Health inspection·September 5, 2025

The following reflects the finding of the California department of Public Health during Investigation of a facility reported incident number CA00964124 A Class A citation was issued. §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. §483.21(b) Comprehensive Care Plans §483.21(b)(1) 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. 22 CCR § 72311 (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. 22 CCR §72523: §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 8/11/2025 California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a Facility Report Incident (FRI) regarding an injury to Resident 1. The facility failed to: 1. Ensure Restorative Nursing Assistant 1 (RNA 1-nursing aide program that helps residents maintain their function and joint mobility) implemented the Activities of Daily Living (ADL- include eating, dressing, getting into or out of a bed or chair) Care Plan to transfer Resident 1 from a shower chair ( an assistive device designed to help people who have limited mobility or physical strength when bathing) to the bed using a Hoyer lift (a mechanical device used to safely transfer individuals with limited mobility) on 7/26/2025 between 8 am to 9 am. 2. Ensure RNA1 provided two-person physical assistance (help from two persons) to transfer Resident 1 from a shower chair to the bed on 7/26/2025 between 8 am to 9 am as indicated in the ADL Care Plan initiated on 6/9/2025. 3. Ensure RNA1 followed the facility policy and procedures (P&P) titled "Transfer of Residents", when transferring Resident 1 from the shower chair to the bed on 7/26/2025 between 8 am to 9 am. On 7/26/2025 at 8:50 am, RNA 1 independently (by himself) transferred Resident 1, who was totally dependent (reliant on) on all ADLs, including chair to bed transfer, Resident 1's left lower leg was caught inside the metal bed frame. As a result, on 7/26/2025 at 10:20 am, Resident 1 sustained a bluish discoloration (refers to any change in the natural skin tone), skin trauma (a physical injury caused by an external force or violence, or an event that causes significant mental or emotional damage), and slight swelling to left mid shin (front parts of the leg). The facility transferred Resident 1 to a general acute care hospital (GACH) for further evaluation and treatment, and Resident 1 was diagnosed with multiple broken bones of the left leg. During a record review, Resident 1's Admission Record indicated the facility originally admitted the resident on 2/14/2025 and re-admitted her on 6/4/2025 with diagnoses that included hemiplegia (partial or total paralysis [extreme form of weakness and nerve dysfunction] and hemiparesis (weakness on one side of the body), reduced mobility (reduced ability to move freely), muscle weakness, lack of coordination (a lack of voluntary control and coordination of muscle movements), aphasia (inability to comprehend or formulate language), and a history of healed traumatic fracture. During a review of Resident 1's Care Plan Report for ADL self-care performance deficit related to activity intolerance, hemiplegia, impaired balance Care Plan, initiated on 6/9/2025, indicated that Resident 1 requires dependent assistance by two staff and Hoyer lift to move from chair to bed/bed to chair. During a record review, Resident 1's History and Physical (H&P) dated 6/20/2025 indicated Resident 1 did not have the capacity to understand and make decisions.   During a record review, Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 6/7/2025 indicated Resident 1's cognition (The mental ability to make decisions of daily living) was severely impaired. The MDS indicated Resident 1 was totally dependent for all activities of daily living (ADL - eating, oral hygiene, toileting hygiene, shower/bathing, upper and lower body dressing, putting on /taking off footwear, and personal hygiene), rolling left to right, moving from sitting to lying position and vice versa, and chair to bed transfer. The MDS further indicated Resident 1's ability to go up and down a curb and/or up and down one step was not attempted due to safety concerns. During a record review, Resident 1's Change in Condition (COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) Evaluation record dated 7/26/2025 at 10:11 am, indicated that during transfer from shower chair to bed (Resident 1) became combative and moved her legs and the left leg got stuck on the bed frame under the bed, causing skin discoloration, slight swelling, and mild pain. The COC indicated Resident 1 had skin discoloration (refers to any change in the natural skin tone) on the left shin area with slight swelling and suffered mild pain of three out of 10 (3/10- numerical pain assessment tool where zero is no pain and 10 is severe pain). The COC indicated Resident 1 suffered bruising and swelling over a joint or bone. A medical doctor "(MD) was informed and a new order received for a stat (now) x-ray of the left knee, left shin, left fibula (the outer bone of the two bones in the lower part of the leg), and left tibia (the inner bone of the two bones in the lower part of the leg)." During a record review, Resident 1's Skin Observation Checks record dated 7/26/2025 at 10:20 am, indicated the first observation that Resident 1 had bluish discoloration, skin trauma (a physical injury caused by an external force or violence, or an event that causes significant mental or emotional damage), and slight swelling to the left mid shin (front parts of the legs). The Skin Observation Checks record indicated that an RNA/CNA transferred Resident 1 to shower chair and that the resident's left leg was accidentally stuck to the bed frame. During a record review, Resident 1's Pain Assessment record dated 7/26/2025 at 9:05 am., indicated Resident 1 presented with left shin skin discoloration related to her left leg having been stuck in a bed frame, Resident 1 had acute (of sudden onset) aching pain of 3/10, and received Tylenol (medication used primarily to relieve mild to moderate pain) for pain. During a record review, Resident 1's Skin Weekly Assessment record dated 7/26/2025 at 11:41 am indicated the initial and current treatment plan to the left mid-shin with skin trauma, slight swelling, bluish discoloration with pain was to apply cold compress (the application of a chilled or frozen material to the body to reduce swelling or inflammation) to affected area every 15 minutes interval. The Skin Weekly Assessment record further indicated Resident 1 with left lower extremity (LLE) with pitting edema plus 2 (+2 - a condition where fluid accumulates in the tissues, causing swelling with an indentation of 3-4 millimeters [mm- unit of measurement] in depth) and left mid shin with bluish discoloration. During a record review, Resident 1's X-ray of the left tibia and fibula (two long bones located in the lower leg) dated 7/26/2025 with service date of 7/26/2025 indicated evidence of multiple fractures of the proximal fibula, lateral malleolus and spiral/ butterfly fracture in the shaft of the tibia. During a record review, Resident 1's of x-ray of the left ankle dated 7/26/2025, indicated a nondisplaced fracture in the lateral malleolus. During a record review, Resident 1's Progress Notes dated 7/26/2025 at 2:51 pm indicated Resident 1 was transferred to GACH due to butterfly (a type of fracture where a large, triangular or wedge-shaped fragment of bone breaks off, resembling a butterfly's wings) spiral fracture (the break spirals around the bone's axis, often caused by a twisting force) of the shaft of the tibia, fracture of the fibula, and tiny fracture in the lateral malleolus (the side of the bony prominence on the outer side of the ankle), nondisplaced fracture in the lateral malleolus, and distal fracture shaft of the tibia.  During a record review, Resident 1's "Nursing Home to Hospital Transfer Form" dated 3/2/2025 (incorrect date) indicated that on 7/26/2025 at 3:04 pm., Resident 1 was transferred to GACH due to butterfly spiral fracture on tibia and fibula to the left leg. Resident 1 received Tylenol 325 milligrams (mg) for pain on 7/26/2025 at 1:30 pm for pain level of 3/10. During a record review, Resident 1's Electronic Medication Administration Record (e- MAR) dated 7/1/2025 - 7/31/2025, indicated Resident 1 received Tylenol 325mg two tablets for pain on 7/26/2025 at 9 am and 1:30 pm. During a record review, Resident 1's Situation Background Assessment Recommendation (SBAR - is a structured communication framework used in healthcare settings to ensure clear and concise information exchange between healthcare professionals) dated 7/27/2025 at 6:50 pm indicated Resident 1 sustained fractures to the proximal tibia, lateral malleolus, spiral/butterfly fragment in the shaft and that the resident had new pain (not quantified). The SBAR indicated that a physician was notified, X-ray ordered, and Resident 1 to have an orthopedic (the branch of medicine dealing with the correction of deformities of bones or muscles) appointment after 3 weeks. During a record review, Resident 1's GACH Discharge Information record dated 7/27/2025 at 4:36 pm, indicated Resident 1 presented to the emergency room with left lower extremity pain after her leg was stuck in a bed rail the day prior (7/26/2025). Discharge Information record indicated Resident 1 had "Acute, comminuted (where the bone breaks into multiple fragments), mildly displaced fracture of the mid to distal left tibial shaft, and acute comminuted and minimally displaced fracture of the proximal left fibular shaft." The Discharge Information record indicated that Resident 1 "has a fracture of her [Resident 1's] tibia and fibula in the left leg. This was splinted by the emergency department. Resident 1 should have an orthopedic surgeon evaluate her soon." During a facility tour on 8/11/2025 at 11:45 am., Resident 1 was observed asleep in bed with a leg cast (a rigid, supportive shell, often made of plaster or fiberglass, used to immobilize and protect a fractured or surgically treated leg or knee while it heals) wrapped with ace bandage elastic bandage used to provide compression and support to injured body parts like ankles, knees, or wrists) covering the left leg from below the left knee to her foot.  During an interview on 8/11/2025 at 12:10 pm, RNA 1 stated that on 7/26/2025 between 8 am to 9 am, Resident 1, who was totally dependent on care, was seated on a shower chair at the bedside waiting to be transferred back to bed. RNA 1 stated that Certified Nurse Assistant (CNA) 2 was also present at the resident's bedside. RNA 1 stated he (RNA1) wrapped his arms under Resident 1's underarms, bear hugged Resident 1, lifted Resident 1 from the shower chair and then began to transfer Resident 1 from the shower chair to the resident's bed. RNA 1 stated that midway during the transfer, Resident 1 became combative, uttering words in her primary language, and he (RNA 1) continued with transferring the resident (Resident 1) to bed. RNA 1 stated he (RNA 1) laid Resident 1 in bed and noticed that Resident 1's left lower leg was stuck inside the metal bed frame. RNA 1 stated that CNA 2 did not assist with transferring Resident 1 to bed. RNA 1 stated he (RNA1) left CNA 2 at the bedside with Resident 1 and called Licensed Vocational Nurse (LVN) 2 for assistance. RNA 1 stated LVN 2 removed Resident 1's left lower leg that was still stuck on the metal bed frame. RNA 1 stated LVN 2 called Registered Nurse 1 (RN) 1 to come and assess Resident 1's left leg.   During an interview on 8/11/2025 at 12:35 pm CNA 2 stated she (CNA2) was standing at the foot of Resident 1's bed and RNA 1 instructed to stand by just in case he needed assistance with transferring Resident 1 from shower chair to the bed. CNA 2 stated Resident 1 was non weight bearing (cannot support weight) on bilateral lower extremities (lower limbs) and was non-ambulatory (unable to walk) prior to the left leg bed injury on 7/26/2025. During an interview on 8/11/2025, RN 1 stated that on 7/6/2025 at approximately 8:30 am, RNA 1 summoned her to Resident 1's room to see something but did not elaborate why. RN 1 stated she immediately went to Resident 1's room and found Resident 1 lying in bed with the resident's feet dangling on the left edge of the bed. RN 1 stated she noticed Resident 1 had redness and slight swelling to the left lower leg. RN 1 stated she knows and understands the word pain in Resident 1's primary language, Resident 1 said "pain." RN 1 stated she performed a full body assessment on Resident 1, notified doctor, received and carried out stat orders including x-rays, and gave Resident 1 Tylenol for pain. RN 1 stated the x-ray results indicated fractures to the left lower leg, and she immediately notified the physician of the x-ray results. RN 1 stated the physician gave an order to transfer Resident 1 to GACH for higher level of care.  RN 1 stated Resident 1 was transferred to acute care on 7/26/2025 at 3:04 pm. During an interview on 8/12/2025 at 12:20 pm, the Director of Staff Development (DSD) stated Resident 1 was totally dependent (requiring full reliance on caregivers for basic needs like mobility, hygiene, and feeding) on staff for care and the resident required 2-person assist with a Hoyer lift for transfers which is in accordance with the facility policy to safely transfer residents. During an interview on 8/12/2025 at 3:30 pm, Director of Staffing (DON) stated Resident 1's injuries were preventable if the staff had utilized an assistive device (Hoyer lift) to safely transfer Resident 1 from shower chair to the bed. During a record review, the facility policy and procedures (P&P) titled "Transfer of Residents" reviewed on 1/24/2025 indicated, "a mechanical lift is used on any resident unable to independently pivot (to turn or rotate) or transfer." The P&P titled indicated, "Purpose: To provide the form of transfer best suited to the residents' needs and maintain resident safety during the procedure... One person pivot transfer (Resident must be able to bear weight... Make sure the resident's feet are on the floor." The facility failed to 1. Provide adequate supervision and assistance devices to prevent accidents from occurring for Resident 1. 2. Ensure RNA 1 implemented the ADL Care Plan to transfer Resident 1 from a shower chair to the bed using a Hoyer lift on 7/26/2025 between 8 am to 9 am. 3. Provide two-person physical assistance when transferring Resident 1 from a shower chair to the bed on 7/26/2025 between 8 am to 9 am in accordance with the ADL Care Plan initiated on 6/9/2025. 4. Ensure RNA1 followed the facility P&P titled "Transfer of Residents" when transferring Resident 1 from the shower chair to the bed on 7/26/2025 between 8 am to 9 am without a Hoyer lift or two-person physical assistance. The above 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 for Resident 1.