Health inspection·April 4, 2025

42 CFR §483.25(d) Accidents. The facility must ensure that - CFR §483.25(d) (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. CFR §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71. (a) Sufficient Staff. (1) The facility must provide services by enough of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. (3) The facility must ensure that licensed nurses have the specific competencies, and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. (4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. CFR §483.35(c) Proficiency of Nurse Aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. 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: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 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 2/21/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate the facility reported incident (FRI) received on 2/10/2025, regarding a staff reported resident accident. The facility failed to: 1. Ensure that Resident 1 remained as free of accident hazards as is possible when a certified nursing assistant (CNA) improperly turned and repositioned Resident 1, who had a high risk of fracture due to osteoporosis and who required repositioning prior to turning due to atypical resting arm posture. 2. Ensure CNA 1 followed Resident 1's untitled Care Plan dated 10/2/2023, which indicated Resident 1 required two-person assistance with turning and repositioning, and did not turn the resident without second person's assistance. 3. Ensure that sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety, when a second CNA was not available to assist with the turn of Resident 1. As a result of the improper turning technique, Resident 1's body weight was applied to her left forearm resulting in an excessive application of force to the bone, and she sustained an acute (sudden onset) fracture (broken bone) of the distal (situated away from the center of the body or from the point of attachment) shaft (part of arm) of the left forearm (lower part of the arm) and was admitted to a general acute care hospital (GACH) on 2/28/2025 for observation. The GACH applied a splint (padded material that is used to secure the injury) to Resident 1's left arm. A review of Resident 1's Admission Record, indicated Resident 1, a 79-year-old-female, was admitted to the facility on 12/26/2022 and readmitted 2/13/2025 with diagnoses including anoxic (lack of oxygen causing tissue death) brain damage, dysphagia (difficulty swallowing), encounter for attention to gastrostomy tube ([GT) a soft tube surgically inserted through the abdomen wall [belly] into the stomach to provide nutrition and medication) age-related osteoporosis (bones become brittle and fragile), and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of muscles. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/6/2024, indicated Resident 1 was rarely or never understood. The MDS indicated Resident 1 had functional limitations (ways that your disability affects your life ) in range of motion (ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point), the extent or limit to which a part of the body can be moved around a joint or a fixed point) and had impairments on bilateral (both) upper extremities (arms) and lower extremities (legs) that interfered with functions of daily living or placed Resident 1 at risk for injury. The MDS indicated Resident 1 was totally dependent on staff in rolling from left to right (the ability to roll from laying on back to left side and right side and return to lying on back on the bed). A review of Resident 1's untitled Care Plan initiated on 10/2/2023, indicated Resident 1 required two-person assistance with turning and repositioning, due to impaired mobility, and was totally dependent on staff for bed mobility (the ability to move around in bed, including rolling, sitting up, and scooting). A review of Resident 1's Alert Charting (Succeeding Documents for Change of Condition [COC] and Skilled Documentation about an event that has occurred with a resident) dated 2/8/2025 indicated restorative nursing assistant ([RNA] a certified nursing assistants that have additional training in specific therapeutic techniques) 1 alerted licensed vocational nurse (LVN) 1 of a potential incident with Resident 1 and CNA 1. The Alert Charting document indicated CNA 1 informed LVN 1 he was working with Resident 1 to change her bed sheets and in the process of turning Resident 1 to her left side, CNA 1 heard a "discomforting", unnatural sound (indicating something was wrong) from what sounded like the left wrist or arm, so CNA 1 asked RNA 1 to get LVN 1. The Alert Charting document indicated Resident 1's physician (MD 1) was notified and ordered a STAT (urgent) Xray (a photographic or digital image of the internal composition of something, especially a part of the body) of the left hand and left forearm. Resident 1 left the facility with emergency services (911) on 2/8/2025 at 3:54 p.m. to the GACH. A review of Resident 1's Radiology (the medical specialty that uses medical imaging to diagnose diseases and guide treatment within the body) Results Report dated 2/8/2025, indicated an Xray taken on 2/8/2025 of the left forearm indicated Resident 1 had an acute fracture of the distal shaft of the left forearm. A review of Resident 1's Order Summary Report (the physician's orders) indicated a physician's order dated 2/8/2025 for a STAT Xray of the resident's left hand and left forearm and to transfer the resident to the GACH via 911 for further evaluation and treatment due to acute fracture of the distal forearm. A review of Resident 1's GACH's Emergency Department (ED) Note dated 2/8/2025, indicated Resident 1 was brought to the ED via 911 for evaluation of a left forearm fracture. The ED Note indicated Resident 1 sustained a left forearm fracture while the resident was being moved in bed at the facility. The ED Note indicated Resident 1 had contractures (a stiffening/shortening at any joint that reduces the joint's range of motion) on all four limbs, left arm deformity and was positive for trauma on the left forearm. The ED Note indicated a left arm splint was applied, and Resident 1 was admitted to the GACH for observation. A review of Resident 1's untitled Care Plan initiated on 2/14/2025, indicated Resident 1 had a fracture of the left forearm with a soft splint. The Care Plan indicated Resident 1 was at risk for pain and skin breakdown. The Care Plan goals for Resident 1 included monitoring (frequency not defined) Resident 1 for pain and ensure the resident would not have any adverse effects (an undesired effect) from the left forearm fracture. The Care Plan Interventions for Resident 1 included two-person assistance for all activities of daily living ([ADL] the everyday tasks that people perform to care for themselves) care, cradling (to support protectively) Resident 1's left arm while providing ADL care and repositioning to keep the left arm in alignment (how the head, shoulders, spine, hips, knees and ankles relate and line up with each other) with the left side of the body, turning Resident 1 to the right side and back only, and gentle handling of Resident 1 during ADL care. A review of the Order Summary Report dated 2/17/2025, indicated an order dated 2/17/2025 for Norco (pain management) tablet 5-325 (strength) milligrams (mg)one tablet via GT every eight hours for pain management for 14 days. During an interview on 2/21/2025 at 12:13 p.m., CNA 1 stated on 2/8/2025 he was going to change Resident 1's soiled adult incontinence (no voluntary control of urination and bowel movements) briefs (disposable, absorbent underwear that helps with urinary or bowel incontinence). CNA 1 stated it was around 9 a.m., and "all the other CNAs were busy with other residents' morning care." CNA 1 stated RNA 1 was putting splints on other residents (unknown), and LVN 1 was busy passing medication. CNA 1 stated there was no one available to help him turn Resident 1. CNA 1 stated Resident 1 required a two-person assistance, but he could not get anyone to help him to turn Resident 1, so he felt "confident" he could turn the resident alone, and he did it. CNA 1 stated Resident 1 resided in the subacute unit and needed two-person assistance when turning due to the resident "being stiff," Resident 1's inability to help with turning, presence of medical devices including GT and tracheostomy [surgically created opening in the trachea [windpipe]) and having contractures. CNA 1 stated that the subacute unit was very busy with residents' care due to the complexity of the sub-acute residents, and he was instructed to call a licensed nurse for help if a CNA could not assist him, "but the LVNs were busy as well." CNA 1 stated this was not the first time he was unable to obtain help to turn Resident 1. CNA 1 stated on 2/8/2025 when he was changing Resident 1, he was standing on the right side of Resident 1's bed and he put one of his hands behind resident 1's right shoulder and one hand behind Resident 1's right knee and began to turn her to the left side when he heard a loud cracking sound. CNA 1 stated he did not know where the cracking sound came from, so he "pulled her" onto her back carefully. CNA 1 stated Resident 1 had a deformity (contracture) in her left wrist that caused her left land to point outward away from her body and after the loud cracking noise, CNA 1 stated he noticed the resident's left hand and wrist appeared "more open and looser" than normal, "meaning the arm was able to move a little more towards the body when it usually could not." CNA 1 stated "RNA 1 just happened to enter the room at that time" and he asked her to call LVN 1 for help. CNA 1 stated when repositioning Resident 1 with two-person assistance "you were able to see where the resident's limbs were including the contracted left hand and wrist from both sides of the bed to ensure you knew where the arm was always." CNA 1 stated staff were able to turn and reposition Resident 1 more carefully using two-person assistance. During an interview on 2/21/2025 at 1:07 p.m., RNA 1 stated on 2/8/2025 CNA 1 asked her to call LVN 1 for help, so she did. RNA 1 stated CNA 1 told her (RNA 1) he heard a "pop." RNA 1 stated Resident 1 was "very stiff," and staff had to take extra precautions when working with the resident because the stiffness made it hard to move and reposition Resident 1. RNA 1 stated it was "kind of scary" to move the resident's limbs around due to the severity of stiffness Resident 1 had, and staff had to be extra gentle and take precautions when moving her around. RNA 1 stated Resident 1 was supposed to be on a two-person assistance because she was very fragile, so they needed two-people to turn her safely. RNA 1 stated CNA 1 was a "big guy," and he may have assumed he could turn the resident by himself without any assistance because Resident 1 was a small lady. RNA 1 stated it gets "kind of hard" because there was usually three CNAs on the subacute unit during the day shift (7 a.m. to 3 p.m.) and if two were helping each other, she does not know who was helping the third CNA. During an interview on 2/21/2025 at 1:45 p.m., MD 1 stated facility staff had to take precautions with this resident population and be careful with the residents because they do not respond appropriately to pain due to anoxic brain damage so staff could not tell if the resident was in pain. MD 1 stated there was an increased risk for fracture in residents with brittle (break or shatter easily) bones, so facility staff had to handle these residents gently, turn the residents carefully, and not rush care. During an observation and concurrent interview in Resident 1's room on 2/21/2025 at 2:16 p.m., with LVN 2, LVN 2 uncovered Resident 1's left arm while Resident 1 was in bed. Resident 1 had a splint on her left forearm. LVN 2 stated the facility staff could not tell if Resident 1 was in pain, so they were giving her around the clock (regularly scheduled) Norco at this time for pain from the fracture. LVN 2 stated Resident 1's left hand and wrist were contracted causing the left hand to point outwards. During an interview on 2/21/2025 at 2:18 p.m., CNA 2 stated staff usually need two-person assistance for the residents on the subacute unit due to their "health status but sometimes everyone was busy, so you must keep going to get your work done and do the work alone." During an interview on 2/21/2025 at 2:26 p.m., the director of rehabilitation ([DOR] a medical specialty that helps people regain abilities lost due to injury, disease, or surgery) stated she reviewed Resident 1's rehabilitative services Discharge (DC) Summary from June 2023 and the DC Summary indicated Resident 1 was totally dependent on staff for bed mobility. The DOR stated total dependence meant the resident could not help with the activity at all and often the resident would be two-person assist. The DOR stated due to Resident 1's stiffness and posturing (involuntary and abnormal positioning of the body due to preserved motor reflexes) it can be harder to turn her. The DOR stated Resident 1's left arm at the shoulder was internally rotated (causes the associated limb to rotate internally or toward the body) which caused the left hand and wrist to point out away from the body, so "you had to adjust the arm and help it become midline prior to turning." During an interview on 2/21/2025 at 2:52 p.m., the director of staff development (DSD) stated if the resident was assessed as a two-person assistance on the care plan, there should be a two-person assistance for resident safety. The DSD stated most subacute residents should be a two-person assistance "they do not want medical devices getting dislodged, or they have contractures, so they do not want any injuries." During an interview on 2/21/2025 at 3:26 p.m., the director of nursing (DON) stated Resident 1 stated had osteoporosis and needed to be handled gently. The DON reviewed Resident 1's care plans and stated Resident 1 had a Care Plan to prevent skin issues that indicated Resident 1 was a two-person assist. The DON stated if the care plan indicated Resident 1 was a two-person assistance for turning and repositioning, she should have had two people assisting her to turn and reposition. A review of the facility's policy and procedure (P/P) titled "Turning a Resident on His/ Her Side Away from You", dated 10/2