Other·March 12, 2026

§483.25(d)(1)(2) 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. §72523(a) 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 1/13/2026, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) complained of pain on 1/2/2026 and was subsequently diagnosed with a fracture (broken bone). The assessment and Change of Condition (COC) documentation regarding Resident 1's pain, was completed by a staff member but was later missing from Resident 1's clinical record. On 1/28/2026, the CDPH conducted an unannounced visit to investigate the complaint allegation. Upon investigation, it was determined that Resident 1 sustained a fracture of the right distal femur (a break in the knee) after Licensed Vocational Nurse (LVN) 1 turned and repositioned Resident 1 without assistance from staff and bumped her knee against the bed frame. The facility failed to: 1. Ensure LVN 1 assessed Resident 1's mobility limitations and took precautions before moving Resident 1, who was dependent on staff to roll from the left to the right side. 2. Ensure LVN 1 requested assistance from another staff member before repositioning Resident 1, who per the Minimum Data Set ([MDS] a resident assessment tool), was dependent on staff and does none of the effort to roll from the left side to the right or the assistance of two or more helpers was required for the Resident to complete the activity. 3. Follow its undated Policy and Procedure (P/P), titled, "Positioning & Moving Residents" that indicated before moving or lifting a resident, staff members were to assess the resident's physical abilities, mobility limitation and use maximum precautions when moving or lifting residents, as well as obtain assistance from other professionals as needed. These deficient practices resulted in LVN 1 repositioning Resident 1 without assistance and bumping Resident 1's right knee on the resident's bed frame. Resident 1 experienced pain, swelling and tenderness to the right knee, and was subsequently diagnosed with an acute (sudden-onset) right distal femur fracture. Resident 1 was transferred to a General Acute Care Hospital (GACH) where the fractured knee was immobilized (to prevent from moving), she was treated for pain and monitored for bleeding and a thromboembolism (obstruction of a blood vessel by a blood clot that has become dislodged from another site in the circulation). Resident 1, an 87-year-old female, was initially admitted to the facility on 11/16/2022 and readmitted on 1/9/2026. Resident 1's diagnoses included a closed fracture (broken bone that does not penetrate the skin) of lower end of right femur, dementia (a progressive state of decline in mental abilities), and Alzheimer's (disease characterized by a progressive decline in mental abilities). A review of Resident 1's MDS dated 11/17/2025, indicated Resident 1's cognition (the ability to think and reason) was severely impaired. The MDS indicated Resident 1 was dependent (helper does all the effort, resident did 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) on staff for rolling left to right. The MDS indicated Resident 1 had a functional limitation in range of motion ([ROM] the full, functional measurement of the distance and direction a joint can move, stretching from maximum bending to full straightening) to both of her upper (arms) and lower (legs) extremities. A review of Resident 1's Situation, Background, Assessment, Recommendation ([SBAR] a communication tool used by healthcare workers when there is a change of condition among the residents) dated 1/2/2026, and timed at 9:30 p.m., indicated during rounds LVN 1 observed Resident 1 at the edge of her bed, upon repositioning the resident, she (LVN 1) accidentally bumped Resident 1's knee against the resident's bed frame. The SBAR indicated Resident 1's knee was slightly swollen, tender to touch and Resident 1 was moaning with facial grimacing. A review of Resident 1's Physician's Orders, dated 1/2/2026, and timed at 11:50 p.m., indicated a STAT (immediate) radiology ([X-ray] a procedure that takes pictures of the inside of the body to diagnose broken bones and other injuries) to Resident 1's bilateral (both sides) hips, right femur and right knee due to pain. A review of Resident 1's X-ray Report, dated 1/3/2026 and timed at 12:01 p.m., indicated Resident 1 had a fracture of the right distal femur. A review of Resident 1's Licensed Nurses Note, dated 1/3/2026, and timed at 3:43 p.m., indicated Resident 1 was transferred to a GACH due to a fracture. A review of the GACH's Emergency Department's History of Present Illness (HPI), dated 1/3/2026, indicated Resident 1 presented to the emergency room with swelling and deformity of the right distal thigh. An X-ray indicated an acute distal femur fracture, and Resident 1 was admitted to the GACH for pain control, immobilization, an orthopedic (a medical specialist focusing on the muscles and bones) surgical evaluation, monitoring for complications including bleeding, thromboembolism (a serious medical condition where a blood clot forms in a blood vessel, breaks loose and travels through the blood stream to obstruct blood flow elsewhere, causing tissue damage) and skin breakdown. A review of the GACH's Orthopedic Consultation report, dated 1/5/2026, and timed at 9:37 a.m., regarding Resident 1's right distal (near the knee area) femur fracture, indicated Resident 1's injury was likely due to chronic malunion (a broken bone that healed in an abnormal, misaligned position) and surgery was not recommended due to Resident 1's dementia and non-ambulatory status. The report indicated Resident 1 was stable for discharge from an orthopedic standpoint. During an interview on 1/28/2026 at 4:40 p.m., Certified Nursing Assistant (CNA) 1 stated Resident 1 required a two-person assist for care. On 1/2/2026 she and CNA 2 provided care to Resident 1 during the 3 p.m. to 11 p.m., shift. CNA 1 stated sometime during the evening (time unknown), she and CNA 2 noticed Resident 1's right knee was bending weirdly. CNA 1 stated they (CNA 1 and CNA 2) informed LVN 1 of Resident 1's leg condition, LVN 1 came to Resident 1's room repositioned Resident 1 and accidentally bumped the resident's right knee on bed frame. During an interview on 1/29/2026 at 10:13 a.m., LVN 1 stated on 1/2/2026, at around 9:30 p.m., while making rounds, she found Resident 1 at the edge of the right side of her bed, with her right foot hitting the bed's footboard. LVN 1 stated she knew Resident 1 was a two-person assist but everyone was busy caring for other residents, so to prevent Resident 1 from falling she decided to reposition Resident 1 without asking for assistance. She used a draw sheet (a small, folded bed sheet or specialized fabric placed across the middle of a mattress, covering the area between a patient's upper back and thighs. Primarily used to reposition, lift, or transfer patients) to pull Resident 1 up while Resident 1's right leg was crossed over the left leg; both legs were straight. Resident 1 was centered in the middle of the bed and as she proceeded to turn Resident 1 toward the left side of the bed, Resident 1 moved her legs, and her right knee hit the bed frame on the bottom of her bed that was exposed because the mattress did not cover the bed frame completely. LVN 1 stated she noticed Resident 1 was grimacing, moaning, and she observed redness and swelling on the resident's right knee. During an interview on 1/29/2026 at 11:54 a.m., the Director of Nursing (DON) stated LVN 1 should have called for help if Resident 1 required a two-person assist. A review of the facility's undated P/P, titled, "Positioning & Moving Residents" the P/P indicated before moving or lifting a resident, staff members were to assess the resident's physical abilities, mobility limitation in joints and muscles, strength, awareness of surroundings, and ability to follow directions. Staff members will use maximum precautions when moving or lifting residents, obtain assistance from other professionals as needed. The facility failed to: 1. Ensure LVN 1 assessed Resident 1's mobility limitations and took precautions before moving Resident 1, who was dependent on staff to roll from the left to the right side. 2. Ensure LVN 1 requested assistance from another staff member before repositioning Resident 1, who per the Minimum Data Set ([MDS] a resident assessment tool), was dependent on staff and does none of the effort to roll from the left side to the right or the assistance of two or more helpers was required for the Resident to complete the activity. 3. Follow its undated P/P titled, "Positioning & Moving Residents" that indicated before moving or lifting a resident, staff members were to assess the resident's physical abilities, mobility limitation and use maximum precautions when moving or lifting residents, as well as obtain assistance from other professionals as needed. These deficient practices resulted in LVN 1 repositioning Resident 1 without assistance and bumping Resident 1's right knee on the resident's bed frame. Resident 1 experienced pain, swelling and tenderness to the right knee, and was subsequently diagnosed with an acute right distal femur fracture. Resident 1 was transferred to a GACH where the fractured knee was immobilized, she was treated for pain and monitored for bleeding and a thromboembolism. These 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 or mental harm would result for Resident 1.