Health inspection·April 10, 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 § 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 2/25/2025 at 9:25 AM to investigate a complaint regarding an allegation of a resident getting poor quality of care, possible neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress) and abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish). The facility failed to report an injury of unknown origin to CDPH for Resident 1, who was observed with unexplained swelling (a raised/ enlarged, curved shape on the surface of your body which appears as a result of an injury or an illness) on the resident’s right hand on 1/26/2025. As a result, Resident 1’s safety and well-being were compromised by delaying appropriate medical evaluation and intervention. A review of Resident 1’s Admission Record, the Admission Record indicated Resident 1, a 64-year-old-male, was admitted to the facility on 4/29/2024 with diagnosis of dementia (a progressive state of decline in mental abilities), Parkinson’s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement), and ataxia (a neurological condition that affects coordination, balance, and movement. It is caused by damage to the cerebellum, the part of the brain that controls these functions). A review of Resident 1’s Minimum Data Set (MDS- resident assessment tool), dated 1/30/2025, the MDS indicated Resident 1 had severely impaired cognition (ability to think, remember and make decisions). The MDS indicated Resident 1 required partial assistance (helper does less than half the effort to lift, hold, or support trunk or arms and legs, but provides less than half the effort) for eating, toileting, oral hygiene, rolling left and right, sitting down, lying down, transferring to a chair and bed, walking ten feet, and lying to sitting on side of bed. The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on staff to shower and required maximal assistance (helper does more than half the effort to lift or hold trunk or limbs and provides more than half the effort) for upper and lower body dressing, putting on footwear, and personal hygiene. A review of Resident 1’s nursing progress notes, dated 1/26/2025, the progress note indicated Family 1 had informed the Registered Nurse (RN) that Resident 1’s hand looked swollen, and Resident 1 was complaining of pain when Family 1 touched the resident’s middle finger. The progress note indicated Resident 1’s right hand looked bigger than the left hand. A review of Resident 1’s Patient Report from Laboratory 1, dated 1/27/2025, indicated Resident 1 had undergone a Radiograph (XRAY- type of medical imaging that creates pictures of bones and soft tissue) of his right hand and localized swelling, mass and a lump (abnormal bumps or mass under the skin) were identified. During an interview on 2/25/2025 at 1:01 PM with the Assistant Director of Nursing (ADON), the ADON stated any injury with unknown cause is considered an unusual occurrence and supposed to be reported within two hours to the Administrator and the Director of Nursing (DON) to provide residents with treatment if needed, investigate the cause of the injury, and protect residents from potential abuse or neglect. During an interview on 2/25/2025 at 1:37 PM with the Administrator, the Administrator stated she was not informed about Resident 1’s unexplained swelling on the right hand on 1/26/2025. The Administrator stated the RN should have reported this unusual occurrence immediately to the Administrator and the facility should have reported the incident within 24 hours of the occurrence to the state agency (CDPH) and should have conducted an investigation to determine how Resident 1 was injured. A review of the facility’s policy and procedure (P&P) titled “Unusual Occurrence Reporting”, dated December 2007, the P&P indicated unusual occurrences shall be reported via telephone to appropriate agencies as required by current law/regulations within 24 hours of such incident. A written report detaining the incident and actions taken by the facility after the event shall be sent to the state agency within 48 hours of reporting the event as required by federal and state regulations. The facility failed to report an injury of unknown origin for Resident 1, who was observed with unexplained swelling on the resident’s right hand on 1/26/2025. As a result, Resident 1’s safety and well-being were compromised by delaying appropriate medical evaluation and intervention. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.