Health inspection·June 30, 2025

HSC 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. § 72315 - Nursing Service-Patient Care b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. § 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. 42 CFR § 483.12 - Freedom from abuse, neglect, and exploitation. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. On 5/19/2025 an unannounced visit was conducted at the facility to investigate a facility reported incident and complaint for an injury of unknown origin. The facility failed to report an unusual occurrence of an acute distal femur fracture (a break in the lower part of the thighbone, near the knee joint) of unknown origin to the Department (California Department of Public Health) within 24 hours of the occurrence, for one of one resident (Resident 1). This failure in reporting delayed an onsite inspection by the Department, to ensure injuries from unknown origin were investigated timely and had the potential to delay the prevention of further injuries. A review of Resident 1's Admission Record, the Admission Record indicated the facility originally admitted Resident 1, a 90-year-old-female, on 2/28/2024, then was re-admitted on 5/8/2025, with diagnoses including but not limited to end age-related osteoporosis (weak and brittle bones due to lack of calcium and vitamin D) without current pathological fracture (broken bone caused by disease), dementia (a progressive state of decline in mental abilities), and contracture of the right knee (the tissues around the joint have become stiff or tight, limiting the knee's ability to move freely). A review of Resident 1's History and Physical, dated 5/9/2025, the H&P indicated Resident 1 did not have the capacity to understand nor make decisions. A review of Resident 1's Minimum Data Set, (MDS - a resident assessment tool), dated 2/24/2025, indicated Resident 1 was dependent on assistance from staff in performing activities of daily living (helper performs all the effort. Resident did none of the effort to complete the activity. Or the assistance of two or more helpers was required for the resident to complete the activity). A review of Resident 1's Radiology Result Report X-ray (a photograph of the internal composition of a body part) of the right knee dated 5/4/2025, indicated Resident 1 had an acute mildly displaced supracondylar fracture of the distal femur. A review of Resident 1's Progress Notes dated 5/6/2025, indicated the results of Resident 1's X-ray were reported to the facility on 5/4/2025. A review of the facility's fax transmittal document, dated 5/7/2025, indicated the facility reported the unusual occurrence regarding Resident 1 to the Department on 5/7/2025 at 8:51 p.m. During an interview on 5/19/2025 at 3:27 p.m. with Registered Nurse Supervisor, (RNS) 1, RNS 1 stated the results of Resident 1 x-ray should have been reported to the Department within 24 hours of the facility becoming aware of the results. RNS 1 stated the failure to report unusual occurrences or test results within the required timeframe could have further jeopardized Resident 1's well-being. During a concurrent interview and record review on 5/19/2025 at 3:27 p.m. with the Director of Nursing (DON), the fax transmittal document reporting the unusual occurrence to the Department, dated 5/7/2025, and Resident 1's Radiology Result Report X-ray, dated 5/4/2025, were reviewed. The DON stated Resident 1's x-ray result should have been reported to the Department as soon as the facility became aware of the results, no later than 24 hours. The DON stated the results of Resident 1's x-ray were not reported to the Department until 5/7/2025 but should have been sent on 5/5/2025. A review of the facility's policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating," revised 3/24/2025, indicated, "All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported: ... 5. Immediately is defined as: a. within two hours of an allegation involving abuse or resulting in physical harm/serious bodily injury; orb. within 24 hours of an allegation that does not involve abuse or result in physical harm/serious bodily injury." A review of the facility's policy and procedure titled, "Unusual Occurrence Reporting," revised 12/2007, indicated, "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, employees or visitors: ... 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations." The facility failed to report an unusual occurrence of an acute distal femur fracture (a break in the lower part of the thighbone, near the knee joint) of unknown origin to the Department within 24 hours of the occurrence, for one of one resident (Resident 1). This failure in reporting delayed an onsite inspection by the Department, to ensure injuries from unknown origin were investigated timely and had the potential to delay the prevention of further injuries. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.