Health inspection·February 2, 2024

22CCR §72541 - Unusual Occurrences. Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. 22CCR §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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. The California Department of Public Health (CDPH) received a complaint on 1/9/2024 at 12:19 p.m. indicating a homeless person broke into the parking garage when one car left and used a ladder to climb into a resident’s window. On 1/10/2024 at 11:10 a.m., an unannounced visit was conducted at the facility to investigate the allegation. The facility failed to: 1. Follow its policy and procedure (P&P) titled Unusual Occurrence Reporting, which indicated to report unusual occurrences via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident required by federal and state regulations. As a result of not reporting to CDPH, there was a delay in the investigation by the State agency. Findings: A review of Resident 1’s admission record dated 1/10/2024 indicated Resident 1 was a 70-year-old female, admitted to the facility on 5/27/21 and re- admitted on 11/21/23 with diagnosis of morbid obesity (overweight) due to excess calorie (serious health condition that results from an abnormally high body mass greater than 40), cerebral infarction (when the blood supply to part of the brain is blocked or reduce), and depression (serious mood disorder). A review of Resident 1’s Minimum Data Set (MDS-an assessment and care planning tool) dated 11/28/23 indicated Resident 1 had a clear speech, the ability to express ideas and wants, and understands. The MDS indicated Resident 1 was dependent on staff for toileting, shower/bathe, upper body dressing and lower body dressing. please indicate exact MDS terms under this section During an interview on 1/10/2024 at 12:20 p.m., with Resident 1 in her room, Resident 1 stated an intruder came through the sliding glass door and she was scared when the police came. Resident 1 stated the intruder moved quickly and did not touch her or her roommate. During an interview on 1/10/2024 at 1:10 p.m., with the Director of Staff Development (DSD), the DSD stated allegation about the “intruder incident” occurred about a month ago. The DSD stated she notified the Administrator, and the police came to the facility and arrested the intruder. The DSD stated the intruder used a ladder that was in the parking garage to access residents’ rooms. During an interview on 1/10/2024 at 1:55 p.m., with the Administrator, the Administrator stated about a month ago the DSD, reported an intruder came through the sliding glass door of Resident 1’s room. The Administrator stated the CDPH and the Ombudsman (patient advocate) were not notified about the incident of the intruder breaking into Resident’s 1 and 2’s room. The Administrator stated failure to report may have delayed the CDPH’s investigation. A review of the facility’s P&P titled “Unusual Occurrence Reporting”, revised 2023 indicated the facility will report unusual occurrences or other reportable events affecting the health, safety, or welfare of our residents, employees, or visitors. The P&P indicated the facility will report other unusual occurrences via telephone to appropriate agencies as required by law and/or regulations within twenty-four (24) hours of such incident required by federal and state regulations. The P&P indicated 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 other appropriate agencies as required by law within forty-eight (48) hours of reporting the event or as required by federal and state regulations. The facility failed to: 1. Follow its policy and procedure (P&P) titled Unusual Occurrence Reporting, which indicated to report unusual occurrences via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident required by federal and state regulations. As a result of not reporting to CDPH, there was a delay in the investigation by the State agency. This violation had a direct or immediate relationship to the health, safety, security of residents.