Health inspection·September 18, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of resident to resident abuse and injury of unknown source within the required 2-hour timeframe to the State Survey Agency (SSA- where state law provides for jurisdiction in long-term care facilities) for three (3) of six sampled residents (Resident 1, Resident 2, and Resident 3). The deficient practice had the potential for delayed provision of care and the potential to compromise the protection of the residents in the facility which could affect the resident's wellbeing. Findings: 1. During a review of Resident 1's Resident Face Sheet (resident profile) indicated, was admitted on [DATE] with diagnoses including stroke, atherosclerosis of aorta (a condition that occurs when plaque builds up in the aorta, the main artery that carries oxygen-rich blood from the heart to the body), high blood pressure, high blood sugar, and chronic low back pain. During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 5/14/24, the MDS indicated Resident 1 had no cognitive (mental action or process of acquiring knowledge and understanding) impairment. During a review of Resident 2's Resident Face Sheet indicated, was admitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), depression (a mental disorder that can affect a person's thoughts, feelings, and behavior), and high blood pressure. During a review of Resident 2's MDS, dated [DATE], indicated, Resident 2 had severe cognitive impairment. Under the functional assessment indicated, Resident 2 had no impairment on both upper and lower extremities and can wheel herself in the corridor with supervision. During a review of Resident 1 and Resident 2's Event Report, dated 7/10/24, indicated, on 7/10/24 at 7:30 PM, a Certified Nursing Assistant (CNA) reported to the Licensed Nurse (LN) that Resident 2 was inside Resident 1's room and started hitting Resident 1 on the right knee. It indicated that the LN called and reported the incident to the San [NAME] Police Department at 7:30 PM. During a review of Resident 2's progress note dated 7/10/24, and time stamped at 7:51 PM, indicated, the Nursing Home Administrator (NHA) received a call from the Charge Nurse (CN) that a CNA observed Resident 2 hitting a resident in [room #]. Page 1 of 3 055188 055188 09/18/2024 Brookside Skilled Nursing Hospital 2620 Flores Street San Mateo, CA 94403

F 0609 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1's progress note dated 7/10/24, and time stamped at 8:00 PM, indicated, the NHA received a call that Resident 1 was hit by another resident. Further review of the progress notes dated 7/10/24, 8:45 PM, indicated, Writer [NHA] called the Ombudsman office at 8:43 PM to report incident. Office closed lvm (left voicemail) and SOC 341 (Report of Suspected Dependent Adult/Elder Abuse) will be sent tomorrow morning. Residents Affected - Few During a review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC 341, with date completed on 7/10/24, indicated, date and time of the incident Resident 2 hitting Resident 1 was 7/10/24. This alleged incident was reported to the police and Ombudsman by phone on 7/10/24, no time indicated; and to the California Department of Public Health (CDPH) and Ombudsman by fax on 7/11/24, no time indicated. Further review indicated, the facility fax cover for the SOC 341 had a date of 7/11/24. The fax cover and SOC 341 also indicated, was received by CDPH Licensing & Certification (L&C) on 7/11/24, time stamped at 12:49:39 PM. During a review of the facility's document titled, Re: 5 Days Conclusion for SOC Reported 7.10.24, dated 7/15/24, indicated, .Actions Taken: .Administrator faxed SOC 341 to CDPH on 7.11.2024 . During an interview on 9/18/24 at 2:10 PM, the Social Services Designee (SSD) stated, the staff present during an incident will report it and the licensed nurse will subsequently report to the Administrator, the person in-charge of reporting to CDPH, Police, and Ombudsman. During an interview on 9/18/24 at 2:31 PM, the NHA stated she received a call about the alleged resident to resident altercation on 7/10/24 in the evening and provided guidance to the CN on the next steps. The NHA stated she left a voicemail to the Ombudsman's office only and faxed the SOC 341 to the Ombudsman and CDPH office on 7/11/24. During further interview, the NHA explained that the Director of Nursing (DON) or SSD do the reporting to the police, Ombudsman, and CDPH if she's not around while the CN report it during off hours. 2. During a review of Resident 3's Resident Face Sheet indicated, was admitted on [DATE] with diagnoses including dementia, need for assistance with personal care, atherosclerosis of aorta, high blood pressure, vitamin B12 deficiency, vitamin D deficiency, and presence of gastrostomy tube (G-tube, a tube inserted through the belly that brings nutrition directly to the stomach). During a review of Resident 3's physician progress notes dated 5/22/23, indicated, Patient remains non-verbal, totally dependent on staff for ADL's (Activities of Daily Living- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and mobility. She has contractures . She is prone to skin breakdown . During a review of Resident 3's Event Report, dated 7/7/23, under the Description section indicated, R (right) displaced humeral mid-shaft fx. (fracture) and R anterior shoulder dislocation. Under the Type of Injury section indicated a check mark on Suspected Fracture, Traumatic Joint Dislocation, Other - Fx. During a review of undated facility document titled, Investigation Summary, indicated, .On 7/7/23 at approximately 9:30 am, Director of Nursing [Name] received a call from [Name], [Name of Hospital] representative, notifying her that resident was returning to [Facility Name] but that the report had 055188 Page 2 of 3 055188 09/18/2024 Brookside Skilled Nursing Hospital 2620 Flores Street San Mateo, CA 94403

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few been filed with APS (Adult Protective Services - agency to help elder adults, 60 years and older; and dependent adults, 18-59 who are disabled) due to the presence of a fracture. Resident returned at approximately 12:30 pm with new medications .and paperwork indicating only UE fx (upper extremity fracture) . During a review of the progress notes from the acute hospital physician, faxed on 7/10/23, indicated, Resident 3 presented with right shoulder and arm pain in the emergency room (ER). It indicated, In the ER, midshaft humerus (upper arm) spiral fracture (broken bone in twisting motion) was noticed .a chronic (persisting in a long time) appearing anterior (in front of) shoulder dislocation with big Hill-Sachs lesion (a type of injury that affects the upper arm caused by shoulder dislocation) . Clinical Impressions: Primary: Right Shoulder Dislocation .Right Humerus Fx . During a review of the facility's Fax Cover dated 7/7/23, indicated, Re: Preliminary: Incident [Resident Name] . Comments: Our facility would like to report on incident identified on 7/6/2023 around 23:20 by our License Nurse. Resident was sent to the ER and returned to our facility to day with a Chronic Dislocation and Midshaft humerus fracture. The Fax Cover also indicated a handwritten note, Faxed to CDPH 7/[blank]/2023 @ (at) [blank] [initial]. The Fax Cover was received by CDPH L&C on 7/12/23, time stamped at 12:17:31 PM. During an interview on 9/18/24 at 11:25 AM, the NHA stated that the facility considers fire, power outage, flood, earthquake, and injury of unknown origin as an unusual occurrence. In addition, the NHA stated that allegations of abuse and injury of unknown origin are reported immediately or within 2 hours or within 4 hours via phone or fax to the police, Ombudsman, and CDPH. Review of the facility's policy and procedure titled, Resident Abuse Protocols, revised 10/01/22, under Reporting indicated, .1. Report all incidents of alleged or suspected abuse and injuries of unknown origin to the Administrator and Director of Nursing. 2. If the Administrator and/or Director of Nursing are unavailable, the person designated to act on his/her behalf will contact him/her immediately, by telephone if necessary. 3. All suspected abuse/neglect or injuries of unknown origin will be reported verbally and documented on an Incident Report. 4. The Administrator and Director of Nursing or their designees shall notify the California Department of Public Health, Licensing and Certification via telephone immediately or as soon as is practically possible but no later than hours after discovery of the alleged incident. 5. The Administrator and the Director of Nursing shall notify the Ombudsman and/or the local law enforcement agency (as required by law) via telephone immediately or as soon as practically possible but no later than 2 hours after discovery of the alleged incident . 055188 Page 3 of 3