Health inspection·January 25, 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 promptly report an injury of unknown origin to the California Department of Public Health (CDPH) in accordance with the facility's policy, for one of three residents (Resident 1). This failure had the potential for an injury of unknown origin to go uninvestigated and unreported thereby increasing the chances of harm to Resident 1. Findings: An unannounced visit was made to the facility on January 25, 2024, at 9:50 AM, to investigate a complaint regarding Injury of Unknown Origin. During a review of residents ' 1 ' s admission Record (General Demographics), the document indicated resident 1 was admitted to the facility on [DATE], with a diagnosis to include Alzheimer ' s Disease (A progressive disease that destroys memory and other important mental functions), Epilepsy (A disorder in which nerve cell activity in the brain is disturbed, causing seizures), Disorder of bone density and structure. During a review of resident 1 ' s progress notes (the records nurses and doctors keep during a patient's hospitalization) on January 25, 2024, at 11:20 AM, the record dated January 10, 2024, at 11:23 PM, it indicated, Resident found lying on the floor on the right side of bed. With legs still up on bed. Skin assessment performed by writer. Resident has bruising to the left upper shoulder. No injuries reported to physician. During a review of resident 1 ' s progress notes on January 25, 2024, at 11:20 AM, the record dated January 14, 2024, at 8:21 PM, it indicates received x-ray results for this resident of the left shoulder s/p (status post) fall occurring January 11, 2024. Results sent to MD (doctor) for review. Doctor ordered for resident to be sent to ER (emergency room) for further follow-up. MD requesting CT(computerized tomography) scan to be completed at ER. Orders carried out. DON (director of nursing) made aware of transfer and agree. Daughter in law, notified of transfer and clinical situation. During an interview of resident 1, Resident was lying down. Resident is Spanish speaking and answers only yes and no. Resident has Alzheimer ' s and dementia. Resident is unable to communicate or answer questions. Resident bed is in low position and has a fall mattress next to the bed. Call light within reach. Page 1 of 2 555772 555772 01/25/2024 Joshua Tree Post Acute 8515 Cholla Ave Yucca Valley, CA 92284

F 0609 Level of Harm - Minimal harm or potential for actual harm During an interview with Assistant Administrator (AA), she stated resident had a seizure (a sudden, uncontrolled burst of electrical activity in the brain), and the x-ray was taken. I asked her why the results of the x-ray were reviewed by the doctor on the 14th when the x-ray was taken on the 11th. She stated she had no answer for that. States she will have the Director of Nursing (DON) come speak to me since she is not sure of what may have happened. Residents Affected - Few During an Interview with Director of Nursing on January 25, 2024, at 11:15AM, she stated there were no visible injuries, the resident was alert, and she had no complaint of pain, so she was not sent out. The doctor was notified. Stated the x-ray was taken on January 11, 2024, and, results of the x-ray were received on January 11, 2024, at night. States the x-ray showed osteopenia therefore the resident was not sent out. Resident had another seizure after that. Stated when doctor reviewed the x-ray on January 14, 2024, he opted to send resident out to hospital for further follow up. MD requested CT scan. The family was notified of transfer and clinical situation. She states the incident was not reported due to resident had seizure that cause the fall and she had no injuries. During a record review on January 25. 2024 at 11:20 AM, review of Policy and procedures titled Unusual Occurrence Reporting Version 1.1, the documented stated, As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents. It also indicates, a written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and or other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state requirements. 555772 Page 2 of 2