Health inspection·March 7, 2024

42 CFR §483.12(c) 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)(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. 22 CCR §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 1/11/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint and a facility reported incident about quality of care and resident abuse. The facility failed to implement its policies and procedures (P&P) to ensure the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by not reporting to CDPH two incidents of injuries of unknown origin (injury resulting without knowing how it happened) to Resident 1, which occurred on 4/15/2023 and 12/12/2023. As a result, there was a delay for an onsite inspection by CDPH to ensure the safety of Resident 1 and other residents and had the potential to result in unidentified abuse. A review of Resident 1’s Admission Record indicated the resident was originally admitted to the facility on 12/28/2021 and readmitted on 1/7/2023 with diagnoses that included functional quadriplegia (paralysis below the neck that affects all limbs) and osteoporosis (a disease in which bones become fragile and more likely to break) with pathological fracture (a broken bone caused by an underlying disease and not by force or impact). A review of Resident 1’s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 1/9/2024, indicated the resident had severely impaired cognition (the mental action or process of acquiring knowledge and understanding). The MDS further indicated that Resident 1 was totally dependent on staff for self-care and mobility. A review of Resident 2’s Admission Record indicated the resident was readmitted on 1/10/2024 with diagnoses including schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and anxiety disorder (a feeling of fear and uneasiness). A review of Resident 2’s MDS dated 11/7/2023, indicated the resident’s cognition was moderately impaired. The MDS further indicated that Resident 2 was able to wheel themselves independently at least 150 feet once seated in the wheelchair. A review of Resident 1’s Change of Condition Form (COC), dated 4/15/2023, timed at 6:00 a.m. indicated Resident 1 had a light-yellow discoloration with edema on the right upper and lower arm, and the right shoulder. A review of Resident 1’s Physician Orders, dated 4/15/2023, timed at 9:30 a.m. indicated that the physician ordered for X-radiation (x-ray- creation of pictures of the inside of the body) of Resident 1’s right shoulder and humerus (long bone of the upper arm). A review of Resident 1’s X-ray report dated 4/16/2023, indicated that Resident 1 had a nondisplaced (bone breaks into pieces that stay in their normal alignment) right humeral fracture (broken upper arm). During an interview on 1/25/2024 at 10:00 a.m., the Director of Nursing (DON) stated that Resident 1’s right upper arm fracture discovered on 4/16/2023 was an injury of unknown origin because the resident was unable to describe how the injury happened and that there were no witnesses to describe how Resident 1 sustained the injury. During an interview on 1/25/2024 at 1:40 p.m., the Administrator (ADM) was asked if the facility reported to CDPH Resident 1’s injury of unknown origin when discovered on 4/16/2023, the ADM stated Resident 1’s injury was not reported. The ADM stated that all injuries of unknown origins should be reported within two (2) hours from the identification of the injury to CDPH. A review of Resident 1’s COC Form dated 12/12/2023, timed at 11:38 a.m. indicated that Licensed Vocational Nurse (LVN 1) observed that Resident 2 was in Resident 1’s room holding Resident 1’s left hand. The COC Form further indicated that LVN 1 noted that Resident 1’s left arm was slightly swollen, and the elbow had with purplish discoloration. A review of Resident 1’s Physician Order, dated 12/12/2023, timed at 1:00 p.m. indicated an order for X-rays of Resident 1’s left shoulder, arm, and elbow. A review of Resident 1’s X-ray report dated 12/12/2023, indicated Resident 1 had no fracture or dislocation. During an interview with Resident 2 on 1/11/2024 at 4:02 p.m., Resident 2 was unable to recall the incident with Resident 1 on 12/12/2023. During an interview on 1/11/2024 at 4:06 p.m., LVN 1 stated that on 12/12/2023 Resident 2 was found holding Resident 1’s hand. LVN 1 stated that after Resident 2 released Resident 1’s hand, there were no initial discoloration or bruises observed. LVN 1 stated that approximately one hour later, Resident 1 had discoloration and swelling to the left upper arm. During an interview on 1/11/2024 at 5:26 p.m., the DON stated that Resident 1’s discoloration and swelling to the left upper arm identified on 12/12/2023 was an injury of unknown origin. The DON stated that Resident 1’s left upper arm discoloration and swelling noted on 12/12/2023 was an injury of unknown origin because Resident 1 was unable to explain what had happened. During an interview on 1/11/2024 at 5:36 p.m., the ADM, stated that the injury Resident 1 sustained on 12/12/2023 which included discoloration and swelling to the left upper arm was not reported to the SSA or the local law enforcement until 12/28/2023. A review of the facility’s P&P titled, “Abuse Prohibition and Prevention Program” revised March/2023, indicated that the facility shall ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property, are reported immediately, but not later than two [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 event 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 SSA. The facility failed to implement P&P to ensure the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by not reporting to CDPH two incidents of injuries of unknown origin to Resident 1, which occurred on 4/15/2023 and 12/12/2023. As a result, there was a delay for an onsite inspection by CDPH to ensure the safety of Resident 1 and other residents and had the potential to result in unidentified abuse. The above violations had a direct relationship to the health, safety, or security of Resident 1.