Health inspection·April 8, 2025

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. (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. (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. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (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§ 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. CCR§ 72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. 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 2/24/2025 the California Department of Public Health (CDPH) received a facility reported incident (FRI) alleging Resident 1 had an unknown source of injury resulting in swelling of the left thigh on 2/21/2025. On 2/26/2025 at 6:07 a.m., CDPH conducted an unannounced visit to the facility to investigate the FRI allegation. CDPH determined the facility failed to: 1. Implement its Policy and Procedure (P&P) titled, "Abuse Reporting and Prevention” dated 4/2024 which indicated “it is the policy of this facility that reporting of alleged violations involving mistreatment, neglect, abuse including injuries of unknown sources, unusual occurrences do not result in serious bodily injury, the facility should report the violation within 24 hours.” As a result of this failure CDPH could not investigate Resident 1’s injury of unknown origin in a timely manner and had the potential for information regarding the source of the injury to be lost and/or forgotten. A review of Resident 1, an 89-year-old female’s, Admission Record, indicated Resident 1 was admitted to the facility on 12/19/2024 with diagnoses including dependence of renal (kidney) dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of muscle on multiple sites, and protein and calorie malnutrition. A review of Resident 1’s History and Physical (H/P), dated 12/21/2024, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set ([MDS], a resident assessment tool), dated 12/26/2024, indicated Resident 1’s cognition was severely impaired. The MDS indicated Resident 1 was dependent on facility staff for all aspects of activities of daily living ([ADL] bathing, toileting, eating, dressing, personal hygiene). The MDS indicated Resident 1 had impairments bilaterally (on both sides) on the upper (arm/shoulders) and lower (hips/legs) extremities A review of Resident 1’s Situation, Background, Assessment and Recommendation ([SBAR] a form of communication between members of a health care team) dated 2/21/2025, indicated Resident 1 had swelling (of unknown source) on her left thigh. A review of the Order Summary Report indicated a physician’s order dated 2/21/2025 and timed at 1:10 a.m., for an immediate (STAT) X-ray (a medical imaging process that creates images of different tissues in the body) of the left femur. A review of Resident 1’s X-ray results report dated 2/21/2025 indicated Resident 1 had nonspecific soft tissue swelling, and an acute (sudden onset) displaced (out of alignment) fracture (broken bone) of the left proximal (near the center of the body) femoral diaphysis (long bone of the thigh). A review of the Order Summary Report indicated a physician’s order dated 2/21/2025 and timed at 11:47 a.m. to transfer resident to the GACH emergency room for pain management due to fracture. During an interview on 2/27/2025 at 2:11 p.m., the Director of Nursing (DON) stated when she found out about Resident 1's left thigh swelling, she notified the Administrator (ADM) and the Medical Doctor 1 (MD 1) and did a thorough investigation of what took place with Resident 1 starting on 2/18/2025 until 2/21/2025. The DON stated this was an unusual occurrence and the initial reporting to CDPH, the ombudsman (resident advocate), and law enforcement, should have happened on the same day (2/21/2025). The DON stated staff should make an initial report to the appropriate agencies, as Resident 1's left thigh swelling was an unusual occurrence, and not reporting would compromise the residents’ safety. During an interview on 2/27/2025 at 3:06 p.m., the ADM stated when she was notified of an injury of unknown origin, she gathered statements/claims, called the police, filled out a report and sent it to the ombudsman, CDPH, and started the investigation the same day. The ADM stated she was supposed to report this injury of unknown origin right away and knew she reported it late. The ADM stated she called CDPH on 2/24/2025 to report this unusual occurrence (of an injury of unknown origin) that was discovered on 2/21/2025 and on 2/25/2025 faxed the investigation report and the 5-day summary report. The ADM stated the facility are supposed to report and notify anything that can impact those residents to the department. During a review of the facility's policy and procedure (P/P), titled, "Abuse Reporting and Prevention” dated 4/2024, the P/P indicated “it is the policy of this facility to ensure that resident rights are protected by providing a method of investigation and reporting of alleged violations involving mistreatment, neglect, abuse including injuries of unknown sources, unusual occurrences. The administrator, as the abuse coordinator, will investigate each alleged violation thoroughly and report results to appropriate agencies and personnel. The administrator, or his/her designee, will report each alleged abuse to the Ombudsman's office and the Department of Public Health immediately or within 2 hours per Section 1418.91 of the Health and Safety Code. If the alleged violation does not involve abuse and does not result in serious bodily injury, the facility should report the violation within 24 hours. All alleged allegations and all substantiated incidents will be reported to the Department of Public Health and to all other agencies as required by State law, i.e., the local law enforcement agency, Certified Nursing Assistant certification board, appropriate licensing board and the local Ombudsman. The results of the investigation must be reported within 5 working days of the incident. The facility failed to: 1. Implement its P&P titled, "Abuse Reporting and Prevention” dated 4/2024 which indicated “it is the policy of this facility that reporting of alleged violations involving mistreatment, neglect, abuse including injuries of unknown sources, unusual occurrences do not result in serious bodily injury, the facility should report the violation within 24 hours.” As a result of this failure CDPH could not investigate Resident 1’s injury of unknown origin in a timely manner and had the potential for information regarding the source of the injury to be lost and/or forgotten. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 1.