Health inspection·May 22, 2024

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00891723. Representing the Department, HFEN # 43452. A Class B Citation was written. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations § 483.12 (c) Freedom from Abuse, Neglect, and Exploitation. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §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 and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Cal. Code Regs. Tit. 22, § 72523 - Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 4/8/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about a resident's neglect. The facility failed to implement their policy regarding reporting of an injury of unknown source and to submit a conclusion report of investigation within five days in accordance with state or federal law for Resident 1. As a result, there was a delay of an onsite inspection by the Department to ensure the safety of the residents and had the potential to place residents at further risk for injuries. A review of Resident 1's Admission Record indicated the resident was admitted on 3/10/2024 with diagnoses including atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart), restless legs syndrome (RLS - is a condition in which one has feelings of "pulling, searing, drawing, tingling, bubbling, or crawling" beneath the skin, usually in the calf area), dysphagia (difficulty swallowing food or liquid) and abnormalities of gait and mobility. A review of Resident 1's History and Physical (H&P) dated 3/11/2024 indicated, Resident (1) has not decision-making capacity and has limited rehabilitation potential. A review of Resident 1's Situation Background Assessment Recommendation (SBAR - a written or verbal communication tool used to provide essential and concise information, usually during crucial situations), dated 3/10/2024, indicated, upon making rounds, patient had a unwitnessed fall, found lower extremity side of the bed, patient with signs and symptoms of pain in the left arm, swelling, discoloration, in patient report physical examination stated, "does not move left arm", Registered Nurse notified and Medical Doctor (MD) notified, ordered x-ray (a form of electromagnetic radiation, similar to visible light). During a concurrent interview and record review with Assistant Director of Nursing (ADON) on 4/9/2024 at 12:48 p.m., a review of Resident 1's Progress Notes dated 3/10/2024, indicated that Resident 1 was found on the floor and with complained of pain and inability to move left arm. ADON stated, Resident might have fallen but it was unwitnessed, and Resident 1 was unable to explained how he ended up on the floor. ADON stated, since the incident was unwitnessed, they don't know what the cause of the injury and this was not investigated by the facility and was not reported to the State Agency, Police and Ombudsman. A review of the facility policy and procedure (P&P) titled, "Reporting Injury of Unknown Origin to Facility Management", revised 1/2024 indicated, it is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source to the facility management... when an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility Administrator, or his/her designess, will immediate (within twenty-four hours of the alleged incident) notify the following persons or agencies of such incident: a. The state licensing/recertification agency responsible for surveying/licensing the facility; b. The resident's attending physician; and c. The facility Medical Director. d. Local Ombudsman ... Notices to the above agencies/individuals may be submitted via special carrier, fax, e-mail, or by telephone. Such notices will include, as appropriate: a. The name of the resident; b. The number of the room in which the resident resides; c. The type of abuse that was allegedly committed (i.e., verbal, physical, sexual, neglect, etc.); d. The date and time the incident occurred; e. The name(s) of all persons involved in the incident; and f. What immediate action was taken by the facility. (1) The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and (2) The injury is suspicious because of: • the extent of the injury; or • the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma); or • the number of injuries observed at one particular point in time; or • the incidence of injuries over time... When an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to facility management regardless of the time lapse since the incident occurred. Reporting procedures should be followed as outlined in this policy." A review of the facility's P&P titled, "Accidents and Incidents - Investigating and Reporting", reviewed on 1/2024 indicated, "All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator." The facility failed to implement their policy regarding reporting of an injury of unknown source and to submit a conclusion report of investigation within five days or in accordance with state or federal law for Resident 1. As a result, there was a delay of an onsite inspection by the Department to ensure the safety of the residents and had the potential to place residents at further risk for injuries. The above violations had direct or immediate relationship to the health, safety, or security of Resident 1.