Health inspection·March 29, 2024

Title 22 Article 5 Administration California Code Regulations, Section 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. On 3/15/2024 at 2:30 p.m., an unannounced visit was conducted at the facility to investigate a complaint regarding the physical environment. The facility failed to report an unusual occurrence (generator failure) to the Department of Public Health (Licensing/Certification) within 24 hours. This violation had a direct or immediate relationship to the health, safety, or security of the residents. During an interview on 3/15/2024 at 2:35 p.m. with the facility Administrator (ADM) and Director of Maintenance (DOM) regarding the facility’s use of a temporary/rental emergency generator in the employee parking lot, the DOM stated that they were performing routine maintenance on the facility’s existing generator on 10/09/2023 and noticed that the existing generator was not holding charge and non-working. The DOM stated that the rental generator was obtained on 10/19/2023 and while waiting for the temporary generator to be connected to the facility, the facility would “plug into” the next-door skilled nursing facility, in the event of a power failure. During a review of the facility’s policy and procedure (P&P) titled, “Unusual Occurrences”, undated, the P&P indicated that “the facility is to report unusual occurrences to the local health department within 24 hours of each occurrence.” Furthermore, the P&P indicated that all unusual occurrences are to be reported immediately to the supervisor of that department in which the incident occurred, and the administrator shall call the local Health Department and must confirm it in writing within 24 hours of its occurrence. The P&P indicated examples for when the facility would report unusual occurrences which included “Inoperable emergency system, equipment, or resident call system, where if not made operable will cause an immediate threat to life, or have a strong potential to become an immediate threat to life (if system inoperable more than four (4) hours)” and “Other occurrences that constitute an interference with facility operations that affect the welfare. safety, or health or residents, personnel, or visitors.” During an interview on 3/15/2024 at 3:02 p.m. with the ADM, the ADM stated that he did not report the generator failure because the facility had alternative power from the next-door facility that they could “plug into” and run the cable next door. The facility was unable to provide records of unusual occurrence reporting to the Department. The facility failed to report an unusual occurrence to the Department of Public Health within 24 hours. This violation had a direct or immediate relationship to the health, safety, or security of the residents.