Health inspection·April 30, 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. 22 CCR § 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. 22 CCR § 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. On 3/4/2025, the California Department of Public Health (CDPH) received a complaint allegation that Resident 1, who had an unexplained right wrist fracture (broken bone) on 3/3/2025, was a possible victim of abuse, neglect, domestic violence or victim of violent crime, while residing at the facility. On 3/12/2025 at 8:25 a.m., the CDPH conducted an unannounced visit to investigate the allegation. The facility failed to: 1). Implement its policy and procedure (P&P) titled, "Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment," which indicated to report injuries of unknown source, immediately but, not later than 2 hours after the allegation was made, if the events that caused the allegation resulted in serious bodily injury, when Resident 1 sustained a right wrist fracture on 3/3/2025. This violation delayed the investigation by the CDPH. Resident 1 was an 81-year-old-male, originally admitted to the facility on 9/27/2024 and re-admitted on 1/27/2025. Resident 1's diagnoses included dementia (a progressive state of decline in mental abilities), cerebral infarction (a medical condition where blood flow to the brain is interrupted, leading to the death of brain cells) and psychotic disorder with delusions (a mental health condition characterized by persistent and false beliefs [delusions] that are not based on reality). A review of Resident 1's Minimum Dat Set (MDS- a federally mandated resident assessment tool) dated 1/3/2025, indicated Resident 1 had clear speech, was able to understand and had the ability to express ideas and wants. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from staff with eating, oral hygiene and personal hygiene. The MDS indicated Resident 1 required set-up assistance (helper sets up; resident completes activity) with sit to stand. The MDS indicated Resident 1 required supervision or touching assistance with chair/bed-to-chair transfer, toilet transfer and walking 10 feet to 150 feet. A review of Resident 1's "Change of Condition (COC) Evaluation," dated 3/3/2025 at 11:37 a.m., indicated Resident 1 had a swollen right wrist. The COC indicated the resident was guarding (protecting) the right hand. The COC indicated the primary physician was notified of the swollen right wrist and ordered an x-ray (process of taking pictures of tissues and structures inside the body for diagnosis and treatment). A review of Resident 1's right wrist x-ray result dated 3/3/2025 at 10:35 p.m., indicated an acute mildly displaced fracture on the distal (outer) radial metaphysis (bone near the wrist), and an acute fracture of the ulnar styloid (bony area near the wrist). A review of Resident 1's progress notes dated, 3/3/2025 at 11:37 a.m., to 3/3/2025 at 11 p.m., did not indicate documented evidence Resident 1's right wrist fracture was reported to CDPH. A review of the facility's investigation report titled, "Wrist Injury Investigation," dated 3/4/2025 (time not indicated), indicated on 3/3/2025, during Resident 1's therapy session, a therapist (unidentified) noted Resident 1's right wrist was swollen, and the resident was guarding (protecting) his right hand. The report indicated, during the facility investigation, interviews were conducted with therapists and Certified Nursing Assistants (CNA) that were directly involved in Resident 1's care. The report indicated, Resident 1's injury occurred because the resident stroked (hit) a hard object during one of his erratic (unpredictable) behavior episodes (dates not specified). During a telephone interview on 3/12/2025 at 4:50 p.m., with Family Member 1 (FM1), FM1 stated he visited Resident 1 on 2/28/2025 and Resident 1 was fine. The FM1 stated before Resident 1 left the facility for out on pass to a family event on 3/1/2025, he noticed Resident 1 was guarding his right wrist and he (FM 1) informed a Licensed Vocational Nurse (not identified). The FM1 stated at the family event, Resident 1 continued to guard his right arm and hand, and refused to shake hands with relatives. During a telephone interview on 3/18/2025 at 4:32 p.m., with the Director of Nursing (DON), the DON stated Resident 1's "Wrist Injury Investigation" report dated 3/4/2025, was not reported and sent to CDPH until after the Surveyor's initial visit on 3/12/2025. During a telephone interview on 3/19/2025 at 9:30 a.m., with the Administrator (ADM), the ADM stated the "Wrist Injury Investigation" report dated 3/4/2025 was not sent to the CDPH on time because the facility did not suspect abuse, neglect or injury of unknown origin. The ADM stated Resident 1 injured himself. A review of the facility's policy and procedure (P&P) titled, "Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment," dated 12/2023, indicated all alleged violations involving abuse or neglect, including injuries of unknown source, should be reported immediately but, not later than 2 hours after the allegation was made, if the events that caused the allegation resulted in serious bodily injury. The facility failed to: 1). Implement its P&P titled, "Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment," which indicated to report injuries of unknown source, immediately but, not later than 2 hours after the allegation was made, if the events that caused the allegation resulted in serious bodily injury, when Resident 1 sustained a right wrist fracture on 3/3/2025. This violation delayed the investigation by the CDPH. This violation had a direct or immediate relationship to the health, safety, or security of the resident.