Health inspection·March 28, 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 observation, interview, and record review, the facility failed to implement their policies and procedures for ensuring the reporting of injuries of unknown source for one of two sampled residents (1) to other officials (including to the California Department Public Health (CDPH) and adult protective services (APS) where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures after when Resident 1 sustained a subdural hemorrhage (is a kind of intracranial hemorrhage, which is the bleeding in the area between the brain and the skull) with multiple rib fractures on 2/19/24 and transferred to an acute hospital for intensive care unit (ICU, provides the critical care and life support for actually ill and injured patients) monitoring and management, and facility's investigation did not identify the reason or cause of Resident 1's injuries. Failure to report alleged violations to the proper authorities could compromise the protection of residents from harm. Findings: Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 9/20/23, indicated her cognitive skills were moderately impaired for daily decision making and her functional status was total dependence for the activities of daily living (transferring, eating, dressing, toileting .). Review of Resident 1's history of present illness notes, dated 2/19/24 at 5:05 p.m., indicated, She had past medical history (PHI) of dementia (is a term used to describe a group of symptoms affecting memory, thinking and social abilities), diabetes mellitus (DM, is a disease of inadequate control of blood level glucose), transient ischemic attack (TIA, is a temporary blockage of blood flow to the brain) .for a head hematoma that was noticed today at around 11:30 a.m. The nursing facility reported that they noticed the hematoma after giving her a shower using a hoister (lift). Per nursing staff her baseline is non-ambulatory and alert and oriented to person (A & O x 1). They denied any recent falls. Patient is on Eliquis (is a prescription medicine used to reduce the risk of stroke and blood clots). Review of Resident 1's change in condition evaluation, dated 2/19/24, indicated she was transferred to the acute hospital's emergency department for further evaluation and treatment. On the change in condition of the skin status evaluation documented, Noted with bump on left side of the forehead, approximately 7 centimeters (cm, unit of measurement) x 8 cm, purplish discoloration in color, skin abrasion with slight bleeding noted. Further assessment done. Noted a linear scratch reddish in color, measuring 10 cm x 0.5 cm, no bleeding noted. Abrasion on left elbow measuring 1 cm x 0.5 cm, with slight bleeding noted. Page 1 of 3 555487 555487 03/28/2024 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 1's progress notes, dated 2/22/24 at 2 p.m., indicated the director of nursing (DON) called Resident 1's daughter at around 11 a.m. on 2/20/24 for follow-up with Resident 1's status as she was admitted in the ICU for her CT scan revealing of her head bleeding with multiple rib fractures on the left second rib to the eighth rib. Review of Resident 1's hospital Discharge summary, dated [DATE], indicated she was discharged from the hospital with diagnoses including rib fractures (left two to three anterior, three to eight posterior rib fractures), subdural hemorrhage and left hemothorax (is blood entering the pleural cavity). Review of the undated facility's investigative summary report for Resident 1's incident of injuries on 2/19/24 at 11:20 a.m., the report indicated the facility was unable to substantiate the allegation of fall or accident from Hoyer lift and did not find the reason and cause to Resident 1's injuries. However, according to the interventions and approaches on the investigative summary report, it did not include notification to proper authorities such as law enforcement office, Ombudsman /and or APS (Adult Protective Services) and CDPH (California Department of Public Health, State Survey Agency). During an observation on 2/26/24, at 10 a.m., in Resident 1's room, Resident 1 was lying in bed with visible light purplish discoloration on her left face, and dark purplish discoloration noted on the left side of her neck. During a follow-up interview on 2/26/24, at 10:10 a.m., with certified nursing assistant B (CNA B), CNA B stated, I do not know what had happened to cause Resident 1's injuries. Before, Resident 1 was forgetful but able to sit on the wheelchair attending activity, but right now she is unable to get up sitting on the wheelchair because complaining of pain when moving her body. During an interview on 2/26/24, at 2:39 p.m., with certified nursing assistant C (CNA C), CNA C stated, on 2/19/24 he helped CNA A transfer Resident 1 using Hoyer lift from her bed to the wheelchair after shower and did not see any bruises or bump on Resident 1's left forehead at that time. During an interview on 2/26/24, at around 4:20 p.m., with the administrator (ADM), he stated, Something happened to Resident 1 but no witness, and the assigned certified nursing assistant (CNA A) denied that Resident had fallen while in the shower and the other two CNAs (CNA B and C) who assisted with CNA A for a Hoyer lift transfer did not see bruises or bump on Resident 1's left forehead. The ADM also stated, Only God knows what had happened to Resident 1. During an interview on 2/27/24, at around 2:15 p.m., with the director of nursing (DON), she confirmed that facility did not make a report to law enforcement, CDPH and APS. Review of the facility ' s policy and procedure (P&P) titled, Abuse Prohibition and Prevention Program, revision dated 3/2023, the P&P indicated, The facility shall 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 of 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 provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. 555487 Page 2 of 3 555487 03/28/2024 Mission DE LA Casa 2501 Alvin Avenue San Jose, CA 95121

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's policy and procedure (P&P) titled, Reporting of Alleged Violations, revised 3/2023, the P&P indicated, Serious Bodily injury as an injury involving extreme physical pain, substantial risk of death or requiring medical attention, including, but not limited to, hospitalization . The administrator or Director of Nursing Services must be immediately notified of suspected abuse or incidents of abuse Reporting procedures should be followed as outlined in this policy. The facility shall report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required. 555487 Page 3 of 3