Health inspection·March 21, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect 1 of 3 residents (Resident 1) when Resident 1 sustained an injury of an unknown origin to his left pinky finger. In addition, the certified nursing assistant (CNA) did not check on the Resident at the beginning of her shift. This had the potential to impair Resident 1's quality of life and delay in noticing any changes of Resident 1's condition. On 2/16/24, the facility reported an injury of unknown source to the Department. The report also stated that CNA 1 was suspended pending investigation. On 2/22/24 at 8 AM, an unannounced visit was conducted. A review of Resident 1 ' s admission record indicated he was admitted to the facility on [DATE] with medical diagnoses of cerebral vascular accident (blockage in the brain) right hemiplegia (weakness), dysphagia, (inability to swallow food or liquid), aphasia, (inability to talk). On 2/22/24 at 11 A.M., an observation of Resident 1 was conducted in his room with the presence of Licensed Clinical Social Worker (LCSW) 1. Resident 1 laid on his back with head of bed 45 degrees. Resident 1 was interviewed but he did not respond to any question asked. Review of Resident 1 ' s Minimum Data Set (MDS, a nursing assessment tool) dated 2/5/24 indicated Resident 1 was rarely/never understood. The MDS also indicated Resident 1 was dependent on staff for toileting, turning and repositioning. A review of Resident 1 ' s nursing interdisciplinary notes progress, dated 2/15/24 at 21:51 P.M( 9 p.m.)., indicated, Around 1800 (6 p.m.) CNA was doing her rounds and noticed Resident ' s left pinky has purplish/bluish discoloration with bruising and mild swelling. Assessed patient and asked if resident has pain when hand is touched, and resident nodded. CNA reported that shower was given in the morning. MD (medical doctor) ordered X-ray (photo image of a body) and result showed mildly displaced fracture at the base of the fifth proximal phalanx (pinky finger) . Result forwarded to MD. A review of Resident 1 ' s X-ray result of the left pinky finger dated 2/15/24, indicated, Mildly displaced fracture at the base of the fifth proximal . A review of Resident 1 ' s weekly summary dated 2/15/24 completed by the day shift (7 AM to 3 PM) licensed nurse was conducted. Page 1 of 2 055074 055074 03/21/2024 Villa Coronado D/P Snf 233 Prospect Place Coronado, CA 92118

F 0600 This weekly summary did not indicate any skin discoloration. Level of Harm - Minimal harm or potential for actual harm A review of Resident 1 ' s Social Work Interdisciplinary Note, dated 2/16/24 at 11 A.M., was conducted. This note indicated, The LCSW decided to ask Uni-Clerk . for the book that showed who was assigned to the resident from the 3-11 shift. The LCSW 1 did see RN (registered nurse) 2 and CNA 1 were working with the resident during the shift the fracture was noticed. LCSW 1 asked in both English and Spanish if he felt that RN 2 accidentally moved his hand that could have caused the bruising. He provided a blank stare and did not react. Once LCSW 1 asked if he thought CNA 1 may have accidentally hurt his hand during bed mobility, he started to shake. Both LCSW 1 and LCSW 2 looked at each other and then asked if he remember his hand getting hurt when CNA 1 was providing his care. He did not nod yes or no, but visibly continued to shake, his breathing got deeper and appeared afraid. Both LCSWs reminded him that the LCSWs were just trying to help find out what happened and advocate for him since he is not able to verbalize what happened. The LCSWs did their best to calm him down and let him know that we only want him to feel safe and make sure no one else experiences getting hurt. He did not engage; he did appear to calm down when the LCSWs agreed to stop asking questions . Residents Affected - Few During a phone interview conducted with CNA 1 on 2/22/24 at 10:06 A.M., CNA 1 stated her shift started at 3 P.M. CNA 1 stated on the day the injury was discovered, she did not check on Resident 1 until 5:30 P.M. CNA 1 stated at 5:30 P.M., she went to take the tray of Resident 1 ' s roommate and happened to glance at Resident 1 and noticed the purplish discoloration to his pinky finger. CNA 1 stated she was the one who noticed it, reported it but got suspended for it. CNA 1 stated she should have checked on Resident 1 at the start of her shift so she can verify any change of condition with the ongoing shift. CNA 1 acknowledged she should have checked Resident 1 at the start of her shift but did not. During an interview with LCSW 1 on 2/22/24 at 10:32 A.M., LCSW 1 stated she interviewed Patient 1 on 2/16/24 at 11:30 A.M. LCSW 1 stated Patient 1 ' s body shook, breathing got deeper and appeared afraid when CNA 1 ' s name was mentioned. LCSW 1 further stated Patient 1 ' s reaction was not his usual behavior. A phone interview was conducted with the facility Medical Doctor (MD) on 2/22/24 at 11:24 A.M. The MD stated Patient 1 did not have a medical or mental condition to cause pain or injury to himself. An interview was conducted with the director of nursing (DON) on 2/22/24 at 1:04 P.M. The DON stated, CNAs should have checked all residents assigned to their care at the start of the shift. The DON further stated at the start of the shift, CNA 1 should have assisted residents with their toileting, turning and identify change in condition and report to the licensed nurse. The DON stated CNA 1 should have checked Resident 1 at the start the rounding handoff, so they should have done a quick head to toe observation. The reporting should have been done inside the resident ' s room so any abnormality or changes of condition would have been observed and handled immediately. The DON stated this was not done immediately for Resident 1. Review of the facility ' s policy titled, Elder Abuse/ Injury of Unknown Origin - Identification and Reporting dated 4/8/21 indicated, Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Failing to protect resident from avoidable injury . 055074 Page 2 of 2