Health inspection·July 24, 2025

§ HSC 1418.91 Abuse Reporting (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. 42 CFR §483.12: Freedom from Abuse, Neglect, and Exploitation (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. (c)(2) Have evidence that all alleged violations are thoroughly investigated. (c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (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. 22 CFR § 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 On 6/11/2025 and 6/12/2025 the California Department of Public Health (CDPH) received two complaints indicating Resident 1 had unexplained injuries and bruises. On 6/24/2025, the CDPH conducted an unannounced complaint investigation at the facility. The facility failed to: 1. Report an injury of unknown origin on 6/4/2025 to the State Agency (CDPH), when Resident 1 was found to have discoloration on the right side of his forehead. 2. Thoroughly investigate an injury of unknown origin when Resident 1 observed with a discoloration on the right side of his forehead. These deficient practices resulted in the facility not being aware of the cause of Resident 1’s injury, delayed the CDPH’s investigation, and had the potential to result in further injury to Resident 1. Resident 1 was a 78-year-old male, initially admitted to the facility on 11/8/2024 and readmitted on 6/17/2025. Resident 1’s diagnoses included metabolic encephalopathy (condition when the brain’s function is impaired due to a chemical imbalance in the body), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and generalized muscle weakness. A review of Resident 1’s Minimum Data Set (MDS- a resident assessment tool), dated 6/9/2025, indicated Resident 1’s cognitive skills (process of thinking) for daily decision making was severely impaired. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) with bathing, upper body dressing, and personal hygiene. A review of Resident 1’s History and Physical (H&P), dated 2/7/2025, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1’s situation, background, assessment, recommendation (SBAR -a communication tool used by healthcare workers when there is a change of condition among the residents) form, dated 6/4/2025, indicated the certified nursing assistant (CNA) reported to the licensed vocational nurse (LVN) of a discoloration on Resident 1’s right side of the forehead. During an interview on 6/24/2025 at 12:35 p.m. with (LVN) 2, LVN 2 stated on 6/4/2025, a CNA informed her of Resident 1’s discoloration to the right side of his forehead. LVN 2 stated she did not know the origin of the discoloration. LVN 2 stated she was unable to recall if the Director of Nursing (DON) or the Administrator (ADM) were informed. LVN 2 stated discoloration on the forehead was considered a type of injury. LVN 2 stated an injury of unknown origin was defined as an injury that could have come from anywhere, but the actual cause was unknown. LVN 2 stated with an injury of unknown origin, there was the concern the injury was inflicted by another person, which would be seen as physical abuse. LVN 2 stated Resident 1’s discoloration on his forehead should have been reported to the ADM and the DON to allow them to investigate and report to the appropriate agencies such as the CDPH, the ombudsman, and the police. During an interview on 6/24/2025 at 1:26 p.m. with Registered Nurse (RN) 1, RN 1 stated when an injury of unknown origin occurred, the source of the injury had to be reported. RN 1 stated Resident 1’s discoloration on his forehead was considered an injury and due to the nursing staff being unable to determine its cause, the injury was from an unknown origin. RN 1 stated once there was knowledge of the injury, the DON and ADM were responsible for investigating to determine if the resident was abused, and reporting to the necessary agencies. During an interview on 6/24/2025 at 3:17 p.m. with the DON, the DON stated injuries of unknown injury had to be reported to the ADM and to CDPH, the police, and the ombudsman for investigation into and to prevent it from occurring again. The DON stated she interviewed the nurses and asked whether Resident 1 fell or had episodes of combativeness. The DON stated upon interviewing the nurses who cared for Resident 1, the cause of the discoloration was unknown. The DON stated she did not investigate whether Resident 1 was hit by another resident or a staff member. The DON stated by not conducting a thorough investigation in all possibilities, Resident 1 and other residents were at risk for further or potential abuse. The DON stated reporting injuries of unknown origin was essential to keep Resident 1 safe. The DON stated the incident was not reported because the facility did not think of the possibility of another individual hitting Resident 1 on the forehead. During an interview on 6/24/2025 at 4 p.m. with the ADM, the ADM stated the purpose of reporting allegations of abuse and injuries of unknown origin was to investigate the cause and to determine if abuse occurred. The ADM stated injuries of unknown origin were to be reported to the appropriate agencies such as CDPH, the ombudsman, and the police. The ADM stated he did not recall if he was informed of the discoloration on 6/4/2025, however, he saw Resident 1 five days later, on 6/9/2025, after the resident was observed with a discoloration. The ADM stated when he saw Resident 1 on 6/9/2025, he did not see a bump or any discoloration on Resident 1’s forehead, he therefore did not report it. The ADM stated he did not conduct a formal investigation regarding Resident 1’s forehead discoloration and only asked the nurses if Resident 1 fell or if any of the nurses witnessed any other unusual occurrences. A review of the facility’s policy and procedure (P&P) titled, “Abuse Investigation and Reporting”, revised 7/2017, the P&P indicated, “All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the State licensing/certification agency responsible for surveying/licensing the facility; The P &P indicated an alleged violation of abuse, neglect, exploitation (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than two hours if the alleged violation involved abuse or resulted in serious bodily injury; or twenty-four hours if the alleged violation did not involve abuse and had not resulted in serious bodily injury.” The facility failed to: 1. Report an injury of unknown origin on 6/4/2025 to CDPH, when Resident 1 was found to have discoloration on the right side of his forehead. These deficient practices resulted in the facility not being aware of the cause of Resident 1’s injury, delayed the CDPH’s investigation, and had the potential to result in further injury to Resident 1. These violations had a direct or immediate relationship to the health, safety, or security of Resident 1 and other residents in the facility.