Health inspection·March 11, 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 unusual occurrence for one of 3 sampled residents (Resident 1) per there policy and procedure to the California Department of Public Health (CDPH) for a fall that resulted in right femur fracture. This failure has the potential to put (Resident 1) a clinically compromised resident health, safety, and well-being at risk. Findings: During review of Residents 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include hemiplegia and hemiparesis right dominant side following cerebral infarction (muscle weakness and paralysis due to disrupted blood flow to brain), Diabetes Type II (condition affecting how body processes sugar), muscle wasting and atrophy (decrease in size and muscle). During a concurrent interview and record review with the Assistant Director of Nursing (ADON) of Resident 1 ' s (R1) medical record are as follows: 1. Change of Condition (medical care record) dated January 12, 2024, at 11:38 states, Fall: During post-shower care, resident turned to adjust self and rolled off the bed and onto floor. Resident complained of pain to right thigh and noted with skin tear to left Forearm. Registered Nurse (RN) assessed, and resident assisted back into bed. Resident did not hit head, no Altered level of consciousness (ALOC). Order, send to hospital .STAT (urgent/rush) Xray Right femur/hip. 2. Progress Note (medical care record) dated January 13, 2024, at 00:44 states, All labs came back within normal limit and no fracture is seen on the femur and hip . 3. Progress Note dated January 15, 2024, at 1722 and 2040, states, Resident on charting r/t witnessed fall and readmission from {hospital} . X-rays taken during shift. Pending results please follow up .Resident sent out to {hospital} related to Fracture of right femur. 4. Progress Note dated January 16, 2024, at 4:03, states, Resident came with diagnosis of fracture: femur distal, surgical procedure reduction and a splint on the Right leg. During an interview on February 22, 2024, with the (ADON), the ADON stated, The staff took Resident 1 to the shower on a shower bed, Resident ' s extremities are contracted. A CNA was on one side and Page 1 of 2 055565 055565 03/11/2024 Waterman Canyon Post Acute 1850 N. Waterman Ave. San Bernardino, CA 92404

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the other CNA was reaching for shower blanket from the other side of shower bed, and because Resident 1 is contacted, Resident 1 tried adjusting himself on the shower bed, he was wet, and he fell off the shower bed. The two CNAs observed the fall, Resident 1 was sent to the hospital and came back. The return documents from hospital stated there was no fracture, but as we kept assessing him, we did another X ray and there was a fracture. We sent him out again, this time to a different hospital and he did come back with a fracture and a soft splint to right leg. It was not reported to state agency because we did not determine any abuse, it was not unusual occurrence, it was witnessed. We determined no neglect was at play. He did have a fracture, but we determined how he got it, so it was not an unusual occurrence for us to report. During an interview on February 29, 2024, with the Administrator (ADMIN), ADMIN stated, This was not reported, this resident had a fracture, but we were aware of how it happened. It was a known cause. It was not an unusual occurrence, so it did not fit the criteria to report. During a concurrent interview and record review with the ADON of the facility ' s policy and procedure titled, Unusual Occurrence Reporting revised December 2007, the policy and procedure indicated, As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees, or visitors . 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations.3. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations. 055565 Page 2 of 2