Health inspection·November 1, 2024

Sunnyvale Gardens Post Acute Complaint Survey Revisit 9/6-9/10/2024 The following reflects the findings of the California Department of Public Health during the first revisit survey of Complaint CA00901977. Event ID: C5IQ12 Representing the Department: 44583, Health Facilities Evaluator Nurse. A Class "B" Citation was written for the following violation: (Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22) §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, On 9/6/2024, an unannounced first revisit survey was conducted at the facility. The facility failed to implement their abuse policy and procedure for one patient (Patient 2) when the facility did not report Patient 2's injury of unknown source. This failure resulted in Patient 2's fractures of left third and fourth metacarpals (broken middle and ring fingers) of unknown source not reported to required agencies (California Department of Public Health [CDPH], law enforcement agency, and Long-Term Care Ombudsman). This failure had the potential to compromise the safety of the residents in the facility. Review of Patient 2's face sheet (a document that gives a resident's information) indicated, Patient 2 was admitted to the facility with diagnoses including unspecified sequelae (after effect of a disease, condition or injury) of cerebral infarction (also called stroke) , wedge compression fracture of unspecified thoracic vertebra (broken backbone that occurs when the front part of the backbone collapses giving it a wedge shape) , initial encounter for closed fracture, vascular dementia (problems with reasoning, planning, judgement, memory, and other thought processes caused by brain damage from impaired blood flow to the brain), age-related osteoporosis (a bone disease that weakens bones and increases the risk of breaking them) without current pathological fracture, reduced mobility and need for assistance with personal care. Review of Patient 2's quarterly minimum data set (MDS, an assessment tool) assessment dated 8/16/2024, indicated Patient 2 had memory problem with short-term memory and long-term memory and her daily decision making with task was severely impaired (never/rarely made decision). Further review indicated Patient 2 required substantial/maximal assistance (helper does more than half the effort) with sit to stand, chair/bed-to-chair transfer, and with wheelchair locomotion (the ability to move and the act of moving from one place to another) from 50 feet with two turns to 150 feet. During an interview with certified nursing assistant B (CNA B) on 9/6/2024 at 1:20 p.m., CNA B confirmed she was assigned to Patient 2. CNA B stated Patient 2 required assistance in moving around her room and in the facility with the use of her wheelchair. CNA B further stated, Patient 2 was unable to wheel herself in the facility. During an observation on 9/6/2024 at 1:26 p.m. inside the facility's dining room, Patient 2 was observed eating lunch and only required supervision with eating. Patient 2 was calm and quiet during observation but was unable to communicate due to Patient 2 was non-English speaking only. Review of Patient 2's Nurse's note, dated 8/28/2024, indicated, "At 0928 bruise found on pts [patients] left hand." Review of Patient 2's Nurse's note, dated 8/30/2024, indicated, Patient 2 was transferred to the hospital for further evaluation and treatment of the non-displaced fracture of the left fourth metacarpal (broken bone in the left ring finger). Review of Patient 2's progress notes titled, "IDT [interdisciplinary team, composed of members from different departments involved in resident's care] NOTE," dated 8/30/2024, indicated to address Patient 2's fracture of the left fourth metacarpal. Further review indicated the physician ordered an X-ray (a type of electromagnetic radiation that produces images of the inside of the body or objects) for Patient 2's left hand and had a result of an acute non-displaced fracture in the fourth metacarpal. It also revealed, " ...staff observed no falls or received report of falls or apparent injuries during their shifts...The interdisciplinary team and attending physician deemed the resident's injury as likely a spontaneous (pathological) [pathological fracture, is a broken bone that occurs when a disease weakens the bone, rather than an injury] fracture secondary to the resident's diagnosis of Osteoporosis (a disease that causes bones to become weak and brittle, increasing the risk of breaking bones)..." Review of Patient 2's Emergency Room (ER) report from the hospital dated 8/30/2024, indicated, "Chief Complaint: Patient presents with Swelling...for evaluation of 2-day history of left hand swelling and pain after a fall. Moderate amount of swelling as well as pain noted to the left hand...Left hand: Swelling, tenderness and bony tenderness present." Further review revealed, "Diagnosis:1. Closed nondisplaced fracture of fourth metacarpal bone of left hand, unspecified portion of metacarpal, initial encounter; 2. Closed nondisplaced fracture of third metacarpal bone of left hand (broken left middle finger), unspecified portion of metacarpal, initial encounter." During an interview with DON on 9/6/2024 at 2:30 p.m., DON confirmed Patient 2 did not fall on or before 8/28/2024. DON stated Patient 2's fracture on left fourth finger was just a pathological fracture due to history of osteoporosis. DON also confirmed they did not report the fracture of unknown source because they found out it was a pathological fracture. DON stated they did not need to report. During an interview with administrator (ADM) on 9/9/2024 at 10:36 a.m., ADM stated Patient 2 did not fall on or before 8/28/2024. ADM further stated, Patient 2 only had a pathological fracture caused by osteoporosis. ADM confirmed they did not report Patient 2's fracture. ADM stated they did not need to report since Patient 2 had diagnosis of osteoporosis and Patient 2 could sustain a fracture even with a slight hit of her hand on the table. During an interview with licensed vocational nurse C (LVN C) on 9/9/2024 at 12:42 p.m., LVN C confirmed he was Patient 2's nurse on 8/28/2024. LVN C stated, one of the CNAs asked him to check Patient 2's left hand because of the discoloration. LVN C confirmed there was a bruise found on Patient 2's lateral side of the left hand. LVN C stated, Patient 2 did not fall on 8/28/2024. During a concurrent interview with ADM and DON on 9/10/2024 at 3:38 p.m., ADM and DON confirmed Patient 2 did not have any falls on August. ADM stated Patient 2 could possibly sustained the fracture while she was wheeling herself in the facility. ADM stated he did not report the fracture because the location of the fracture did not indicate an abuse but he confirmed they investigated the injury of unknown source. During a review of the facility's policy and procedure titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating," date revised April 2021, "All reports of resident abuse (including injuries of unknown origin)...are reported to local, state and federal agencies (as required by current regulations)...If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law." The above violation had a direct or immediate relationship to the health, safety, or security of the patients.