Health inspection·April 2, 2026

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §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. HSC 1418.91. (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. (c) For purposes of this section, "abuse" shall mean any of the conduct described in subdivisions (a) and (b) of Section 15610.07 of the Welfare and Institutions Code. On 3/2/26, an unannounced visit was conducted at the facility to investigate a complaint regarding Resident 1's facial bruise. The facility failed to report an injury of unknown origin to the California Department of Public Health (CDPH) within 24 hours for one of three sampled residents (Resident 1). This failure delays the investigation and has the potential to put Resident 1's health and safety at risk. During a record review, the Admission Record indicated Resident 1 was admitted to the facility on 6/27/23 with diagnoses which included a history of Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). A record review of Resident 1's MDS (Minimum data set: nursing facility assessment tool) dated 1/27/26, indicated that Resident 1 was rarely or unable to understand others or make self-understood and had severe cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) deficits to make decisions. On 3/2/26 at 9:21 A.M., a telephone interview with the complainant ECPD (El Cajon Police Department) Officer was conducted. The ECPD Officer stated Resident 1, a non-verbal resident, had a bruise on the left eye of unknown origin. The officer confirmed ECPD responded to a call for service at the skilled nursing facility on 1/30/26 and notified CDPH and the Ombudsman (a patient advocate who investigates and helps to resolve complaints and concerns for long term care facilities) about the incident. The ECPD Officer stated there was "suspicious documentation", and staff was unable to explain how the injury occurred. On 3/2/26 at 11:40 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated they (the facility) had not called the ECPD. The DON verified that the ECPD Officer was at the facility because they (ECPD) had received a report that Resident 1 had an injury of unknown origin. The DON stated the facility had identified Resident 1 with a bruise to the left eye as an injury of unknown origin and had conducted an internal investigation. The DON stated staff believed the bruise may have occurred when Resident 1's head leaned against the bed rail. The DON stated the injury was unwitnessed and of unknown origin, but the facility did not report the incident to the required entities (CDPH, Ombudsman and/or ECPD) and/or submitted a required report because staff believed the ECPD Officer did not identify wrongdoing. The DON further stated the incident should have been reported to all required entities (CDPH, Ombudsman and/or ECPD). On 3/2/26 at 11:45 A.M., an interview was conducted with the Administrator (ADM), in the DON's office. The ADM stated the facility did not report Resident 1's injury of unknown origin to the required entities because the responding ECPD Officer had indicated there was no evidence of abuse. The ADM stated the facility relied on the officer's conclusion and did not complete the required reporting to all required entities. On 3/2/26 at 4:07 P.M., an observation was conducted in Resident 1's room. Resident 1 had padded bed rails on both sides of her bed. Resident 1 was non-verbal and was unable to be interviewed. On 3/2/26 at 4:10 P.M., an interview and record review were conducted with Licensed Nurse (LN) 1, in the third-floor nursing station. LN 1 stated Resident 1 had a change in skin condition with discoloration to the left eye identified on 1/29/26. LN 1 stated injury was unwitnessed, and it was unknown how Resident 1 was injured. LN 1 stated Resident 1's injury should have been reported to all required entities within 24 hours to initiate an investigation and ensure Resident 1's safety. LN 1 stated she did not see documentation indicating the incident had been reported to the required entities. On 3/3/26 at 3:25 P.M., an interview was conducted with the Social Service Director (SSD), in the ADM's office. The SSD stated staff identified discoloration to Resident 1's face on 1/29/26. The SSD stated nursing staff believed the bruise may have occurred when Resident 1 leaned her head against the bed rail. The SSD stated the injury appeared to be a yellow bruise and Resident 1 was at baseline with no signs of distress when observed. The SSD further stated injuries of unknown origin should be reported to CDPH, law enforcement, and the Ombudsman within 24 hours, or immediately within two hours if serious injuries was sustained, to ensure all resident safety and initiate an investigation. On 3/5/26 at 5:30 P.M., an interview was conducted with ECPD Officer, by telephone. ECPD Officer stated he and another officer observed discoloration to Resident 1's left eye (1/30/26) which appeared as a light-yellow bruise that was fading. On 3/5/26 at 5:48 P.M., a phone interview was conducted with the DON. The DON stated injuries of unknown origin and suspected abuse should have been reported. The DON stated it was to ensure resident (all facility staff) safety and to allow an investigation to be conducted in accordance with reporting requirements. A review of the facility's policy and procedure titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating" dated December 2017, indicated "...1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law...." In violation of the above cited standards, the facility failed to report an injury of unknown origin to the state licensing/certification office within 24 hours, which delayed the abuse investigation. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.