Other·April 28, 2026

Code of Federal Regulations, Title 42, Section 483.12 §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. §483.12(c)(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. California Code, Health and Safety Code - 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. On 4/1/26, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate two complaints regarding resident safety. The Department determined the facility failed to report to the Department (CDPH) an injury of unknown source in accordance with the facility's abuse policy and procedure (P&P) for Resident 1 when on 2/2/26, Resident 1 was found with an unexplainable left shoulder dislocation (an injury that occurs when the upper arm bone pops out of the cup shaped socket near the shoulder blade). This failure denied the Department the ability to conduct a timely investigation and placed Resident 1 at risk of abuse. In addition, the facility failed to comply with federal and state reporting regulations. A review of Resident 1's "ADMISSION RECORD," indicated that Resident 1 was admitted to the facility with diagnoses which included subarachnoid hemorrhage (SAH, a type of stroke characterized by bleeding in the space between the brain and the tissues that cover the brain), traumatic brain injury (a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head or penetrating head injury), and hypertension (a condition in which the force of the blood pushing against the blood vessel walls is consistently too high and causes the heart to work harder to pump blood). A review of Resident 1's "Minimum Data Set [MDS, a comprehensive care assessment tool] Section C: Cognitive Patterns," dated 3/9/26, indicated that Resident 1's Brief Interview for Mental Status score was 00 (BIMS, a tool to assess cognition (memory and thinking). The total possible BIMS score ranges from 0 to 15 with scores and corresponding interpretation as follows: 13 - 15 is cognitively intact; 08 - 12 is moderately impaired; 0 - 07 is severe impaired and 00 is no response or nonsensical answers to questions). A review of Resident 1's "MDS Section GG: Functional Abilities and Goals," dated 3/9/26, indicated that Resident 1 required maximal assistance and was totally dependent on others for all care needs. A review of Resident 1's "Nurses Progress Notes," dated on 2/1/26, at 1:34 p.m., indicated, "...patient [Resident 1] rp [Responsible Party, the person designated to direct the care of a loved one admitted into a nursing facility] stated to writer that patient looked like he "did not feel good" and pointed to patient left shoulder and stated that "something was wrong" and that the patient has a "bad shoulder". patient appeared to be in some discomfort, writer informed rp that patient was changed and received wound treatment about 30 minutes prior and that patient was most likely recovering from this, rp disagreed and requested...x-ray [a quick painless test that captures images of the structures inside the body particularly bones]. administered PRN [as needed] pain medication and informed MD [medical doctor]. MD ordered...left shoulder x-ray...called [x-ray provider]...scheduled left shoulder x-ray for tomorrow 2/2/26. rp at bedside and informed..." A review of Resident 1's "X-ray Report," dated 2/1/26, indicated, "...DATE OF EXAM...02/01/2026...HISTORY...STIFFNESS/PAIN...SIGNIFICANT FINDINGS...LEFT SHOULDER X-ray...Multiple views of the left shoulder show anterior [toward the front of the body] shoulder dislocation...IMPRESSION: Left anterior shoulder dislocation..." A review of Resident 1's "Nurses Progress Notes," dated 2/2/26, at 2:58 a.m., indicated, "...shoulder x-ray result came back with a significant findings Left anterior shoulder dislocation...Called [MD]...send to ER [emergency department at acute care hospital] to fix the shoulder...Called the RP..." During an interview on 4/1/26, at 12:20 p.m., with Resident 1's RP in Resident 1's room, the RP stated she asked staff to call the physician for an x-ray when she noticed that Resident 1 grimaced when she touched his shoulder on 2/1/26. The RP further stated staff that day (2/1/26) told her that Resident 1 had recently been cleaned and repositioned after providing incontinent care (skin care after involuntary or accidental leakage of urine or feces). The RP stated the x-ray showed that Resident 1's left shoulder was dislocated. During an interview on 4/1/26, at 4:51 p.m., with the Director of Nursing (DON), the DON confirmed Resident 1's left shoulder injury was an injury of unknown origin. The DON further confirmed Resident 1's injury to the left shoulder was not reported to the Department. The DON acknowledged Resident 1's injury of unknown origin should have been reported. During a joint concurrent interview and record review on 4/2/26, at 2:03 p.m., with the Administrator (ADM) and the DON, Resident 1's "Progress Notes," were reviewed. The ADM stated he talked to Resident 1's RP and the RP stated that the injury was due to contractures (when muscles, tendons, joints, or other tissues tighten or shorten causing loss of movement). The ADM further stated that he talked with the RP a day or so after the injury to Resident 1's left shoulder was discovered. The ADM stated he asked Resident 1's RP if Resident 1 fell and the RP said "No," and the RP also stated that she did not notice any trauma to Resident 1's shoulder. The ADM further stated that he did not document the conversation that he had with Resident 1's RP but he spoke to the DON about it. The ADM stated the RP was happy with Resident 1's care at the facility. The ADM further stated that he followed the RP's lead and it did not lead him to suspect abuse. The ADM acknowledged that Resident 1 was under the facility's care. The ADM confirmed that the injury to Resident 1's left shoulder was not reported to the Department. The ADM and the DON both acknowledged that the cause of Resident 1's left shoulder dislocation should have been investigated to rule out abuse related to the injury of unknown origin. A review of a facility P&P titled, "Abuse Prohibition Policy and Procedure," dated 5/23/21, indicated, "...Policy...The Center will implement an abuse prohibition program through the following...Identification of possible incidents or allegations which need investigation...Investigation of incidents and allegations; and Reporting of incidents, investigations, and Center response to the results of their investigations...Federal Definitions...Injuries of unknown source are defined as an injury with both of the following conditions...The source of the injury was not observed by any person or the source of the injury could not be explained by the patient...The injury is suspicious because of the extent of the injury or the location of the injury...or the number of injuries observed at one particular point in time or the incidence of injuries over time...Purpose...To ensure that Center staff are doing all that is within their control to prevent occurrences of...injuries of unknown source...Process...1. The Center Executive Director...is responsible for operationalizing policies and procedures that prohibit...injuries of unknown source...6.3 Injuries of unknown origin will be investigated to determine if abuse or neglect is suspected...7. Upon receiving information concerning a report of suspected or alleged abuse...the CED (Center Executive Director) or designee will perform the following...7.2 Report allegations involving neglect, exploitation of mistreatment (including injuries of unknown source) ...no later than two (2) hours after the allegation is made if the event results in serious bodily injury. Serious bodily injury is reportable. Only an investigation can rule out abuse, neglect, or mistreatment...7.2.1 Serious bodily injury is defined as an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ or mental faculty; or requiring medical intervention such as surgery, hospitalization or physical rehabilitation...7.4 Notify local law enforcement, Ombudsman, Licensing District Office...and other agencies as required...7.6 Initiate an investigation within 2 hours of an allegation of abuse that focuses on...7.6.1 Whether abuse or neglect occurred and to what extent...7.6.2 clinical examination for signs of injuries...7.6.3 causative factors..7.6.4 interventions to prevent further injury...7.7 The investigation will be thoroughly documented...interview forms will be kept confidential in a file in the administrative office...9. The CED or designee will...9.2 Report findings of all completed investigations within five (5) working days to the Licensing District office..." Therefore, the Department determined the facility failed to report to the Department an injury of unknown source in accordance with the facility's abuse P&P for Resident 1 when on 2/2/26, Resident 1 was found with an unexplainable left shoulder dislocation. This failure denied the Department the ability to conduct a timely investigation and placed Resident 1 at risk of abuse. In addition, the facility failed to comply with federal and state reporting regulations. This violation had a direct or immediate relationship to the health, safety and or security of patients or residents and is a B citation.