Health inspection·April 23, 2026

42 C.F.R. § 483.25(d)(2) Accidents The facility must ensure that - Each resident receives adequate supervision and assistance devices to prevent accidents. 42 C.F.R. § 483.21 (b)(1) Comprehensive Care Plans The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. §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 3/6/2026, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) reporting the facility was notified by a General Acute Care Hospital (GACH) that a resident (Resident 1) sustained a bilateral (both sides) fracture (a break in the bone) of the lower leg. On 3/12/2026, the CDPH conducted an unannounced visit to the facility to investigate the FRI. Upon investigation the CDPH determined Resident 1, who required a two-person assist for transfers from a sitting to standing position and from a chair to a bed, was transferred by Certified Nursing Assistant (CNA ) 1 without assistance. The facility failed to: 1. Ensure CNA 1 requested assistance from another staff member and used a full body lift to transfer Resident 1 from a chair to her bed. 2. Implement Resident 1's Care Plan, dated 6/2/2023, that indicated to transfer Resident 1 with a full body lift using a two person assist when CNA 1 transferred Resident 1 from a chair to her bed without the help of another staff member. 3. Follow its Policy and Procedure (P/P), titled, "Falls and Fall Risk, Managing" dated 3/2018, that indicated the staff will identify interventions related to the resident's specific risks to try to prevent the resident from falling and to minimize complications from falling. As a result, Resident 1 stood up, attempted to transfer from a chair to her bed without assistance, and fell to the floor. Resident 1 was transferred to a GACH where she was diagnosed with bilateral acute distal fibular fractures (a sudden traumatic break in the lower end of the calf bone) of both ankles. Resident 1, a 62-year-old female, was initially admitted to the facility on 11/28/2019 and readmitted on 11/16/2025. Resident 1's diagnoses included diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing), morbid obesity (overweight), and extrapyramidal movement disorder ([EPS] drug induced movement causing involuntary spasms, tremors, rigidity, and restlessness). A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 3/1/2026, indicated Resident 1's cognition (the ability to think and reason) was intact. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort by lifting or holding trunk or limbs) when going from sitting to standing. A review of Resident 1's at Risk for Falls Care Plan, dated 6/2/2023, indicated Resident 1 was at risk for falls related to her diagnosis of hypotension (abnormally low blood pressure, typically below 90/60 mmHg), neuropathy (damage to the nerves outside the brain and spinal cord, often causing weakness, numbness, and pain, typically in the hands and feet), generalized weakness, obesity, a history of falls and EPS movement disorder. The Care Plan's goal indicated Resident 1 would have a reduction in the risk for falls. The intervention included safe resident handling, transfer of the resident with a full body lift using a two person assist. A review of Resident 1's Fall Risk Evaluation, dated 11/16/2025, indicated Resident 1 was at moderate risk for falls. A review of Resident 1' s Weight Summary report, dated 3/4/2026, indicated Resident 1 weighed 219 pounds ([lbs.] a unit of measurement) and was four feet 10 inches tall. The Weight Summary report indicated Resident 1's body mass index ([BMI] a quick calculation using a person's weight and height to estimate their total body fat) was 45.8. A review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 3/4/2026, and timed at 2:28 p.m., indicated at 9:38 a.m., when Resident 1 was being transferred from a chair to her bed both of her legs became weak, and she was eased to the floor. The SBAR indicated at approximately 3 p.m., Resident 1 complained of pain in both her legs and had swelling to her right ankle along with a bluish discoloration. A review of Resident 1's Physician's Orders, dated 3/4/2026, and timed at 4:24 p.m., indicated Resident 1 may be transferred to a GACH. A review of Resident 1's Transfer Form, dated 3/4/2026, and timed at 5:34 p.m., indicated Resident 1 was transferred to a GACH. A review of Resident 1's GACH Admission Record, dated 3/4/2026, indicated Resident 1 was admitted to the GACH on 3/4/2026 at 5:37 p.m. A review of Resident 1's GACH Emergency Department (ED) Note, Physician (ED) Note, dated 3/4/2026, indicated Resident 1 presented with bilateral ankle pain and stated she fell when getting out of her shower chair that morning (3/4/2026). The ED Note indicated Resident 1 had significant diffuse swelling (a generalized accumulation of fluid in body tissues that causes widespread puffiness, tight skin, and reduced movement) and ecchymosis (bruising resulting from bleeding underneath the skin) to her right ankle and her left ankle was assessed as "likely swelling." The ED Note indicated the X-ray (a procedure that takes pictures of the inside of the body to diagnose broken bones and other injuries) showed an acute distal fibular fracture of both ankles. A review of Resident 1's GACH Radiology (a medical specialty that uses imaging to diagnose and treat diseases) report, dated 3/4/2026, and timed at 6:08 p.m., indicated Resident 1 had displaced fractures (a broken bone where the pieces have moved out of their normal alignment) of the left and right distal fibula. A review of Resident 1's GACH Orthopedic Consultation note, dated 3/7/2026, and timed at 2:05 p.m., indicated Resident 1 had bilateral bimalleolar fractures (a severe, unstable ankle injury involving fractures of both the inner and outer parts of the ankle). The Orthopedic Consultation note indicated the plan was for Resident 1 to undergo an Open Reduction and Internal Fixation ([ORIF] a surgery to fix a broken bone where the surgeon makes an incision to realign the broken bone pieces into the correct position by using hardware such as screws, plates, or rods to hold the bone in place while it heals) of both ankles. A review of Resident 1's GACH Physician's Progress Note, dated 3/11/2026, and timed at 10:04 p.m., indicated the Pulmonologist (a medical doctor specialized in diagnosing and treating diseases of the respiratory system) recommended a closed reduction (a non-surgical orthopedic procedure used to realign a fractured or dislocated bone to its natural position without making an incision) for Resident 1's ankle fractures instead of surgery because it was safer. The Physician's Progress Note indicated on 3/5/2026 Resident 1 had two doses of morphine and a rapid response team (specialized healthcare professionals called to a hospital patient's bedside when they show early signs of decline to provide immediate critical care to prevent heart attack or respiratory failure) was called to place Resident 1 on a Bilevel Positive Airway Pressure ([BiPAP] a noninvasive ventilator used to assist breathing by delivering pressurized air through a mask) machine due to her labored breathing and was administered one ampule of Narcan (a medication used to reverse opioid overdoses. The Physician's Progress Note indicated Resident 1 would likely run into problems postoperatively such as difficult extubating (removing a breathing tube from a patient's airway, signaling the end of mechanical ventilation) and respiratory acidosis (a condition occurring when the lungs cannot remove enough carbon dioxide [a colorless odorless, non-flammable gas) due to the use of narcotics. A review of Resident 1's GACH Progress Note Physician (Physician's Note), dated 3/10/2026, indicated the Pulmonologist ordered Boniva (a prescription bisphosphonate medication used to treat or prevent osteoporosis in women after menopause by strengthening bones and reducing fracture risk), vitamin D2 (a supplement essential for calcium absorption, bone health, and treating deficiencies), and Calcium (a supplement for bone health, muscle function, and nerve transmission) to treat osteopenia (a condition where bones have low bone density, a measurement of the amount of calcium and other minerals packed into a segment of bone, indicating its strength and durability). Also, bilateral casts on her ankles. During a concurrent interview on 3/12/2026 at 4:11 p.m., with the MDS Specialist and a review of Resident 1's at risk for falls Care Plan, dated 6/2/2023, the MDS Specialist stated despite the Care Plan's initiation date of 6/2/2023 the care plan was current and accurately indicated Resident 1 required a two-person assist when transferring from a chair due to her obesity and having poor strength in her lower extremities. During an interview on 3/13/2026, at 10:19 a.m., Licensed Vocational Nurse (LVN) 1 stated on 3/4/2026 at approximately 9:30 a.m., she was informed by CNA 1 that Resident 1 fell when transferred from a shower chair to her bed. LVN 1 stated she assessed Resident 1 and at the time of her fall Resident 1 was without pain or swelling. At approximately 2 p.m., CNA 1 reported to her that Resident 1 had pain and swelling to her right leg. LVN 1 stated she was not aware of Resident 1's Care Plan, but Resident 1 likely required a two-person assist with transfers due to her obesity and muscle weakness. During an interview on 3/13/2026, at 11:27 a.m., CNA 1 stated on 3/4/2026 in the morning (exact time unknown) after showering Resident 1, she brought her back to her room on a shower chair. Resident 1 stood up using a walker, she was next to her bed, and she held onto the bed's side rail. CNA 1 stated Resident 1 would normally pivot (a technique used to move a patient with limited mobility between two surfaces by having them stand or partially stand, rotate on one or both feet, and sit down) in order to get onto her bed, but that day, Resident 1 screamed for help and stated her legs felt weak. CNA 1 stated she got behind Resident 1, yelled for help, and eased Resident 1 onto the floor and the resident landed on her bottom with her knees and feet bent. CNA 1 stated she worked with Resident 1 for four years and usually assisted Resident 1 during transfers alone without assistance because Resident 1 was able to help by walking on most days. CNA 1 stated prior to Resident 1 transferring she would ask her how she felt to determine if she was able to stand or not. If Resident 1 felt tired, she (CNA 1) would ask for assistance transferring Resident 1. CNA 1 stated she was not aware Resident 1's Care Plan indicated she required a two-person assist with transfers using a full body lift. During an interview on 3/13/2026, at 3 p.m., the Director of Nursing (DON) stated CNA 1 should have asked for assistance when she transferred Resident 1 from the shower chair to her bed on 3/4/2026. The DON stated the licensed nurses should have communicated Resident 1's need for a two person assist during transfers to prevent Resident 1 from falling. A review of facility's P/P titled "Falls and Fall Risk, Managing," revised 3/2018, indicated "based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks to try to prevent the resident from falling and try to minimize complications from falling. Risk factors include conditions such as lower extremity weakness and functional impairments, and medical conditions such as neurological disorders, and balance/gait disorders. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls." The facility failed to: 1. Ensure CNA 1 requested assistance from another staff member and used a full body lift to transfer Resident 1 from a chair to her bed. 2. Implement Resident 1's Care Plan, dated 6/2/2023, that indicated to transfer Resident 1 with a full body lift using a two person assist when CNA 1 transferred Resident 1 from a chair to her bed without the help of another staff member. 3. Follow its P/P titled, "Falls and Fall Risk, Managing" dated 3/2018, that indicated the staff will identify interventions related to the resident's specific risks to try to prevent the resident from falling and to minimize complications from falling. As a result, Resident 1 stood up, attempted to transfer from a chair to her bed without assistance, and fell to the floor. Resident 1 was transferred to a GACH where she was diagnosed with bilateral acute distal fibular fractures of both ankles. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security and welfare of Resident 1.