Health inspection·July 5, 2024

The following reflects the findings of the California Department of Public Health during the investigation of a complaint with intake number CA00901373. Representing the Department, HFEN # 43452. A State B Citation was written. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation (c) Freedom from Abuse, Neglect, and Exploitation. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 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. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. § 72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. 22 CFR § 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. § HSC 1418.91 Abuse Reporting (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. The California Department of Public Health (CDPH) received a complaint on 5/22/2024 alleging Resident 1 was observed with ecchymosis (a small bruise caused by blood leaking from broken blood vessels into the tissues of the skin or mucous membranes) on the inferior aspect of the bilateral breast. On 5/23/2024, CDPH conducted an unannounced visit to the facility to investigate an allegation regarding resident abuse. The facility failed to implement its policy titled "Abuse Prohibition and Prevention Program," which indicated the facility will report all alleged violations involving abuse, or injuries of unknown source immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involved abuse or result in serious bodily injury, by not notifying the CDPH when Resident 1 was observed with discoloration on the left lateral side of the breast, and trunk. As a result, there was a delay in the investigation by the CDPH and it placed Resident 1, and other residents at risk for injury. A review of Resident 1's Admission Record indicated the resident was originally admitted to the facility on 4/26/2024 and readmitted on 5/11/2024. Resident 1's diagnoses included metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), dysphagia (difficulty swallowing) following unspecified cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), and unspecified dementia (loss of cognitive functioning-thinking, remembering, and reasoning). A review of Resident 1's History and Physical (H&P) dated 5/13/2024 indicated, Resident (1) did not have the capacity to understand and make decisions. A review of the of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 5/20/2024, indicated Resident 1 required total dependence from staff for activities of daily livings (ADLs- oral hygiene, personal hygiene and repositioning with rolling left to right). A review of Resident 1's Situation Background Assessment Recommendation (SBAR - a written or verbal communication tool used to provide essential and concise information, usually during crucial situations), dated 5/18/2024 indicated, upon assessing Resident 1 the Treatment Nurse, observed scattered discoloration on the left lateral side of the resident's breast, extending to the left trunk, with dark purplish red colors. The SBAR indicated Resident 1 was side lying and contracted. During an interview with Certified Nurse Assistant (CNA) 1, on 5/23/2024 at 1:26 p.m., CNA 1 stated, on 5/18/2024, she observed bruises on the left side of Resident 1's trunk, CNA 1 stated Resident 1's skin was purple in color, and she notified the charge nurse right away. CNA 1 stated, the next day, on 5/19/2024, the bruise had extended to the right side of Resident 1's trunk, under her breast, was much bigger. CNA 1 stated, Resident 1 was unable to talk, both hands were contracted and the resident was unable to move on her own. CNA 1 stated, she did not see how Resident 1 obtain the bruise because no one mentioned anything to her on prior days. During an interview with Licensed Vocational Nurse (LVN) 2, on 5/24/2024 at 11:17 a.m., LVN 2 stated, Resident 1 was non-verbal, did not communicate in English, with both arms contracted, was unable to turn herself and required total assistance with turning and ADL care. LVN2 stated, the incident on Saturday was an onset incident and when she assessed Resident 1 upon observed the purple skin color, Resident 1 was unable to verbalize what happened, and how she obtained the skin discoloration. During an interview with Occupational Therapist Assistant 1 (OTA 1), on 5/23/224 at 11:27 a.m., OTA 1 stated, on 5/17/2024, Resident 1 received OT with an order to put a splint on the left elbow for three hours and he did not notice anything out of ordinary with Resident 1. OTA1 stated, Resident 1 was non-verbal, fully dependent and contracted on both upper and lower extremities. During an interview with Director of Nursing (DON), on 5/24/2024 at 4:03 p.m., the DON stated, she investigated and interviewed the staff who took care of Resident 1 upon knowing the incident that started on 5/18/2024. The DON stated, Resident 1 was on an anticoagulant (medicines that help prevent blood clots) medication which put her at high risk of bleeding. The DON stated the incident was not witnessed and Resident 1 was unable to verbalized how the incident happened. The DON stated the location of the injury was not a usual place for someone to have a trauma (a tissue injury that occurs suddenly due to violence or accident). The DON stated, Resident 1's hands were contracted and the resident required total assist from staff with ADLs and repositioning. The DON stated this incident was not reported to the State Agency and to any other reporting agencies as she did not think this was a case of abuse or injury of unknown source. A review of the facility's policy and procedures (P&P) titled, "Abuse Prohibition and Prevention Program", revised on 4/2024, indicated the facility will report all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved 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, in accordance with State law through established procedures. The facility failed to implement its policy titled "Abuse Prohibition and Prevention Program," which indicated the facility will report all alleged violations involving abuse, or injuries of unknown source immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involved abuse or resulted in serious bodily injury, by not notify the CDPH when Resident 1 was observed with discoloration on the left lateral side of the breast, and trunk. As a result, there was a delay in the investigation by the CDPH and it placed Resident 1, and other residents at risk for injury. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.