Health inspection·March 24, 2025

§483.12(b) The facility must develop and implement written policies and procedures that: (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. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (2) Have evidence that all alleged violations are thoroughly investigated. 22CCR §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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. 22CCR §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 02/12/2025 at 8:00 a.m., the California Department of Public Health (CDPH) conducted an unannounced complaint investigation at the facility. The facility failed to: 1. Investigate areas of skin discoloration (a change in the color, texture, or pigmentation of the skin) and skin tears for Resident 3. As a result, there was a delay in the facility’s investigation for Resident 3’s skin tear and skin discolorations. Resident 3 was a 73-year-old female, admitted on 11/7/2024 with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities) and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). A review of Resident 3’s Minimum Data Set (MDS- a federally mandated resident assessment tool), indicated Resident 3’s cognitive skills were severely impaired. The MDS indicated Resident 3 required supervision with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 3’s nursing progress notes dated 12/7/2024, indicated Resident 3 had light greenish skin discoloration to the left hip. A review of Resident 3’s change of condition form (COC), dated 12/20/2024, indicated Resident 3 had light purple-yellowish skin discoloration around her left elbow and on her right buttock. A review of Resident 3’s skin assessment dated 12/22/2024, indicated Resident 3 had a skin tear (a wound that occurs when the skin layers separate, often due to blunt force or friction) on her left elbow. A review of Resident 3’s care plan, titled “Skin Integrity,” dated 12/30/2024, indicated Resident 3 had skin discolorations to her left arm and right upper thigh. There was no care plan documentation on Resident 3’s skin tears. During a concurrent interview and record review on 02/12/2025 at 12:02 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated investigative reports should be completed if a resident had multiple falls, unexplainable skin discoloration, unknown or unusual injuries. LVN 1 stated she was only aware of Resident 3’s skin discoloration on her left hip and skin tear on her left elbow. LVN 1 stated she was not aware of any other areas of Resident 3’s skin discolorations. LVN 1 stated the facility should have initiated a risk management assessment and an investigation report for all areas of Resident 3’s skin discoloration and skin tears. LVN 1 stated the facility did not document any evidence of an investigation for Resident 3’s skin tears or skin discoloration. LVN 1 stated the risk of not completing an investigation report for skin tears and skin discoloration could result in a delay of care and potential abuse. During a concurrent interview and record review, on 02/13/2025, at 12:57 p.m., with Registered Nurse 1 (RN 1), RN 1 stated she was not aware of Resident 3’s skin discoloration or skin tears. RN 1 stated the facility was required to investigate unusual skin discolorations and skin tears on residents. RN 1 stated the facility did not conduct investigations for Resident 3’s skin tears or skin discoloration. RN 1 stated the risk of not investigating Resident 3’s skin tears and skin discoloration origin could result in skin breakdown and possible abuse. During an interview on 02/13/2025 at 1:21 p.m., with the Director of Nursing (DON), the DON stated the protocol for any skin discoloration required the facility to complete a risk management assessment and conduct a thorough investigation to determine the root cause of the origin. The DON stated she was aware of Resident 3’s skin discoloration to her left hip, left elbow and right buttock but not the right thigh. The DON stated she could not recall if the facility investigated Resident 3’s skin tears and discoloration. The DON stated the risk of the facility failing to complete an investigation report for Resident 3’s skin tears and skin discoloration could result in “not knowing what happened to the resident” and potential abuse. A review of the facility’s policy and procedures, titled “Unusual Occurrence Reporting,” dated 6/12/2024 indicated, “The facility conducts and documents timely and thorough investigations into all unusual occurrences and takes corrective action as appropriate. The P&P indicated, investigation and documentation should include but is not limited to: interviews with residents, staff, and any other witnesses and review of the facility records.” The P&P indicated, “The facility maintains copies of incident reports of any unusual occurrences for at least one (1) year.” The facility failed to: 1. Investigate areas of skin discoloration (a change in the color, texture, or pigmentation of the skin) and skin tears for Resident 3. This violation had a direct or immediate relationship to the health, safety, or security of Resident 3 and other residents in the facility.