Health inspection·January 17, 2025

CFR§483.12 Freedom from Abuse, Neglect and Exploitation. (b) The facility must develop and implement written policies and procedures that: (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. (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. CCR§ 72523(a) 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. Health and Safety Code 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. On 12/2/2024, the California Department of Public Health (CDPH) conducted an unannounced annual recertification survey. During recertification survey CDPH determined on 12/1/2024 Resident 41 had a blood blister (a raised pocket of skin that contains blood, usually caused by an injury to the skin) on his right great big toe and the origin or cause of this injury was unknown. The facility failed to: 1. Report an injury of unknown origin when Resident 41 developed a blood blister on the right big toe. 2. Implement its Policy and Procedure (P&P) titled "Abuse Prevention" dated 6/2021, by failing to report an injury of unknown origin when Resident 41 developed a blood blister on his right big toe to CDPH within regulatory time frame. As a result, there was a delay of onsite investigation by CDPH to ensure injuries of unknown origin were investigated timely to rule out potential abuse. According to the X-ray (imaging that shows organs and bones of the body) report dated 12/2/2024 at 12:49 p.m., Resident 41 had a possible nondisplaced (broken, but not shifted out of alignment) tuft (tip) of the big toe fracture (break) and soft tissue swelling overlying the big toe. A review of Resident 41's Admission Record, indicated Resident 41, a 38-year-old male, was admitted to the facility on 2/19/2022 with diagnoses including respiratory failure (condition when the lungs are not able to effectively take in oxygen and remove carbon dioxide from the blood), cerebral vascular accident (CVA-stroke, loss of blood flow to a part of the brain), tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs) in place, gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). A review of Resident 41's Minimum Data (MDS- a resident assessment tool) dated 10/23/2024, indicated the resident had severely impaired cognitive (significant decline in a person's ability to think, learn, remember, reason, and make decisions affecting their daily life) skills and was dependent on staff with bed mobility, oral hygiene, bathing, dressing, personal hygiene, and transfer to and from a bed to chair or wheelchair. The MDS indicated Resident 41's skin was intact with no infection on the foot and no presence of pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence). A review of Resident 41's Flow Sheets for Skin Assessment dated 11/30/2024 and timed at 2:51 p.m., 11/30/2024 and timed at 10:22 p.m., 12/1/2024 and timed at 1:33 p.m., and 12/1/2024 timed at 11:54 p.m., indicated Resident 41's skin color was consistent with ethnicity, blanchable (skin appeared white or not as reddened after being pressed on and skin returns to its normal color) warm, dry skin, and skin was elastic (ability of skin to stretch and return to its original shape). A review of Resident 41's Progress Notes dated 12/2/2024 and timed at 7:22 a.m., indicated on 12/1/2024 at 6:27 a.m., an unidentified Certified Nursing Assistant (CAN U)), observed Resident 41 had a blood blister on his right great toe, while she was providing morning care. A review of Resident 41's Progress Notes dated 12/2/2024 and timed at 12:09 p.m., indicated Registered Nurse (RN) 3 received report from the outgoing shift nurse (unidentified) that Resident 41 had a bruise to the right great toe . The Progress Notes indicated Resident 41's right great toe had a large blood blister, of purple, dark red brown color measuring 1.5-centimeter (cm- unit of measurement) x 2 cm, with slight swelling and tenderness on the right big toe on assessment. The Progress Notes indicated the family, and the physician were notified, and right toe x-ray was ordered. A review of Resident 41's x-ray of the right big toe performed on 12/2/2024 at 12:49 p.m., and resulted on 12/2/2024 at 1:48 p.m., indicated a possible nondisplaced tuft of the big toe fracture and soft tissue swelling overlying the big toe. A review of Resident 41's Custodial Progress Note dated 12/3/2024 and timed at 10:56 a.m., indicated a possible nondisplaced area is less than 2 millimeter (mm- unit of measurement) and minor enough to buddy tape (a method of treating an injured toe by taping it to an uninjured digit or toe next to it to provide support and protection for an injured digit) as if there is a minor fracture. The Progress Notes indicated the resident would be receiving an antibiotic (medicine used to treat an infection) for five days for the redness and swelling like cellulitis (skin infection that causes swelling and redness). During an observation on 12/3/2024, at 10:37 a.m., Resident 41 was sitting in a wheelchair watching a program on an electronic device. An unnamed physician came and examined resident 41's right foot. Resident 41's right foot was resting on a pillow and appeared slightly swollen and red. During an interview on 12/3/2024, at 12:18 p.m., Resident 41's family member (FM1), stated she could not understand why Resident 41's great big toe was broken or how the injury occurred. During an interview on 12/5/2024, at 3:32 p.m., CNA 1, stated she gave Resident 41 a shower on 12/1/2024. CNA 1 stated Resident 41's skin was intact. CNA 1 stated she asked CNA 2 to assist her with the Resident 41's shower. During a concurrent interview and record review with Registered Nurse (RN) 3, on 12/5/2024, at 4:53 p.m., Resident 41's electronic chart was reviewed. RN 3 stated the x-ray of Resident 41's right big toe indicated a possible nondisplaced fracture on the tuft of the right big toe. RN 3 stated the treatment was, splinting by buddy taping (supporting the injured toe by taping it to an uninjured toe) the first and second toes together. RN 3 stated blood blisters can be caused by pressure or trauma, and nobody knew how the resident got the blood blister or what caused it. RN 3 stated she did not report the incident to CDPH because she did not think it was abuse. RN 3 stated she notified the House Supervisor (HS) but was not told to reported to CDPH. During a concurrent interview and record review of facility's policy and procedure titled "Abuse Prevention" on 12/6/2024, at 6:35 p.m., and subsequent interview on 12/6/2024, at 7:05 p.m., with the Director of Nursing (DON), the DON stated an injury of unknown origin is reported to CDPH within 24 hours. The DON stated it was important to report any suspicion of abuse or injury of unknown origin to CDPH within 24 hours to rule out abuse or neglect. During a review of facility's P&P titled "Abuse Prevention" dated 6/2021, the P&P indicated investigation of injuries of unknown origin, or suspicious injuries must be immediately investigated to rule out abuse. The P&P indicated if the injury is unexplainable, a report must be made to the facility designated State agency within 24 hours of the initial findings and employee must always report any abuse or suspicion of abuse immediately. The facility failed to: 1. Report an injury of unknown origin when Resident 41 developed a blood blister on the right big toe. 2. Implement its P&P titled "Abuse Prevention" dated 6/2021, by failing to report an injury of unknown origin when Resident 41 developed a blood blister on his right big toe to CDPH within regulatory time frame. As a result, there was a delay of onsite investigation by CDPH to ensure injuries of unknown origin were investigated timely to rule out potential abuse. According to X-ray report dated 12/2/2024 at 12:49 p.m., Resident 41 had possible nondisplaced tuft of the big toe fracture and soft tissue swelling overlying the big toe. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 41.