 stated she did not ask another nurse for help because she did not usually need help with Resident 23’s repositioning or peri care. CNA 4 stated the normal process to determine each resident’s level of performance and the number of staff needed to perform the task was to refer to the “Kardex (a type of platform (paper or electronic) that nurses use to quickly reference key patient information for care planning).” CNA 4 stated no one there was no information provided about Resident 23’s bed mobility in the Kardex. CNA 4 stated there was only information about the number of staff needed to perform a transfer for Resident 23. CNA 4 stated Resident 23’s fall may have been prevented if she asked another nurse for help before providing peri care and repositioning the resident alone. During a concurrent interview and record review on 3/11/2025 at 4:00 p.m. with Minimum Data Set Nurse (MDSN) 1, Resident 23’s MDS Section GG (an assessment that evaluates the need for assistance with self-care and mobility activities, functional limitations in range of motion, and current and prior device use), dated 12/29/2024, was reviewed. MDSN 1 stated the MDS indicated Resident 23 was dependent on staff for toileting hygiene. MDSN 1 stated Resident 23’s MDS Section GG indicated Resident 23 required substantial, maximal assistance when rolling left and right in bed. During an interview on 3/11/2025 at 4:15 p.m. the Director of Rehabilitation (DOR) stated it was best practice to have a second staff member assist in changing or repositioning a resident that was identified as "maximal assist” or “dependent” for repositioning or toileting hygiene. The DOR stated that CNA 4 could have “probably done better.” The DOR stated Resident 23 was hurt because of the fall. During an interview on 3/12/2025 at 8:06 a.m., Restorative Nurse Aide (RNA) 1 stated she was familiar with Resident 23’s bed mobility before the resident’s fall (on 12/31/2024). RNA 1 stated it was necessary to have a nurse on each side of Resident 23’s bed for repositioning or cleaning to ensure the resident’s safety and to prevent a fall. During a concurrent interview and record review on 3/12/2025 at 1:38 p.m. with Occupational Therapist (OT) 1, Resident 23’s CNA Task Flowsheet, dated 12/2024, was reviewed. OT 1 stated the CNA Task Flowsheet indicated Resident 23 was “dependent” for the task of rolling to the left and right in bed. OT 1 stated the CNA Task Flowsheet indicated “dependent” meant two or more nurses were needed for repositioning. During an interview on 3/13/2025 at 9:29 a.m., CNA 8 stated Resident 23 used an air mattress which caused residents to be unstable in bed because of the slippery texture of the mattress. CNA 8 stated Resident 23 required the assistance of two CNAs during care and repositioning to ensure safety. During a concurrent interview and record review on 3/13/2025 at 10:13 a.m. with CNA 5, Resident 23’s CNA Task Flowsheet, dated 12/2024, was reviewed. CNA 5 stated the CNA Task Flowsheet indicated Resident 23 was “dependent” for bed mobility and toileting hygiene [which meant Resident 23 required two-person assistance for safely repositioning Resident 23]. CNA 5 stated Resident 23’s trunk and core strength was unstable before the fall on 12/31/2024. CNA 5 stated she was always very cautious with Resident 23, especially because the resident utilized an air mattress that contributed to Resident 23’s bed instability. CNA 5 stated the texture of all air mattresses were very “slippery” which was why she (CNA 5) always made sure she had another nurse to assist her whenever she repositioned or provided peri care to Resident 23. CNA 5 stated she always exercised caution with Resident 23 even if Resident 23 was able to grab the “grab bars” on her bed. CNA 5 stated the use of two nurses to reposition and provide peri care for Resident 23 was best practice to ensure Resident 23’s safety, and to prevent bodily injury from a fall. During a concurrent interview and record review on 3/13/2025 at 10:26 a.m. with the (DOR), Resident 23’s Physical Therapy Discharge Summary, dated 12/29/2022, was reviewed. The DOR stated he was not made aware of any improvements or decline in mobility for Resident 23 after she had been discharged from physical therapy in 2022. The DOR stated Resident 23 was assessed as “total dependence with attempts to initiate” for bed mobility. The DOR stated Resident 23’s fall was preventable if a second nurse had assisted Resident 23 reposition in bed. During a concurrent interview and record review on 3/13