Health inspection·January 27, 2025

42 CFR §483.12 Freedom from abuse, neglect, and exploitation. (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. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. 22CCR §72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be implemented to ensure that patient related goals and facility objectives are achieved. HSC 1418.91 (a) A long-term health care facility shall report all incident of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) Failure to comply with the requirements of this section shall be a class "B" violation. On 12/23/2024 at 9:37 a.m., the California Department of Public Health (CDPH) received a complaint indicating a Licensed Vocational Nurse (LVN) [unidentified]) who worked during the night shift (11:00 p.m.- 7:00 a.m.) pushed Resident 3 and caused the resident to fall, hit her head and fracture her arm (site unspecified). On 12/24/2024 at 5:45 a.m., the CDPH conducted an unannounced visit at the facility to investigate the allegation. The facility failed to: 1). Ensure Resident 3's injuries of unknown source sustained on 6/18/2024, 11/5/2024 and 12/24/2024 were reported to the CDPH, within 24 hours according to its Policy and Procedure titled, "Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating." This deficient practice resulted in a delay of investigation by the CDPH. A review of Resident 3's Admission Record indicated Resident 3 was an 85-year-old female, originally admitted to the facility on 4/26/2022 and readmitted on 6/17/2024. Resident 3's diagnoses included schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves) and major depressive disorder (mood disorder that causes a persistent low mood and loss of interest in activities). A review of Resident 3's Minimum Data Set ([MDS], a resident assessment and tool), dated 2/2/2024, indicated Resident 3 had impaired cognitive impairment. The MDS indicated Resident 3 required set-up assistance with eating, toileting, and personal hygiene. The MDS indicated Resident 3 required supervision with oral hygiene, shower/ bathing, and putting on/taking off footwear. A review of Resident 3's Change of Condition (COC)/ Interact Assessment Form (Situation, Background, Assessment, and Recommendation [SBAR] a structured way to communicate to the care team about a resident's change in condition), dated 6/18/2024 at 1:29 p.m., indicated Resident 3 was noted with swelling of the right leg from the resident's knee to her foot and had complained of pain upon touch of the affected areas. A review of Resident 3's progress notes dated 6/18/2024 and 6/19/2024 did not indicate the swollen tibia, fibula was reported to CDPH. A review of Resident 3's SBAR dated 11/5/2024 at 6:28 p.m. indicated Resident 3 had a swollen left wrist. The SBAR indicated Resident 3 did not know what happened and how the swelling happened. During a review of Resident 3's progress notes dated 11/5/2024 and 11/6/2024, the notes did not indicate swollen left wrist was reported to CDPH. During an interview on 12/24/2024 at 9:58 a.m., with Certified Nurse Assistant (CNA 1), CNA 1 stated Resident 3 was on one-on-one care ([1:1] when a facility staff provides constant, individualized supervision to one resident) because Resident 3 would get out of bed without asking for assistance and had a very poor balance, poor self-awareness and was at risk for falls and injuries. During a concurrent interview and record review on 12/24/2024 at 11:31 a.m. with the Treatment Nurse (TN), Resident 3's SBAR dated 12/24/2024 at 2:07 p.m. was reviewed. The TN stated the SBAR indicated Resident 3 sustained left lower extremities skin discolorations. The TN stated even though Resident 3 had been on 1:1 monitoring, the facility did not know how Resident 3 sustained the left lower extremities' skin discolorations, swelling, and bruises on 6/18/2024 and 11/5/2024. The TN stated it was suspicious for a resident to wake up with a bruise or swelling without a reason on how it happened. A review of Resident 3's progress notes dated 12/24/2024 and 12/25/2024, did not indicate the skin discolorations found on Resident 3's left lower extremities' were reported to the CDPH. During an interview on 12/31/2024 at 2:40 p.m., with the Administrator (Admin), Admin stated it was suspicious that staff were monitoring Resident 3, 24-hours a day, 7 days a week and did not know how the swelling and skin discolorations on Resident 3 occurred on 6/18/2024, 11/5/2024 and 12/24/2024. The Admin stated, the facility should have investigated and reported Resident 3's unexplained bruises and swelling of the resident's leg and wrist to the CDPH within two hours per their policy. A review of the facility's P&P titled, "Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating," dated 3/2023, indicated, if injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to the state licensing/ certification agency responsible for surveying/ licensing the facility according to state law. The P&P indicated immediately was defined as within two hours if the allegation resulted in serious bodily injury and 24 hours if the allegation did not result in serios bodily injury. The facility failed to: 1). Ensure Resident 3's injuries of unknown source sustained on 6/18/2024, 11/5/2024 and 12/24/2024 were reported to the CDPH, within 24 hours according to its P&P titled, "Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating." This deficient practice resulted in a delay of investigation by the CDPH. This violation had a direct or immediate relationship to the health, safety, or security of Resident 3.