Health inspection·June 12, 2025

§483.12(b) The facility must develop and implement written policies and procedures that: §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. § 72523(a) Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. § 72541. Unusual Occurrences. Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. On 4/21/2025 the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) had skin discoloration on her forehead, black eye with swelling due to an unreported fall. On 4/30/2025, CDPH conducted an unannounced visit at the facility to investigate complaint allegation. Upon investigation, CDPH determined Resident 1 sustained an injury of unknown origin resulted in skin discoloration on her forehead, left black eye with swelling. The facility failed to: 1. Ensure Resident 1's an injury of unknown origin was reported to California Department of Public Health (CDPH) within 24 hours in accordance with facility's policy and procedure titled, "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating and Unusual Occurrence Reporting," As a result, the facility did not reported to CDPH Resident 1's skin discoloration on a forehead and left black eye with swelling in a regulated time frame of two hours and did not thoroughly investigate the injury of unknown origin to rule out a potential abuse or neglect. A review of Resident 1's Admission Record, indicated Resident 1, a 56-year-old female, was admitted to the facility on 4/25/2024 with diagnoses including chronic kidney disease, abnormalities of gait and mobility, dementia hypertension and schizophrenia. A review of Resident 1's History and Physical (H&P), dated 4/26/2024, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set, (MDS - a resident assessment tool), dated 1/31/2025, indicated Resident 1 was dependent on nursing staff for oral hygiene, toileting, showering, and dressing. The MDS indicated Resident 1 needed substantial to maximal nursing assistance with eating and transferring to a chair. The MDS indicated Resident 1 needed partial to moderate nursing assistance with rolling from left to right, sitting, lying in bed and walking. A review of Resident 1's Change in Condition (COC) Evaluation form dated 3/20/2025, indicated on 3/20/2025 at 7:30 a.m., Resident 1 was noted to be agitated sitting on the bed with side rails up. The COC indicated a certified nursing assistant (CNA) observed that Resident 1 had skin discoloration (no specific description included) to the forehead. The COC indicated Resident 1's medical doctor (MD) and family member were notified. The COC indicated Resident 1's MD ordered a skull x-ray and skin monitoring. A review of Resident 1's Physician's Orders, dated 3/20/2025, indicated, to monitor Resident 1's forehead for skin discoloration, and for skin management. The Physician's Orders indicated a skull x-ray for Resident 1. A review of Resident 1's Physician's Orders, dated 3/21/2025, indicated, neurological checks (examination of mental status, motor function, sensory) every two hours for 72 hours every shift for left eye swelling. A review of Resident 1's Physician's Orders, dated 3/21/2025, indicated to instill Pataday Ophthalmic Solution, two drops in both eyes two times a day for eye irritation. A review of Resident 1's Physician's Progress Notes, dated 3/24/2025, indicated, Resident 1 had a bump on the forehead, with swelling and bruising over the left eye. During an observation on 4/29/2025 at 1:10 p.m., in Resident 1's room, Resident 1 was lying in bed with a pillow covering her head and mumbling. Resident 1 was observed with bruising to the left side of the forehead and a left black eye and swelling to the forehead. The Licensed Vocational Nurse (LVN) 1 was observed pulling Resident 1 up in bed with the help from other staff and elevating the head of the bed. During an interview on 4/29/2025 at 1:15 p.m., Resident 2 stated she has been the roommate of Resident 1 for a year. Resident 2 stated one day (unknown date) in the morning before breakfast Resident 1 was sitting in the wheelchair outside of the room leaning forward and the wheelchair tipped forward. Resident 2 stated Resident 1 injured her eye. Resident 2 stated Resident 1's eye had redness and swelling. Resident 2 stated nurses came to help Resident 1. Resident 2 stated Resident 1 fell while trying to stand up from the wheelchair. Resident 2 stated she heard the charge nurse told Resident 1's family member she (Resident 1) hit her head on the bed railing. During an interview on 4/30/2025 at 12:35 p.m., with CNA 1, CNA 1 stated she worked the night shift (11 p.m. to 7 a.m.) on 3/19/2025. CNA 1 stated she provided total care, diaper change and linen change for Resident 1. CNA 1 stated she did not observe any discoloration on Resident 1's forehead or left eye. During an interview on 4/30/2025 at 12:42 p.m., Registered Nurse Supervisor (RNS) 1, stated she works the 11 pm to 7 am shift. RNS 1 stated Resident 1 required maximal assistance with activities of daily living such as feeding, bathing, and toileting. RNS 1 stated Resident 1 was being fed by the CNAs and probably (unwitnessed) Resident 1 hit her left forehead on the side rails. RNS 1 stated she assessed Resident 1 for pain. RNS 1 stated when on 3/20/2025 she assessed Resident 1's forehead Resident 1 grimaced (a facial expression usually of disgust, disapproval, or pain). RNS 1 stated Resident 1's forehead was tender to touch. RNS 1 stated Resident 1 was given icepacks for comfort. During an interview on 4/302025 at 1:02 p.m., CNA 2 stated she saw Resident 1 at around 7 a.m., on 3/20/2025. CNA 2 stated Resident 1 had "bruising" on the forehead. CNA 2 stated she asked CNA 3 what happened to Resident 1. CNA 2 stated CNA 3 stated she did not know. CNA 2 stated she reported the bruising on Resident 1's forehead to the charge nurse on 3/20/2025. During an interview on 4/30/2025 at 1:11 p.m., CNA 3 stated he saw Resident 1 on 3/20/2025 at 7 a.m. CNA 3 stated he asked CNA 2 for help to pull Resident 1 up in bed. CNA 3 stated Resident 1 had swelling and discoloration on the left eye. CNA 3 stated he did not know how the injury to Resident 1's left eye occurred. During an interview on 4/30/2025 at 1:29 p.m., RNS 2 stated on 3/21/2025 she noticed Resident 1 had a swollen left eye with discoloration. RNS 2 stated she informed the Nurse Practitioner. RNS 2 stated the Nurse Practitioner ordered cold eye compresses to the left eye for 20 minutes for three days and eye drops for eye irritation. RNS 2 stated she did not know how the resident sustained the injury to the left side of forehead. RNS 2 stated she did not receive any report on how Resident 1 injured her head. RNS 2 stated there was no documentation of what happened to Resident 1 on 3/20/2025. RNS 2 stated when a resident has an injury and no one knows a Change of Condition evaluation should be done, MD and family member should be informed. RNS 2 stated the injury (unknown origin) was monitored to see if it was getting worse. RN 2 stated the Director of Nursing (DON) was notified. RNS stated that the injury of unknown origin such as discoloration on Resident 1's forehead, black eye and eye swelling should have also been reported to the Ombudsman, police and CDPH. RNS 2 stated that the injury was reportable because it could have been a result of abuse. During an interview on 4/30/2025 at 2:35 pm RNS 3 stated on 3/20/2025 at 7 a.m., RNS 1 told her Resident 1 had discoloration on the forehead. RNS 3 stated she asked RNS 1 what happened to Resident 1. RNS 1 stated RNS 3 said Resident 1 probably hit her head on the side rails (but no witness). RNS 3 stated an injury of unknown origin or unknown cause such as Resident 1's discoloration on the forehead and swelling of left eye, "needed to be investigated and reported within one hour to the police, CDPH, the Administrator and the DON.". RNS 3 stated the DON conducts incidents investigation. RNS 3 stated an investigation should have been done to determine the cause of the injury and to prevent it from happening again. During a concurrent interview and record review on 4/30/2025 at 3:48 pm, with the DON, the facility's Policy and Procedure (P&P) titled "Abuse & Neglect," date revised 5/30/2024 was reviewed. The P&P indicated "Injury of unknown source is defined as an injury that meets 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 resident and the injury is suspicious because of the extent of the injury, the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma), the number of injuries observed at one particular point in time, or the incidence of injuries over time." The DON stated she did not know she had to report Resident 1's injury of unknow origin. The DON stated at the change of shift on 3/20/2025, CNA 1 noticed Resident 1's left eye with swelling and discoloration. The DON stated she was not clear on what shift Resident 1's injury has occurred. The DON stated Resident 1 could have hit herself while in bed, but it was not witnessed by staff. The DON stated Resident 1 was observed with the "discoloration" on the left side of the forehead and left eye. discoloration and swelling. The DON stated an x-ray was done to make sure Resident 1 did not have a fracture. A review of the facility's policy and procedure (P&P) titled, "Abuse & Neglect," date revised 5/3/2024, indicated, "Injury of Unknown source is defined as an injury that meets both 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 resident and the injury is suspicious because of the extent of the injury, the injury, the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma), the number of injuries observed at one particular point in time, or the incidence of injuries over time." A review of the facility's P&P titled, "Unusual Occurrence Reporting," date revised 5/30/2024, indicated "The facility reports the following events by phone and in writing to the appropriate State or Federal agencies; ...major accidents, allegations of abuse... other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees, or visitors. Unusual occurrences are reported to the appropriate agency within 24 hours by telephone and then confirmed in writing. The facility conducts documents timely and thorough investigations into all unusual occurrences and takes corrective action as appropriate. The investigation should include but not limited to interviews with residents, staff, and other witnesses. The facility failed to: 1. Ensure Resident 1's an injury of unknown origin was reported to California Department of Public Health (CDPH) within 24 hours in accordance with facility's policy and procedure titled, "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating." As a result, the facility did not reported to CDPH Resident 1's skin discoloration on a forehead and black left eye with swelling in a regulated time frame of two hours and did not thoroughly investigate he injury of unknown origin to rule out a potential abuse or neglect. These violations had a direct or immediate relationship to the health, safety, or security of patients or residents.