Health inspection·January 3, 2025

Vienna Nursing and Rehab Center The following reflects the findings of the California Department of Public Health during an Abbreviated Survey to investigate Complaint #CA00931640 and Facility Reported Incident #CA00931754. Survey Event ID: 30B211 State Citation B was written 12/9/24 Code of Federal Regulations, Title 42, Section §483.12 483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported 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 not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. California Health and Safety Code, 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours; (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 12/9/24 at 1:45 p.m., the California Department of Public Health (CDPH) conducted an unannounced Abbreviated Survey to investigate one Complaint one Facility Reported Incident regarding abuse. The department determined the facility failed to report timely 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. 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. 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. 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..." 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..." 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. 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. 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..." Therefore, the department determined the facility failed to report timely to the Department an injury of unknown source when Resident 1 had a bruise on the right side of her neck and left clavicle, 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 Departments investigation into Resident 1' s bruises and had the potential for an occurrence of abuse to go undetected. The violation had a direct or immediate relationship to the health, safety, or security of patients or residents.