Health inspection·December 9, 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. Based on interview and record review, the facility failed to report to the Department an injury of unknown source (an injury which was not observed, cannot be explained by the resident, and is suspicious because of the extent or location) for one of three sampled residents (Resident 1) when Resident 1 had a bruise on the right side of her neck and left clavicle (a bone that connects the breastbone to the shoulder blade) identified on 11/14/24 and 11/15/24 respectively, and the facility did not report this to the Department until 11/21/24. This failure resulted in a delay in the Department investigation into Resident 1' s bruises and had the potential for an occurrence of abuse to go undetected. Findings: A review of Resident 1' s admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included dementia (a decline in memory or other thinking skills severe enough to reduce a person ' s ability to perform everyday activities). During a review of Resident 1' s Minimum Data Set (MDS-an assessment and care planning tool), dated 10/17/24, the cognitive patterns section of the MDS indicated Resident 1 had short-term and long-term memory problems. The MDS also indicated Resident 1 was severely impaired with daily decision making. During a review of Resident 1 ' s Skin Integrity Care Plan (a document that summarizes a person ' s health needs, care, and treatment, and helps ensure their needs are met), dated 4/11/24, indicated on 11/14/24 a discoloration to the right neck was discovered, and a discoloration to the left clavicle was discovered on 11/15/24. During a review of Resident 1' s ED Physician Notes (ED- hospital emergency department), dated 11/16/24, indicated, Patient has unexplained bruising on her neck and the ER [emergency room] nurse filled out an APS [adult protective services] report. During a review of a report received by the Department from the facility dated 11/21/24, the report indicated Resident 1 had bruising to both sides of the neck. The bruise on the right side of the neck was found by staff on 11/14/24, and the left clavicle on 11/15/24. Review of Resident 1 ' s clinical record, PROGRESS NOTE dated 11/21/24, written by Resident 1 ' s physician indicated, Pt [patient] has dementia + unable to give any history. Page 1 of 2 055481 055481 12/09/2024 Vienna Nursing and Rehabilitation Center 800 So. Ham Lane Lodi, CA 95242

F 0609 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/22/24, at 9:45 a.m. with the Administrator (ADM), the ADM stated he reported Resident 1 ' s bruises to the Department on 11/21/24 after Resident 1 ' s family members requested an investigation into the possibility of abuse. The ADM explained the cause of the bruises to Resident 1 ' s neck was identified during the facility ' s 5-day follow-up investigation and did not warrant a report of potential abuse. Residents Affected - Few During an interview on 12/9/24, at 1:45 p.m. with the Director of Nursing (DON), the DON stated Resident 1 was taken to the emergency department of an acute hospital for evaluation of the unexplained bruising of Resident 1 ' s neck. The DON further indicated the facility had investigated and ruled out abuse, so there was no need to report the injury of unknown source to the Department. During a review of the facility ' s policy and procedure titled, Abuse Prevention Policy and Procedure, revised date 3/29/17, indicated, .It is the responsibility of staff, consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of an unknown source .All injuries to unknown source will be reported to appropriate agencies .All suspected or alleged abuse/neglect will be investigated and reported to the local ombudsman or the local law enforcement agency by telephone or written document immediately or within 24 hours, and by written report sent within two working days .Facility shall report all incidents of alleged abuse/neglect or suspected abuse/neglect .to DHS [Department of Health Services] within 24 hours . 055481 Page 2 of 2