Health inspection·September 13, 2024

Code of Federal Regulations, Title 42, Section 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. California Code of Regulations, Title 22, Section 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 7/31/2024, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding quality of care, resident abuse, infection control, and other services. As a result of the investigation, the CDPH determined the facility failed to report an injury of unknown origin/source (the source of the injury was not observed by any person and could not be explained by the resident) immediately, but not later than 24 hours to the Administrator (ADM) of the facility, the CDPH, local law enforcement, and Ombudsman as indicated in the facility's policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating," for Resident 3. This failure violated Resident 3’s rights, had the potential to compromise Resident 3's safety, and could result in further injuries to Resident 3 potentially related to abuse. A review of Resident 3's Admission Record indicated the facility admitted Resident 3, a 94-year-old female to the facility on 12/28/2021, with diagnoses that included Alzheimer's Disease, encephalopathy, and dysphagia. A review of Resident 3's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 6/19/2024, indicated Resident 3 had severely impaired cognition. The MDS indicated Resident 3 was dependent on staff for eating, oral, toileting and personal hygiene, upper and lower body dressing, putting on and taking off footwear, and rolling left and right in bed. A review of Resident 3's Change of Condition (COC)/Interact Assessment Form (Situation-Background-Assessment-Recommendation [SBAR]), dated 7/15/2024, timed at 2:34 pm, indicated Resident 3 was weak and lethargic, and noted with “one bruise” on the right knee. The COC/SBAR Form indicated Licensed Vocational Nurse (LVN) 2 notified Resident 3's hospice nurse on 7/15/2024 at 2:20 pm. A review of Resident 3's Interdisciplinary Team (IDT- group of health care professionals with various areas of expertise who work together toward goals of their residents) Narrative, dated 7/17/2024, timed at 3:54 pm, indicated the IDT met and discussed Resident 3's condition. The IDT Narrative indicated Resident 3 had bluish discolorations to the right knee and right foot. The IDT Narrative indicated Resident 3's Responsible Party (RP 1), was present at bedside and notified of the plan of care. The IDT Narrative indicated staff did not report any fall incident involving Resident 3, and Resident 3 was unable to tell staff how the discolorations occurred. The IDT Narrative indicated Certified Nursing Assistant (CNA) 1 found discoloration to Resident 3's right knee measuring one (1) by 1 centimeter (cm) and discoloration to Resident 3's right foot measuring 8.3 cm by 6.2 cm while changing Resident 3's brief. The IDT Narrative indicated CNA 1 notified LVN 2. The IDT Narrative indicated Resident 3 was unable to give a description of the incident. A review of Resident 3's Progress Notes (PN), dated 7/17/2024, timed at 9:49 pm, indicated (on 7/17/2024), at 3:45 pm, Resident 3 had a fracture to the right proximal phalanx of the great toe with soft tissue swelling. During an interview on 7/31/2024 at 3:31 pm, CNA 1 stated while changing Resident 3's brief on 7/15/2024, unable to recall time, CNA 1 noticed a bruise on Resident 3's right knee. CNA 1 stated CNA 1 did not notice a bruise on Resident 3's right foot at that time. CNA 1 stated CNA 1 immediately reported the bruising to LVN 2. During a telephone interview on 7/31/2024 at 3:36 pm, LVN 2 stated on 7/15/2024, unable to recall time, CNA 1 reported to LVN 2 that Resident 3 had bruising to Resident 3's right knee. LVN 2 stated LVN 2 reported Resident 3's right knee bruising to the hospice nurse right away. LVN 2 stated LVN 2 did not observe the bruising to Resident 3's right foot at that time (7/15/2024). LVN 2 stated LVN 2 did not report Resident 3's right knee bruising (injury of unknown origin) to the Administrator. LVN 2 stated LVN 2 reported Resident 3's right knee bruising to the Director of Nursing (DON) on 7/16/2024, (at 2:45 pm and more than 24 hours later), after RP 1 noticed and questioned the bruising on Resident 3’s right knee and right foot while at Resident 3's bedside. During an interview on 7/31/2024 at 4:18 pm, the DON stated the facility investigated Resident 3's right foot fracture, but the origin/source of the injury could not be determined. The DON stated there were no witnesses to the incident and Resident 3 could not tell staff what happened. The DON stated the DON could not say for certain how the injury occurred. The DON stated the DON did not report Resident 3's injury of unknown origin to the CDPH and/or inform the ADM so the injury could be reported to the CDPH. The DON stated if any resident sustained an injury of unknown origin, the facility needed to inform the physician and family, complete the COC Form, and report the injury to the CDPH immediately. The DON stated staff needed to report injuries of unknown origin to the CDPH for safety purposes so the facility could attempt to prevent further occurrences. A review of the facility's P&P titled, "Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating," revised 3/2023, indicated if resident abuse or injury of unknown source was suspected, the suspicion must be reported immediately to the ADM and to other officials according to state law. The P&P indicated the ADM or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility, the local/state ombudsman, the resident's representative, law enforcement officials, the resident's attending physician, and the facility medical director. The P&P indicated immediately was defined as within two hours of an allegation involving abuse or result in serious bodily injury or within 24 hours of an allegation that did not involve abuse or result in serious bodily injury. The P&P indicated upon receiving any allegations of injury of unknown source, the ADM was responsible for determining what actions, if any, were needed for the protection of residents. The P&P indicated all allegations were thoroughly investigated, and that the ADM initiated investigations. The facility failed to report an injury of unknown origin/source immediately, but not later than 24 hours to the ADM of the facility, the CDPH, local law enforcement, and Ombudsman as indicated in the facility's P&P titled, "Abuse, Neglect, Exploitation or misappropriation- Reporting and Investigating," for Resident 3. This failure violated Resident 3’s rights, had the potential to compromise Resident 3's safety, and could result in further injuries to Resident 3 potentially related to abuse. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 3.