Health inspection·July 11, 2025

Code of Federal Regulations, Title 42, Section 483.25 Quality of Care. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices, including but not limited to the following: Code of Federal Regulations, Title 42, Section 483.25 (d) Accidents. The facility must ensure that – (d)(1) The patient environment remains as free of accident hazards as is possible; and (d)(2) Each patient receives adequate supervision and assistance devices to prevent accidents. California Code of Regulations, Title 22, Section 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. California Code of Regulations, Title 22, Section 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 5/28/2025, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to the facility to investigate a complaint regarding quality of care and treatment. The facility failed to ensure Certified Nursing Assistant (CNA) 4 provided two-person physical assistance (help from two persons), in accordance with the facility's policy and procedure (P&P), when CNA 4 attempted to transfer Resident 1 from Resident 1's bed to the shower gurney using the Hoyer lift (mechanical lift - a device used by staff to lift and transfer residents from bed to a chair or one location to another). As a result, on 5/26/2025 at 9:45 am, Resident 1 fell to the floor from the Hoyer lift. Resident 1's back of head and neck hit the floor and Resident 1's right lower leg was pinned (trapped) between the shower gurney and Hoyer lift. Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 5/26/2025 at 12:14 pm for further evaluation and was monitored for a closed head injury (any injury to the head that does not break through the skull), right lower leg swelling, and blunt trauma to the neck. A review of Resident 1's Admission Record (AR) indicated the facility admitted Resident 1, a 67-year-old male, on 9/11/2020, and readmitted Resident 1 on 12/28/2024, with diagnoses that included morbid obesity and acute respiratory failure with hypoxia. A review of Resident 1's Care Plan (CP) titled, "Care Plan Report," revised 3/27/2023, indicated Resident 1 had activities of daily living (ADLs)/self-care deficit due to requiring assistance with ADLs. The CP interventions included for staff to provide Resident 1 a safe environment and follow bed mobility /ADL standard of care. A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/12/2025, indicated Resident 1 had intact cognition. The MDS indicated Resident 1 was dependent on staff for toileting hygiene, showering/bathing self, chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers. A review of Resident 1's Change of Condition/Interact Assessment Form (COC form) dated 5/26/2025, timed at 9:45 am, indicated on 5/26/2025 at 9:45 am, Resident 1 had an "assisted fall due to weight shifted onto one side of the Hoyer lift." The COC form indicated CNA 4 called out for help from Resident 1's room and when Licensed Vocational Nurse (LVN) 2 arrived, Resident 1 was noted to be in the sling while the sling was still attached to the Hoyer lift, and the Hoyer lift was tilted on its right side. The COC form indicated the top of the Hoyer lift was caught by the shower gurney, and CNA 4's left arm was wedged between Resident 1 and the shower gurney "in assist to the fall." The COC form indicated Resident 1's (right) leg was noted to be caught between the sides of the shower gurney. The COC form indicated Resident 1 had pain (pain level unrated) to his right lower leg, bruising to his right lower leg and right finger (location unspecified), and a lump on the back right side of his head. The COC form indicated Nurse Practitioner (NP) 1 was notified and ordered to transfer Resident 1 to GACH 1 for further evaluation. A review of Resident 1's Order from NP 1, dated 5/26/2025, timed at 11:18 am, indicated to transfer Resident 1 to GACH 1 Emergency Room (ER) for a Computed Tomography (CT- medical imaging technique used to obtain detailed internal images of the body) Scan of Resident 1's head due to status post (S/P, after) fall. A review of Resident 1's GACH 1 Emergency Department Note Physician (EDNP) dated 5/26/2025 at 12:14 pm, indicated Resident 1 presented to GACH 1 for a mechanical fall at the skilled nursing facility (SNF). The EDNP indicated the SNF staff was attempting to lift Resident 1 with a Hoyer lift, but Resident 1 fell causing Resident 1 to strike the back of his head on the bed and hit his right shin against the bed. The EDNP indicated given Resident 1 being on blood thinners (medications that help prevent blood clots from forming), a comprehensive (a large scope; covering completely or broadly) workup was initiated for evaluation of possible brain bleed, fractures, spinal injury, dislocation, and neurovascular injury. The EDNP indicated Resident 1 was to be admitted to GACH 1's Trauma Intensive Care Unit (TICU- specialized unit within a hospital that provides critical care to patients with severe trauma injuries, requiring advanced monitoring) and started on Keppra (a medication used to treat certain types of seizures through intravenous (IV- soft, flexible tube inserted into a vein) drip (medical technique used to administer fluids, medication, or nutrients directly to the bloodstream)). A review of Resident 1's head CT Scan Report (CT Report), dated 5/26/2025, timed at 5:32 pm, indicated there was no evidence of subarachnoid hemorrhage (SAH- serious condition where bleeding occurs in the space between the brain and the tissue covering it). A review of Resident 1's GACH 1 EDNP Addendum dated 5/26/2025, timed at 6:44 pm, indicated Resident 1 was cleared for discharge and was discharged in stable condition. During an interview on 5/29/2025 at 11:09 am, Resident 1 stated Resident 1's fall (on 5/26/2025) was a very traumatic experience. Resident 1 stated CNA 4 prepped Resident 1 and put Resident 1 in the Hoyer lift. Resident 1 stated only CNA 4 was helping Resident 1 with the Hoyer lift the day of Resident 1's fall (5/26/2025). Resident 1 stated there were normally two staff assisting Resident 1 with the Hoyer lift, but it was just CNA 4 that day (5/26/2025). Resident 1 stated CNA 4 told Resident 1 that CNA 4 was busy because they (the facility) were short-staffed. Resident 1 stated CNA 4 suspended (hanging or being held in the air) Resident 1 in a lying position using the Hoyer lift. Resident 1 stated, "All of a sudden, I felt myself falling and then I hit my head on something close to the floor." Resident 1 stated "It felt metal, like maybe the foot of the bed." Resident 1 stated, "My right knee was wedged between the Hoyer lift and the shower gurney, and it (right knee) was very painful." Resident 1 stated it was a very slow process to get help into Resident 1's room, and it was, "painful and frustrating." Resident 1 stated, "The whole experience made me feel overwhelmed because I couldn't believe it (the fall) happened." Resident 1 stated, "Usually once I'm in the (Hoyer) lift, someone comes to help CNA 4, but that day (5/26/2025) no one was helping CNA 4." Resident 1 stated Resident 1 was worried that Resident 1's (right) leg was broken. During a concurrent observation of Resident 1 inside Resident 1's room and interview on 5/29/2025 at 11:41 am with LVN 2, Resident 1 was lying in bed with noticeable injuries to his right index (pointer) finger and right leg. LVN 2 stated Resident 1 had a bruise on the right index finger and a bump on the back right side of Resident 1's head, near Resident 1's neck. LVN 2 stated Resident 1 had a raised bump on his right shin that was approximately two (2) inches by one and a half (1.5) inches with purple and yellowish tone around the bump's edges. LVN 2 stated Resident 1's (right) leg was swollen from the injury. LVN 2 stated the right outer side of Resident 1's foot was also bruised and slightly purple and greenish in color. During an interview on 5/29/2025 at 11:46 am, LVN 2 stated on 5/26/2024 during the morning shift (7 am to 3 pm), LVN 2 and CNA 4 were assigned to care for Resident 1. LVN 2 stated the facility was short-staffed on Station 3 (the station where Resident 1 resides) that day (5/26/2025). LVN 2 stated LVN 2 was two doors down from Resident 1's room when LVN 2 heard CNA 4 asking for help in Resident 1's room. LVN 2 stated when LVN 2 came into Resident 1's room, LVN 2 saw that the Hoyer lift was in between Resident 1's bed and Resident 1's roommate's bed, tilted over on its right side but was stopped by the shower gurney. LVN 2 stated LVN 2 found CNA 4 still assisting Resident 1 and trying to stop Resident 1 from falling by wedging CNA 4's left arm between Resident 1's right leg and the shower gurney. LVN 2 stated one of the bolts (a screw-like metal object without a point, used to fasten things together) on the Hoyer lift popped out. LVN 2 stated LVN 2 and other staff had to work to get the cuffs (the end part, usually thicker) off the sling to free Resident 1's (right) leg. LVN 2 stated after LVN 2 and other staff freed Resident 1's right leg, LVN 2 noticed Resident 1's right leg injury. LVN 2 stated Resident 1's right leg was "instantly a goose egg (when blood collects between the skin and the muscle)." LVN 2 stated less than 30 minutes after Resident 1 fell, Resident 1 complained of a bump on the back right side of Resident 1's head. LVN 2 stated the Treatment Nurse (TN) assessed Resident 1's head, while LVN 2 called 9-1-1. During an interview with on 5/29/2025 at 1:14 pm, the TN stated on 5/26/2025 (unable to remember exact time), Registered Nurse (RN) 2 asked the TN to assess Resident 1 after, "an incident with the Hoyer lift." The TN stated Resident 1 had swelling to the right shin that was mildly red and had mild redness to the right index finger. The TN stated the TN assessed Resident 1's head but did not feel anything (without abnormal findings). The TN stated about 30 to 40 minutes after the assessment was completed, Resident 1 asked the TN to assess Resident 1's head again because Resident 1 told the TN, "I think I hit my head." The TN stated the TN assessed Resident 1's head again and felt a bump to the back right side of Resident 1's head. The TN stated the TN notified NP 1 and NP 1 ordered to transfer Resident 1 to ER for further evaluation. The TN stated two staff needed to operate the Hoyer lift for safety reasons because "it was a mechanical lift." The TN stated if two staff were operating the lift, it was possible that the resident (Resident 1) may not have fallen or gotten hurt. During a concurrent record review and telephone interview on 5/29/2025 at 3:48 pm, with the Director of Staff Development (DSD), the facility's Record of the In-Service Training (RIST) titled, "Lifting/Transferring: Hoyer Lift, Slings and Gait Belts," dated 2/19/2025 was reviewed. The RIST indicated staff would "Verbalize the understanding of facility policy requiring Two-Person Assist when using a (Hoyer) lift ... Acknowledge that one-person lift will lead to suspension or possible termination." The RIST indicated CNA 4 signed the RIST to confirm CNA 4 attended the training dated 2/19/2025. The DSD stated CNA 4 needed to be operating the Hoyer lift with another staff member (two-person physical assistance) in case there was an issue with the Hoyer lift such as a malfunction. The DSD stated the second person could assist with the fall so, "No one gets hurt." The DSD stated the facility provided an in-service (staff education) on Hoyer lifts around the end of 2/2025, and CNA 4 attended the in-service. The DSD stated it was possible that when two staff were operating the Hoyer lift then Resident 1's fall and injuries could have been prevented. During a telephone interview on 5/30/2025 at 12:54 pm, CNA 4 stated on 5/26/2025 (unable to remember exact time), CNA 4 was assigned to care for Resident 1. CNA 4 stated there were only five (5) CNAs working on Station 3 that day (5/26/2025). CNA 4 stated when CNA 4 transferred Resident 1 in the Hoyer lift, CNA 4 did not ask for a second staff to help because, "Everyone was so busy and there weren't enough people on our station (Station 3)." CNA 4 stated, "I didn't really think to ask for help because of it (short-staffed)." CNA 4 stated CNA 4 was getting Resident 1 ready for a shower and had hooked Resident 1 into the Hoyer lift sling and was using the Hoyer lift and, "All of a sudden the (Hoyer) lift gave out." CNA 4 stated the Hoyer lift made a noise and CNA 4 saw the sling and Resident 1 tilting down toward the floor. CNA 4 stated, "It's hard to describe the angle." CNA 4 stated Resident 1 and the Hoyer lift fell to the floor. CNA 4 stated, "I was holding onto Resident 1 and got hurt myself." CNA 4 stated "I'm not sure how it happened." CNA 4 stated there were supposed to be two staff operating the Hoyer lift for safety reasons. During an interview on 5/30/2025 at 1:05 pm, the Director of Nursing (DON) stated two staff needed to operate the Hoyer lift for safety reasons and to avoid falls, accidents, and injuries. The DON stated the Hoyer lift was a machine so there should be at least two staff or more if needed operating the Hoyer lift. The DON stated the two staff allowed the resident to be comfortable in the Hoyer lift during transfers. The DON stated if two staff were operating the Hoyer lift when CNA 4 was transferring Resident 1, "it was possible Resident 1's fall and injuries could have been prevented." The DON stated, "When we don't follow our education and training, and there are not enough staff working, it can lead to consequences like injury and fall." A review of the facility's most updated P&P titled, "Safe Lifting and Movement of Residents," revised 7/2017, indicated, "In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents." The P&P indicated, "Staff would be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding the use of equipment and safe lifting techniques.” The P&P indicated only staff with documented training on the safe use and care of the machines and equipment (Hoyer lift) used in this facility will be allowed to lift or move residents. The P&P indicated, "Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order." The facility failed to ensure CNA 4 provided two-person physical assistance, in accordance with the facility's P&P, when CNA 4 attempted to transfer Resident 1 from Resident 1's bed to the showe