Health inspection·May 20, 2025

42 CFR §483.25 Accidents. The facility must ensure that: (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. 42 CFR §483.21(b) Comprehensive Care Plans (1) The facility must 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 22 CCR 72311- Nursing Service – General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing 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 implemented to ensure that patient related goals and facility objectives are achieved. On 4/1/2025, the California Department of Public Health (CDPH) received a complaint indicating Resident 1 fell off the bed while being changed and broke her hip on 3/21/2025 at 5 a.m. On 4/8/2025 at 7:30 a.m., the CDPH conducted an unannounced visit to investigate the allegation. The facility failed to: 1). Provide two-person assistance (one on each side of the bed) to Resident 1, who was dependent on staff for turning and repositioning. Certified Nurse Assistants (CNA 1 and CNA 2) repositioned Resident 1 while both were standing on the left side of the resident’s bed. As a result, Resident 1 fell to the floor, sustaining a femur (thigh bone) fracture (broken bone) experiencing pain and fear, and was transferred to a general acute care hospital (GACH) for evaluation and treatment. Resident 1 was a 62-year-old female, initially admitted to the facility on 4/11/2022 and readmitted on 3/25/2025. Resident 1’s diagnoses included morbid (severe) obesity (excessive fat accumulation), bilateral (both sides) osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the knee, chronic pain syndrome (condition of persistent pain, muscle weakness and unspecified lack of coordination (problem with movement, balance or coordination). A review of Resident 1’s History and Physical (H&P) dated 2/13/2025, indicated Resident 1 had the capacity to understand and make medical decisions. The H&P indicated Resident 1 had a history of paraplegia (paralysis of the legs and lower body) and was bedridden. A review of Resident 1’s Care Plan titled “The resident has an activities of daily living (ADL) self-care performance deficit related to impaired balance and limited mobility” dated 2/28/2024, indicated Resident 1 had an activity of daily living, self-care performance deficit related to impaired balance and limited mobility. The care plan indicated Resident 1 was totally dependent (staff does all the effort, resident does none of the effort to complete the activity or requires two or more staff to complete the activity). The nursing interventions indicated Resident 1 required two staff assistance to turn and reposition the resident in bed. A review of Resident 1’s Minimal Data Set (MDS – a resident assessment tool) dated 3/13/2025, indicated Resident 1 had no cognitive (ability to think and reason) impairment The MDS indicated Resident 1 was dependent on staff for ADLs such as dressing, personal hygiene and bed mobility (the ability to roll from lying on back to left and right side, and return to lying back on the bed). A review of Resident 1’s Care Plan titled “Documented Safety Concerns” dated 3/13/2025, indicated Resident 1 would remain safe. The care plan’s intervention indicated staff will provide safety measures to reduce the risk of falls and injury. A review of Resident 1’s Change of Condition (COC), dated 3/20/2025, indicated Resident 1, who weighed 501.8 pounds, had a witnessed fall. The COC indicated Resident 1 sustained a skin tear (unspecified location) and complained of right leg/foot pain rated at 8 out 10 (pain rating reference 1-3 mild pain; 4-6 moderate pain, 7-10 severe pain). A review of Resident 1’s progress notes, dated 3/20/2025, indicated Resident 1 slipped out of bed and fell. The progress notes indicated Resident 1 had an avulsion (tearing of skin from the body) to the right great (big) toe, and a skin tear to posterior (backside of) the left knee. A review of Resident 1’s physician orders, dated 3/20/2025, indicated stat (urgent) x-ray (process of taking pictures of the inside of the body to help diagnose conditions or injuries) to the right lower extremity (leg) including right foot and to transfer Resident 1 to a GACH 1. A review of Resident 1’s GACH Orthopedic (medical specialty focused on injuries and diseases affecting the musculoskeletal system [bones, muscles, joints and soft tissues]) Surgery Consult H&P dated 3/23/2025, indicated Resident 1 was admitted for evaluation of a right leg pain. The H&P indicated the Resident 1’s family (FM 1) reported Resident 1 was “dropped” by the facility’s nursing staff when the staff tried to roll the resident. The H&P indicated Resident 1 had pain (unrated), to the right leg and she had a displaced fracture (a type of bone fracture where the broken bone fragments move out of their normal alignment) of the right distal femur. The H&P indicated based on Resident 1’s weight, shape of her legs and feet, the resident was unable to stand or walk. During an interview on 4/8/2025 at 8:33 a.m., Resident 1 stated on 3/20/2025 (time unknown), she fell off the right side of the bed when CNAs 1 and 2 were standing on the left side of the resident’s bed, while trying to turn her in bed during care. Resident 1 stated no staff members were present at the right side of the bed when CNAs 1 and 2 were turning and repositioning her. Resident 1 stated after she fell, she was so scared and experienced excruciating right leg pain. During an interview on 4/9/2025 at 8:40 a.m., CNA 1 stated Resident 1 was dependent on staff to turn and move in bed. CNA 1 stated during Resident 1’s ADL care, Resident 1 was lying at the edge of the right side of the bed, while she (CNA 1) and CNA 2 were both standing on the left side of the resident’s bed. CNA 1 stated, when she (CNA 1) and CNA 2 pulled Resident 1’s draw sheet (a sheet placed across the middle of the bed to facilitate repositioning and moving the resident) towards them, to move the resident to the middle of the bed, Resident 1 fell off the right side of the bed. CNA 1 stated it was not safe for both staff members to be on the left side of the bed, while turning Resident 1 to the opposite direction. CNA 1 stated one of the CNAs (CNA 1 or CNA 2) should have stood on the right side of the bed to secure Resident 1 and prevent the resident from falling and sustaining an injury. During an interview on 4/9/2025 at 11:35 a.m., the Director of Staff Development (DSD) stated, CNAs were in-serviced on ADL care, repositioning residents in bed with emphasis on ensuring there was at least one staff member on each side of the bed when turning and cleaning dependent residents such as Resident 1. During an interview on 4/9/2025 at 12:40 p.m., CNA 2 stated she (CNA2) and CNA 1 were standing on the left side of the bed when Resident 1 fell on the right side of the bed. CNA 2 stated this technique was not safe. CNA 2 stated Resident 1’s fall could have been prevented if safe techniques were used and one of them (CNA 1 or CNA 2) stood on the right side of Resident 1’s bed when the resident was repositioned. During a concurrent interview and record review on 4/9/2025 at 3:10 p.m. with the Director of Nursing (DON), Resident 1’s IDT notes, dated 3/25/2025, were reviewed. The DON stated the IDT notes indicated two CNAs were standing on the left side of the bed while they turned and cleaned Resident 1. The DON stated no staff were present on the right side of the bed when Resident 1 fell out of the bed. The DON stated the CNAs were unsafe and at least one staff member should have been on each side of the bed to prevent falls. The DON stated staff’s unsafe patient handling resulted in Resident 1’s fall and injury. The DON stated Resident 1’s fall on 3/20/2025 resulted in femur fracture, severe pain, and hospitalization. During an interview on 4/16/2025 at 2:50 p.m., with the Orthopedic Physician (Ortho), the Ortho stated, Resident 1 sustained an acute (new) fracture of the distal femur (lower end of the thigh bone) close to the knee. The Ortho stated Resident 1’s fracture was caused by a traumatic mechanism from the fall and was very painful. The Ortho stated the fracture was inoperable due to Resident 1’s large size and being bedbound (someone who is confined to the bed). A review of the facility’s In-Service (training or education) Meeting titled, “Repositioning, Turning” dated 1/16/2024, indicated CNAs were trained on the procedures to follow when turning and repositioning residents who could not assist and ensuring safety of residents when turning/repositioning. The In-Service lesson plan indicated: CNAs were to perform the procedure (turning/repositioning) positioned on opposite sides of the bed. The In-Service sign-in indicated CNA 1 and CNA 2 attended the In-Service. A review of the facility’s policy and procedure (P&P) titled, “Fall Management Program,” dated 3/13/2021, indicated the purpose of facility’s Fall Management program was to provide residents a safe environment that minimized complications with falls. The P&P indicated the facility will implement a fall management program that supported providing an environment free from fall hazards. The facility failed to: 1). Provide two-person assistance to Resident 1, who was dependent on staff for turning and repositioning. CNA 1 and CNA 2 repositioned Resident 1 while both were standing on the left side of the resident’s bed. As a result, Resident 1 fell to the floor, sustaining a femur fracture experiencing pain and fear, and was transferred to a GACH for evaluation and treatment. 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 harm would result.