Health inspection·December 10, 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 implement its abuse prevention policy by failing to report an unusual occurrence of an acute (sudden and severe onset) right femoral neck fracture (a particular type of hip fracture that occurs at hip region below the ball-and-socket joint ) and right temporal (side of the head behind the eye between the forehead and the ear) hematoma (a closed wound where blood collects and fills a space inside your body because it can't flow or drain out) of unknown cause to the State Survey Agency (California Department of Public Health-CDPH) within 24 hours of the occurrence for one of three sample residents (Resident 1). This failure had the potential to result in a delay of an onsite inspection by CDPH to ensure injuries from unknown origins were investigated timely and lead to a delay in prevention of potential ongoing unknown injuries. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) without current pathological fracture (broken bone caused by disease), dementia (a progressive state of decline in mental abilities), and spondylosis (a condition in which there is abnormal wear on the cartilage and bones of the neck). During a review of Resident 1 ' s History and Physical (H&P), dated 3/22/2024, the H&P indicated, Resident 1 had fluctuating capacity (ability) to understand and make decision. During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 10/29/2024, the MDS indicated Resident 1 required moderate assistance (Helper does less than half the effort) from one staff for roll left and right, sit to lying, lying to sitting on side of bed, and toilet transfer. During a review of Resident 1 ' s Change in Condition (COC) report, dated 11/27/2024, at 10:00 a.m., the COC indicated, LVN 1 noticed reddish-purple skin discoloration on Right hip and Right side of the forehead. Resident 1 was unable to recall where she got injuries, and Resident 1 was in bed throughout night. During assessment, Range of Motion (ROM - The distance and direction to which a bone joint can be extended) was limited and complained of 10 out of 10 pain, especially when being touched. During an interview on 12/4/2024, at 11:30 a.m., with Certified Nurse Assistant (CNA) 1, CNA 1 Page 1 of 3 055758 055758 12/10/2024 Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated, Resident 1 had been refusing to eat breakfast and morning hygiene care since 7:00 a.m. on 11/27/2024. CNA 1 stated, Resident 1 seemed very upset and did not want to get out of her bed. CNA 1 stated, she notified Licensed Vocational Nurse (LVN)1. During an interview on 12/4/2024, at 2:03 p.m., with Treatment Nurse (TN)1, TN 1 stated, he went to Resident 1 ' s room on 11/27/2024 between 10:30 a.m. and 11:00 a.m., to provide treatment. TN 1 stated, Resident 1 refused to turn on her right side and complained of right hip pain. During an interview on 12/4/2024, at 2:16 p.m., with LVN 1, LvN 1 stated, she went to Resident 1 ' s room because TN 1 reported Resident 1 ' s pain on 11/27/2024, between 12:00 p.m. and 12:30 p.m. LVN 1 stated, she noted a red-purplish discoloration on her right hip and right forehead. LVN 1 stated, Resident 1 complained of 10/10 pain on the numeric pain scale (a pain screening tool, commonly used to assess pain severity at that moment in time using a 0–10 scale, with zero meaning no pain and 10 meaning the worst pain imaginable) on her right hip. LVN 1 stated, she notified the Director of Nursing (DON) and the DON came to assess Resident 1. LVN 1 stated, Resident 1 was transferred to the General Acute Care Hospital (GACH) emergency room (ER). During an interview on 12/5/2024, at 3:08 p.m., with the DON, the DON stated, she was notified regarding Resident 1 ' s incident on 11/27/2024, before 10:00 a.m. The DON stated, she noted right hip discoloration and pain on same site, but she did not recall seeing discoloration on right forehead. The DON stated, the facility ' s policy indicated, unusual occurrence should be reported within 24 hours of occurrence. The DON stated, she waited until she received the medical record confirmation of fracture from the GACH before reporting to CDPH. During an interview on 12/5/2024, at 5:15 p.m., with the ADM, the ADM stated, the facility policy indicated, an unusual occurrence should be reported within 24 hours of occurrence and Resident1 ' s incident was an injury of unknown origin which was considered an unusual occurrence. The ADM stated, there was no witness and no one was able to find the cause of the injuries. The ADM stated, she recieved the test result medical record from the GACH on 12/2/2024. The ADM stated, she reported to CDPH on 12/2/2024 when she found out about Resident 1 ' s fracture. ADM stated, she did not report the incident to CDPH on 11/27/2024 because she did not get the medical record from GACH until 12/2/2024. The ADM stated, she could have reported on 11/27/2024, but she was not sure if the pain level of 10 out of 10 and discolorations on right hip would be considered as reportable injuries even though there was possibility of fracture. The ADM stated, it was important to report unusual occurrences in a timely manner and was important to prevent repeated similar incidents. During a review of Resident 1 ' s Emergency Medical Services (EMS) Report, dated 11/27/2024, the EMS Report indicated, dispatch received a 911 call on 11/27/2024, at 12:21 p.m., and arrived at the facility at 12:30 p.m. The EMS Report indicated, Resident 1 was in her bed and complained of right side hip pain. Resident 1 had shortening (one leg shorter than the other due to fracture) and external rotation (the leg rotates outward, away from the rest of your body). During a review of Resident 1 ' s GACH ER Note, dated, 11/27/2024, the GACH ER Note indicated, Resident 1 complained of right hip pain and there was a hematoma on the right temporal area. The GACH ER note indicated shortening of the right lower extremity noted. During a review of Resident 1 ' s GACH X-ray (a way for providers to get pictures of the inside of the body) Report, dated 11/27/2024, the GACH X-ray Report indicated, Resident 1 had comminuted (bone broken into three or more pieces) moderately displaced right femoral neck fracture (the pieces of 055758 Page 2 of 3 055758 12/10/2024 Cottage Crest Post Acute 12350 Rosecrans Norwalk, CA 90650

F 0609 the bone moved so much that a gap formed around the fracture) with soft tissue swelling. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1 ' s Skilled Nursing Facility (SNF) to Hospital Transfer Form, dated 11/27/2024, the SNF to Hospital Transfer Form indicated, Resident 1 was transferred to GACH on 11/27/2024, at 11:00 a.m. Residents Affected - Few During a review of the facility ' s Policy and Procedure (P&P) titled, Unusual Occurrence, revised 12/19/2022, the P&P indicated, Policy Statement: It is the policy of the facility that an unusual occurrence is reported to the Department of Public Health within 24 hours of occurrence. Policy Interpretation and Implementation: Reporting to the Department of Public Health will be made by telephone and confirmed in writing within 24 hours of occurrence. During a review of the facility ' s P&P titled, Abuse, Neglect and Exploitation, revised 12/19/2022, the P&P indicated, Policy Explanation and Compliance Guidelines .IV. Identification of Abuse, Neglect and Exploitation . B. Possible indicators of abuse include, but are not limited to: Physical marks such as bruises, Physical injury of a resident, of unknown source, Sudden or unexplained changes in behaviors and/or activities . V. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur . VII. Reporting/Response: A. The facility will have written procedures that include: I. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 055758 Page 3 of 3