Health inspection·April 16, 2025

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 ensure that Resident 1's alleged abuse incident was reported within the prescribed timeframes. This failure placed the Resident 1 at risk for further possible abuse incidents, mental anguish or emotional distress. This failure also resulted in the delay in the abuse investigation. Findings: During a review of Resident 1's Facesheet (information containing contact details, brief medical history at-a-glance) indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (memory loss and impaired decision-making capacity) and major depressive disorder (a mental disorder characterized by persistently depressed mood and loss of pleasure and interest in life). During an interview on 4/16/25 at 12:57 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 4/14/25 at approximately 7:30 a.m., Resident 1 was complaining of left arm pain and stated that the night shift Certified Nursing Assistant (CNA) 1 was mean and rough with her and hit her left arm. LVN 1 further stated that at around 12:15 p.m., she had observed Resident 1's left arm to be swollen so she obtained an order for left arm X-ray from the physician. LVN 1 stated Resident 1's left arm X-ray was done in the facility at around 4 p.m., and at around 5:00 p.m., the X-ray results revealed that Resident 1 had a fracture (broken bone) in her left arm. Stated at around 6:00 p.m., Resident 1 was transferred to the hospital for further evaluation. LVN 1 acknowledged she should have reported the alleged abuse accusation to the Administrator (Adm) and the Director of Nursing (DON) immediately when Resident 1 initially complained of the alleged abuse but stated she forgot to report the incident. Stated she was aware that alleged abuse with injury should be reported to the state department immediately or within two hours. During a review of Resident 1's left arm X-ray results dated 4/14/25 at 5:07 p.m., indicated: Acute minimally displaced mid ulnar diaphyseal fracture (a broken bone in the thinner and longer of the two bones in Resident 1's left forearm on the side opposite to the thumb). During a review of Resident 1's nurses progress notes 4/14/25 at 11:17 p.m., the notes indicated Resident 1 went to the hospital on 4/14/25 at 6:20 p.m. for evaluation of the pain in her left arm. The notes also indicated that the Adm was informed of the alleged incident at this time. During an interview on 4/16/25 at 3:00 p.m., with the DON, the DON acknowledged Resident 1's Page 1 of 2 555016 555016 04/16/2025 St John Kronstadt Convalescent Center 4432 James Avenue Castro Valley, CA 94546

F 0609 Level of Harm - Minimal harm or potential for actual harm complaint of alleged abuse incident with injury should have reported to the department immediately or within 2 hours. During a phone interview with the Adm on 4/24/25 at 11:30 a.m., stated she only found out of Resident 1's alleged abuse incident at on 4/14/25 at 6:00 p.m. Residents Affected - Few During a review of the SOC 341 submitted by the facility, the SOC 341 was faxed to CDPH on 4/14/25 at 8:15 p.m., eight hours after the left arm was observed to be swollen by LVN 1. (SOC 341 is a Report of Suspected Dependent Adult/Elder Abuse. It is a mandated reporting form used in California to report suspected abuse, neglect, or financial exploitation of elders or dependent adults). During a review of the facility's policy and procedure (P&P) titled, Abuse Protocols, revised 8/1/24, the P&P indicated, . Reporting: 1.Verbal notification to the Department of Public Health . shall be followed by an initial written notification using the SOC 341 and submitted within 24 hours of discovery .( The P&P did not mention to report an allegation of abuse with injury to the Adm of the facility and to other officials including CDPH immediately or within two hours). According to State Operations Manual, Appendix PP, Reporting Allegations, 483.12 (b): The facility must develop and implement written policies and procedures that, .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 .).( The State Operations Manual is a detailed information on regulations, policies, and procedures that facilities like nursing homes must follow to ensure compliance with federal or government requirements). 555016 Page 2 of 2