Health inspection·April 16, 2025

F609 42 CFR §483.12(b) The facility must develop and implement written policies and procedures that: (b)(5) Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. 42 CFR §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 42 CFR §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. 22 CCR §72513 Administrator (3)(e) The administrator shall have be responsible for informing the department, via telephone within 24 hours of any unusual occurrence as specified in section 72541. 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 established and implemented to ensure that patient related goals and facility objectives are achieved. An unannounced visit was conducted by California Department of Public Health (CDPH) on 3/3/2025 to investigate a complaint regarding Resident 1’s unusual occurrence of fracture (break in the bone) on left hip. The facility failed to report to the State Agency (SA) within 24 hours after an unusual occurrence (events or situations that do not happen daily or that may have had an impact on the residents) for Resident 1 by failing to ensure the facility reported to SA when the facility was made aware on 2/3/2025 of Resident 1’s sustained a fracture (complete or partial break in the bone) from a fall in accordance with the facility’s policy and procedure titled “Unusual Occurrence Reporting”. This deficient practice had a potential for unusual occurrence for Resident 1 or other residents in the facility. A review of Resident 1’s Admission Record, the Admission Record indicated Resident 1 is a 97- year- old- female resident who was originally admitted to the facility on 12/3/2024 and was readmitted on 2/3/2025 with the following diagnoses of dementia (a progressive state of decline in mental abilities), muscle weakness and fracture of the left ilium (the large broad bone forming the upper part of the pelvis). A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 2/10/2025, the MDS indicated resident was moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 1 required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) with oral hygiene and personal hygiene. The MDS indicated Resident 1 was also dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, roll left and right, sit to lying, lying to sitting on the side of bed, sit to stand, chair/bed to chair transfer, toilet transfer and tub/shower transfer. A review of Resident 1’s Fall Risk Assessment, dated 12/3/2024, the assessment indicated Resident 1 was at high risk for potential falls. A review of Resident 1’s SBAR (situation, background, assessment, recommendation – a communication tool used by healthcare workers when there is a change of condition [COC] among the residents)/COC, dated 1/26/2025, the SBAR/COC indicated an unwitnessed fall with skin laceration (skin tear) on right upper eyelid and left hip and sacral (a large triangular bone at the base of the spine) pain. The SBAR/COC also indicated Resident 1 was found on the floor, complained of pain on the left hip and sacral area and was transferred to a general acute care hospital (GACH). A review of Resident 1’s Progress Notes, dated 1/26/2025 at 1:14 PM, the Progress Notes indicated Resident 1 was transferred to GACH via ambulance due to an unwitnessed fall with a right upper eyelid laceration and left hip and sacral pain. A review of Resident 1’s GACH discharge instructions, dated 2/3/2025 at 1:15 PM, the discharge instructions indicated a diagnosis of left iliac (the largest and uppermost bone of the hip) fracture. A review of Resident 1’s Progress Notes, dated 2/3/2025 at 9:38 PM, the Progress Notes indicated Resident 1 was admitted back to the facility around 4 PM with a left iliac fracture. A review of Resident 1’s Fall Risk Assessment, dated 2/3/2025, the assessment indicated Resident 1 was at high risk for potential falls. During an interview on 3/3/2025 at 11:09 AM, the Registered Nurse (RN) stated Resident 1 fell on 1/26/2025. During an interview on 3/3/2025 at 1:09 PM, the RN stated when the resident falls and sustains a fracture, it is considered an unusual occurrence. During a concurrent record review and interview on 3/3/2025 at 2 PM with the Director of Nursing (DON), the facility’s Policy and Procedure titled, “Unusual Occurrence Reporting,” revised 2/2025 was reviewed. The P&P indicated unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within 24 hours of such incident or as otherwise required by federal and state regulations. The DON stated if a resident has an unwitnessed fall, the facility will need to report to SA as indicated in the P&P. During an interview on 3/3/2025 at 2:16 PM, the RN stated the facility found out about Resident 1’s fracture was when the resident was readmitted to the facility on 2/3/2025. During an interview on 3/3/2025 at 2:40 PM, the DON stated Resident 1’s fall needs to be reported to SA as an unusual occurrence since the fall resulted to the resident sustaining a fracture. A review of the facility’s P&P titled, “Unusual Occurrence Reporting,” revised 2/2025, the P&P indicated a written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency as required by federal and state regulations. The facility failed to report to the SA within 24 hours after an unusual occurrence for Resident 1 by failing to ensure the facility reported to SA when the facility was made aware on 2/3/2025 of Resident 1’s sustained a fracture from a fall in accordance with the facility’s policy and procedure titled “Unusual Occurrence Reporting”. This deficient practice had a potential for another unusual occurrence for Resident 1 or other residents in the facility. The above violations had a direct or immediate relationship to the health, safety, or security of patients or residents.