Health inspection·August 22, 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 observation, interview, and record review, the facility failed to implement policies and procedures (P&P) for ensuring the reporting of a reasonable suspicion of abuse in accordance with section 1150B of the Act for one of five sampled residents (Resident 1) when Resident 1 alleged that a female staff grabbed him firmly on the right arm. This failure resulted in a delayed investigation of Resident 1's abuse complaint and had placed Resident 1 and other residents in the facility at risk for further abuse, and possible serious physical and/or psychosocial harm. Findings: A review of Resident 1's clinical record indicated Resident 1 was admitted January of 2024 and had diagnoses that included parkinsonism (a clinical syndrome characterized by tremor, slowed movement, rigidity, and postural instability), care provider dependency, weakness, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with daily lives). A review of Resident 1's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 6/26/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 13 out of 15 which indicated Resident 1 had an intact cognition. A review of Resident 1's MDS Mood status, dated 6/26/24, indicated Resident 1 had experienced feeling down, depressed, or hopeless half or more of the days in two weeks. A review of Resident 1's MDS Functional Abilities, dated 6/26/24, indicated Resident 1 needed partial/moderate assistance with toileting hygiene, showering/bathing, and upper body dressing. During an observation on 8/22/24 at 11:20 a.m. at Resident 1's room, Resident 1 was observed to be wearing a gray hand splint on the right hand. During an interview on 8/22/24 at 11:44 a.m. with Resident 1's daughter/ Responsible Party (RP) 1, RP 1 stated when she visited Resident 1 on the morning of 8/14/24, Resident 1 told her about his complaint on his right arm. RP 1 further stated, .Yes, I told them [nursing staff] about his [Resident 1] complaint of his arm, I told [name of Licensed Nurse (LN) 1]. I did tell [name of LN 1] about dad saying that a female went and grabbed him in the arm firmly. That time, he [Resident 1] was so adamant that I listen to him [Resident 1], and he wrote the number 5. He [Resident 1] was basically saying it happened around 5 a.m . I notified the nurse around 11 a.m. of that day .When I talked to her [LN 2], the nurse already had noticed about his [Resident 1] arm .He [Resident 1] was in a lot of pain. They [nursing staff] knew but were not sure why he [Resident 1] was hurting. Page 1 of 2 056304 056304 08/22/2024 Mission Carmichael Healthcare Center 3630 Mission Avenue Carmichael, CA 95608

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 1's assessment record titled, .Skin Only Evaluation, dated 8/14/24 at 4:30 p.m., indicated, .24. Location .Right Forearm .25. Skin Issue .Erythema (redness) and warmth .42. Painful .Yes Episodic (irregular interval) Pain .53. Location .Right wrist .54. Skin Issue .Erythema and warmth .71. Painful .Yes - Episodic Pain . A review of Resident 1's Nurses Progress Notes, dated 8/15/24 at 6:07 a.m., indicated, .X-Ray (a procedure commonly used to produce images of the inside of the body and is a very effective way of looking at the bones which can be used to help detect a range of conditions) results received . A review of Resident 1's x-ray results titled, Radiology Results Report, with examination date of 8/14/24 at 8:12 p.m., indicated, .FINDINGS: There is a hamate (bone in the wrist) fracture without soft tissue swelling or evidence of healing consistent with subacute injury (an injury that has happened recently) . During an interview on 8/22/24 at 3:18 p.m. with the Assistant Director of Nursing (ADON), the ADON stated LN 2 told her on 8/14/24 at around 1 p.m. that Resident 1 had an allegation that a female staff went and grabbed him firmly on the right arm, but they did not do the abuse allegation reporting on that time. The ADON acknowledged that the x-ray result confirming Resident 1's fracture on the right wrist was received on 8/15/24 at around 6 a.m. The ADON further stated she sent the abuse allegation report to the state agency on 8/15/24 in the afternoon. The ADON agreed that the abuse allegation of Resident 1 was not reported to the state survey agency/CDPH within 24 hours or within two hours after the confirmation of the right wrist fracture. The ADON also agreed that there is a risk of delayed investigation of the abuse allegation if the reporting is late. A review of the facility's abuse allegation report sent to the state survey agency titled, REPORT OF SUSPECTED DEPENDENT ADULT/ELDER ABUSE, dated 8/15/24, indicated a received date and time stamp of 8/15/24 at 5:05 p.m. During an interview on 8/22/24 at 3:18 p.m. with the Administrator (ADM), the ADM acknowledged that the abuse allegation of Resident 1 was not reported to the state survey agency/CDPH within 24 hours or within two hours after the confirmation of the right wrist fracture. A review of facility's P&P titled, Abuse, Neglect and Exploitation, revised 12/19/22, indicated, .VII. Reporting/Response .1. 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 . 056304 Page 2 of 2