Health inspection·March 21, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to report an injury of unknown origin within 24 hours for one of one sampled resident (Resident 1). This failure resulted in Resident 1's injury of unknown origin to not be reported to the state licensing/certification office, delayed the abuse investigation, and placed residents at risk for abuse. Findings: During a review of Resident 1's admission Record on 3/13/25, Resident 1 was admitted on [DATE] with diagnoses which included muscle weakness and dementia (a condition which causes memory loss, language, and problem-solving skills). A review of Resident 1's Minimum Data Set (MDS - a care planning and assessment tool), dated 1/2/25 indicated Resident 1 's cognition (ability to think, understand and make daily decisions) was 7, which suggested severe cognitive impairment. On 3/13/25 at 12:36 P.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated on 3/9/25 around 11 A.M . she observed Resident 1 .having an altercation with his roommate [Resident 2] . LN 1 stated Resident 1 and Resident 2 were, .yelling, getting into each other ' s face . LN 1 stated a room change was necessary because it was not the first incident between the two residents. LN 1stated both residents get verbally aggressive, not sure if there was physical contact between the two residents. On 3/13/25 at 1 P.M., a joint interview and observation of Resident 1 was conducted with Certified Nursing Assistant (CNA) 1 inside Resident 1 ' s room. Resident 1 was 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, .[Resident 1] is always confused, he ' s always grumpy .He yells at other residents a lot . CNA 1 stated she believes Resident 1 sustained the bruise, .because he got into a fight with [Resident 2] . but she did not see the incident occur. On 3/13/25 at 1:21 P.M., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated on 3/10/25, Resident 1 ' s family member was at the facility. The ADON stated while at the facility, the family member informed him that Resident 1 ' s left cheek was black and blue, and he had a cut on his left arm. The ADON further stated he was notified there was a room change and an altercation had occurred on 3/9/25. Additionally, the ADON stated on 3/9/25 staff found Resident 1 outside the facility, attempting to open a side gate. The ADON stated, What we determined was the Page 1 of 2 555878 555878 03/21/2025 Granite Hills Healthcare & Wellness Centre, LLC 1340 E Madison Ave El Cajon, CA 92021

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident was injured when he was trying to open the gate .he wanders aimlessly . The ADON stated we believed Resident 1 was pinned between the gate and the fence which caused the injury. On 3/13/25 at 1:45 P.M. an interview was conducted with the Director of Nursing (DON). The DON stated Resident 1 ' s family member had been in the facility on 3/10/25 and had reported to her that Resident 1 said he had been punched in the eye. On 3/13/25 at 2:07 P.M., an interview was conducted with CNA 2. CNA 2 stated on 3/9/25 around 5:30 P.M., he heard the activated gate alarm. CNA 2 stated he went outside and found Resident 1 next to the gate. CNA 2 stated he observed Resident 1 sitting in his wheelchair in front of the gate. CNA 2 stated the gate was closed, but he thinks Resident 1 had opened the gate which activated the alarm. 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. During an interview on 3/21/25 at 12:01 P.M. with the Director of Nursing (DON), the DON stated he was aware that Resident 1 was confused and had an altercation with Resident 2. The DON stated, .we determined the bruise was most likely caused by attempting to exit the courtyard gate [not from the altercation with Resident 2] .but it cannot be concluded . The DON confirmed the injury was not reported to the state licensing agency. The DON stated, This should have been reported immediately to the Ombudsman, to California Department of Public Health, to the police . immediately and then we should have started the abuse investigation . The DON further stated, .We have a duty to protect our residents . A review of the facility ' s policy titled Injuries of Unknown Origin-Investigation revised 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 revised 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 . 555878 Page 2 of 2