Health inspection·April 18, 2025

42 CFR §483.12(c) 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. Health and Safety Code - §1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a Patient 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 facility failed to report an injury of unknown origin for one of one sampled resident (Resident 1). Failure to report had the potential to put Resident 1's health and safety at risk. On 3/13/25, at 12:24 P.M., an unannounced visit was conducted at the facility to investigate a complaint of injuries of unknown origin. Per the complaint, Resident 1 sustained a bruised and swollen left eye and a laceration to the left hand. According to the facility's Admission Record, Resident 1 was admitted to the facility on 3/24/23, with diagnoses which included muscle weakness and dementia (a condition which causes memory loss, language, and problem-solving skills). Resident 1 had severely impaired thinking ability and memory. A joint interview and observation on 3/13/25 at 1 P.M., with Certified Nursing Assistant (CNA) 1 was conducted. Resident 1 was observed lying in bed, on his back. There was a dark purple bruise underneath Resident 1's left eye, which extended down to the cheek. CNA 1 stated, she believes Resident 1 sustained the bruise, "...because he got into a fight with another resident..." but she did not see the incident occur. An interview on 3/13/25 at 1:21 P.M., with the Assistant Director of Nursing (ADON) was conducted. The ADON stated on 3/10/25 Resident 1's family member reported to him that Resident 1's left check was, "black and blue." Per the ADON, Resident 1's family member also reported a cut to Resident 1's left arm. The ADON further stated on 3/9/25, Resident 1 had an altercation with another Resident and on the same date, staff found Resident 1 outside the facility attempting to open the side gate. The ADON stated, "What we determined was the resident was injured when he was trying to open the gate...we believed Resident 1 was pinned between the gate and the fence which caused the injury..." An interview with CNA 2 on 3/13/25 at 2:07 P.M., was conducted. CNA 2 stated on 3/9/25 around 5:30 P.M., he observed Resident 1 sitting in his wheelchair in front of the gate. CNA 2 stated, "...I believe he got [the bruise] from the gate...we didn't see a bruise on his face...we didn't see the gate hit him. The gate was already closed when we got to him..." CNA 2 stated he reported the incident to the charge nurse. An interview with the Director of Nursing (DON) on 3/21/25 at 12:01 P.M., was conducted. The DON stated he was aware that Resident 1 had attempted to exit the courtyard gate as well as the altercation with another Resident. The DON further stated, "...we determined the bruise was most likely caused by attempting to exit the courtyard gate [not from the altercation with another Resident] but it cannot be concluded..." The DON confirmed the injury of unknown origin was not reported to the state licensing agency. The DON acknowledged this should have been reported to the Ombudsman, Department of Public Health, the police immediately but was not. The DON also stated, "We should have started the investigation, we have a duty to protect our residents..." A review of the facility's policy titled, Injuries of Unknown Origin-Investigation, dated 11/18/15 indicated,"...To protect the health and safety of residents by ensuring all unexplained injuries are promptly and thoroughly investigated and addressed... Unexplained injuries are promptly and thoroughly investigated by the Director of Nursing Services and/or other staff person appointed by the Administrator, to ensure that resident safety is not compromised and action is taken whenever possible, to avoid future occurrences..." A review of the facility's policy titled, Reporting Abuse, dated 1/8/14 indicated, "...III. Reporting Requirements...A. The Facility will report known or suspected instances of physical abuse to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations..." The facility failed to report the injuries of unknown origin to the California Department of Public Health, as required by State Law. This violated state law and had the potential to put Resident 1's health and safety at risk. The above violations either jointly, separately, or in any combination had a direct or immediate relationship to health, safety or security of residents.