Health inspection·April 25, 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. 22 CCR § 72523 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. H&S § 1418.91 (a)A long-term health care facility shall report all incidents of alleged 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 3/13/2025, the California Department of Public Health (CDPH) received a complaint indicating Resident 1 had unexplained facial swelling and bruising. On 3/13/2025, the CDPH conducted an unannounced visit at the facility to investigate the allegation. The facility failed to: 1. Report injuries of unknown origin (injuries not observed by any person or the source of the injury could not be explained by the resident) to the CDPH for Resident 1, who had bruises to the right and left lower side of face and a swollen cheek. This failure resulted in a delay of investigation by the CDPH and placed Resident 1 at risk for further injuries. Resident 1 was an 84-year-old male, who was originally admitted on 1/17/2024 and readmitted on 3/12/2025. Resident 1’s diagnoses included dementia (a progressive state of decline in mental abilities), paroxysmal atrial fibrillation (irregular heartbeat), and other abnormality of gait and mobility (unsteady walking, and difficulty with coordination). A review of Residents 1’s Minimum Data Set (MDS – a resident assessment tool) dated 1/20/2025, indicated Resident 1 had cognitive (ability to think and reason) impairment. The MDS indicated Resident 1 required substantial/maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). A review of Resident 1’s Change of Condition (COC) dated 3/8/2025 at 1:05 p.m. indicated Resident 1 had bruises on the right side of the resident’s face, left lower side of the face and had a swollen left cheek. The COC indicated the physician recommended to send Resident 1 to a general acute care hospital (GACH). A review of Resident 1’s progress notes dated 3/8/2025, did not indicate the bruises on the resident’s right side of the face, left lower side of the face and swollen left cheek were reported to the CDPH. During a concurrent observation and interview on 3/13/2025 at 4:45 p.m., with Resident 1, Resident 1 was observed with a round, quarter-sized, purplish skin discoloration on the left side of the resident’s chin and swelling to the right side of the cheek. Resident 1 stated, he did not know what happened to his face. During an interview on 3/17/2025 at 3:49 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated she saw Resident 1 with a bruise on the left side of his face while passing medications and notified Registered Nurse (RN) 2 (date not specified). During an interview on 3/17/2025 at 5:00 p.m. with the Director of Nursing (DON), the DON stated Resident 1’s injuries of unknown origin (bruise on the right side of the resident’s face, left lower side of the face and swollen left cheek) should have been reported to the CDPH, Ombudsman (patient advocate) and police, however, the facility did not because the facility thought the injuries were caused by a medical issue and not due to abuse. The DON stated injuries (bruises) did not happen commonly to residents and needed to be reported to the CDPH to ensure the safety of the residents. During an interview on 3/19/2025 at 4:30 p.m., with RN 3, RN 3 stated, Resident 1 had a one-on-one sitter ([1:1] one facility staff provides constant, individualized supervision to one resident) for safety and fall prevention. RN 3 stated on 3/8/2025, RN 2 told him about Resident 1’s swollen face. RN 3 stated, he assessed Resident 1 with swelling to the right side of the resident’s face and had a light small bruise on the left side of the resident’s face. RN 3 stated Resident 1’s swollen face and bruising to the left side of face were injuries of unknown source and should have been reported to the CDPH for investigation. RN 3 stated, the facility’s priority was to provide safety to Resident 1 and all the residents in the facility. RN 3 stated it was the facility policy to report to the CDPH if there was a suspected abuse. During an interview on 3/20/2025 at 1:30 p.m., with Certified Nurse Assistant (CNA) 6, CNA 6 stated, on 3/8/2025 while Resident 1 was eating breakfast, she noticed Resident 1 had greenish discoloration to the left side of the resident’s chin and swelling to the right cheek. CNA 6 stated she reported her observation (greenish discoloration to Resident 1’s left side of the chin and swollen right cheek) to the charge nurse on 3/8/2025. A review of the facility’s policy and procedures (P&P) titled, “Injuries of Unknown Origin- Investigation,” dated 11/18/2015 indicated, an injury of unknown source are injuries not observed by any person or the source of the injury could not be explained by the resident. A review of the facility’s P&P titled, “Abuse Reporting and Investigations,” dated 12/21/2023 indicated when the Administrator or designated representative receives a report of injuries of an unknown source, the Administrator or designated representative, will notify outside agencies and send a written SOC341 report to CDPH Licensing and Certification within 24 hours. The facility failed to: Report injuries of unknown origin to the CDPH for Resident 1, who had bruises to the right and left lower side of the face and swollen left side of the cheek. This failure resulted in a delay of investigation by the CDPH and placed Resident 1 at risk for further injuries. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.