Health inspection·June 11, 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 immediately report an injury of unknown origin for one resident (Resident 1) of three sampled residents. This failure decreased the facility's potential to protect Resident 1 from a possible allegation of abuse and ensure a safe environment during the investigation of the cause of the injury. Findings: Resident 1 was a [AGE] year-old female, re-admitted to the facility on [DATE]. She had multiple diagnoses, which included Unspecified dementia (impaired ability to remember) without behavior disturbance, Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills), unspecified site of disorders of bone density and structure (osteoporosis), history of falls, and muscle weakness. A review of Resident 1's Practitioner's Progress Notes (PPN), dated 5/14/24 at 4:05 p.m. indicated, [Resident 1] seen in [the] room after nursing report she is c/o [complaining of] left forearm pain. [Resident 1] with significant tenderness to palpation [touch]. She yelps and pulls [her] arm away during the exam. Will obtain xray of left forearm. A review of Resident 1's Radiology Results Report (x-ray), dated 5/15/24 at 3:52 a.m., indicated, .LEFT FOREARM .There is evidence of an acute [sudden onset] or possibly subacute fracture [break] of the distal radial diaphysis [both bones of the forearm] .There is [a] deformity of the distal ulna consistent with [a] distal diaphyseal fracture [wrist fracture] . A review of Resident 1's Daily Documentation (DD), dated 5/15/24 at 8:35 a.m., indicated at 5:29 a.m., Resident 1 was complaining of pain with a pain level of 6 over 10 (between moderate and severe level). A review of Resident 1's DD dated 5/16/24 at 2:50 a.m., indicated, Resident noted with pain [8/10] to left arm due to recent fracture . A review of Resident 1's Interdisiplinary Team (IDT) progress notes, dated 5/16/24 at 1:33 p.m. indicated, .IDT to review [Resident 1's] fx. [fracture] of [the] distal end of the L [left] radius. [Resident 1] c/o pain to left arm . was evaluated by NP [Nurse Practitioner] with rec. [recommendation] for [an] x-ray. X-ray ordered and results indicate fracture to left arm . Page 1 of 2 555450 555450 06/11/2024 American River Center 3900 Garfield 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 PPN dated 5/16/24 at 6:08 p.m. indicated, .[Resident 1] seen in [the] room after xray results come back showing a new fracture of left arm . A review of Resident 1's Minimum Data Set (MDS, a standardized comprehensive assessment tool) dated 6/3/24 indicated a score of seven out of 15, which indicated moderate cognitive impairment. On 6/11/24 at 10:30 a.m., the Department conducted an unannounced visit at the facility to investigate a complaint received by the Department on 5/29/24 involving an alleged injury to Resident 1 on 5/15/24. During an interview on 6/11/24 at 10:57 a.m., with the Director of Nursing (DON), the DON stated on 5/14/24, the NP saw Resident 1 due to a complaint of pain and the NP recommended obtaining x-ray. During an interview on 6/11/24 at 11:20 a.m., the DON confirmed she became aware of Resident 1's left arm fracture on 5/15/24. The DON acknowledged Resident 1's fracture was an injury of unknown origin because no one had reported Resident 1 had fallen. The DON verified the fracture could have been a pathological fracture (a fracture cause by disease of the bone) and stated she conducted an investigation to determine what the cause was. During an interview on 6/11/24, at 11:42 a.m., the DON confirmed and stated, .We didn't report it [Resident 1's fracture] . A review of the facility's policy and procedure titled Abuse Investigation and Reporting, revised July 2017 indicated, All reports of resident .injuries of unknown source .shall be promptly reported to .state .agencies .All .injuries of unknown source .will be reported immediately .The Administrator, or his/her designee, will provide the appropriate agencies .with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. 555450 Page 2 of 2