Incident investigation·March 6, 2025

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management-Incident visit. LPA Tarin met with General Manager, Candace Bolin and explained the purpose of the visit. On 3/5/2025, the Department received an Incident Report and SOC341 for Resident R1 who was noted to have bruising on the left eye and sides of neck on 3/5/2025. The Incident Report states the neck bruising was discoloration due to 'dye transfer' from a necklace worn by R1 on 3/4/2025 and an unknown cause for the bruising on R1's left eye. The Incident Report states the facility sought medical care for R1, and all responsible parties and physician were informed about the incident on 3/5/2025. During visit, LPA interviewed 7 staff, observed R1 and toured R1's room. Based on interviews, the discoloration/'bruising' observed on R1 on 3/5/2025, was green dye that transferred onto R1's neck from beaded necklaces worn during a Mardi Gras event on 3/4/2025. Staff were able to wipe away the green discoloration from R1's neck on 3/5/2025. LPA did not observe bruising or discoloration on R1's neck during visit. LPA observed R1 to have bruising under the left eye. The facility does not know how R1 obtained bruising under the left eye on 3/5/2025. After this incident, the facility's plan of action is to provide more frequent checks on R1, including recognizing any areas of discoloration. The facility is also providing additional training for staff on recognizing bruising and discoloration. LPA requested the following documentation: photos from the events on 3/4/2025, R1's service plan and physician's report, staffing roster for 3/4/2025 and 3/5/2025. No deficiencies were issued during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with General Manager, Candance Bolin and a copy of this report was provided.