Health inspection·October 31, 2025

§483.12(c)(1) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. §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 9/2/2025 and 9/11/2025, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1), was mishandled, and was transferred to the emergency department (ED) due to pain and discomfort. At the GACH Resident 1 was diagnosed with a dislocated left arm/shoulder. On 9/9/2025, CDPH conducted an unannounced visit at the facility to investigate the complaint allegation. CDPH determined the facility did not report Resident 1's injury of unknown origin. The facility failed to: 1. Ensure an injury of an unknown origin was reported when the facility was made aware of Resident 1's left shoulder dislocation. 2. Ensure the facility followed their Policy and Procedure (P/P) titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating" dated 9/2022, which indicated the facility will report all resident abuse (including injuries of unknown origin) to local, State and Federal agencies (as required by current regulations). This deficient practice resulted in the inability of CDPH to investigate the injury of unknown injury in a timely manner and had the potential for facts related to Resident 1's injury to be lost and/or forgotten. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, a 70 year old male, was initially admitted to the facility on 1/13/2025 and readmitted on 8/28/2025 with diagnoses including metabolic encephalopathy (a brain disorder that occurs when an underlying condition causes a chemical imbalance in the blood that affects the brain), epilepsy, and intellectual disability. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 4/22/2025, indicated Resident 1 had severe cognitive impairment. A review of Resident 1's History and Physical (H&P) dated 8/29/2025, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's SBAR ([situation, background, assessment, recommendation] a communication tool used by healthcare workers when there is a change of condition among the residents) dated 9/4/2025 and timed at 11:18 a.m., indicated Resident 1's left elbow had redness in a circular shape surrounding the entire left elbow and part of the posterior (refers to the back or rear of a structure or organism) arm, edema (swelling) and was warm to touch. The SBAR indicated Resident 1's physician ordered an X-Ray of Resident 1's left arm. A review of Resident 1's Physicians Order Summary Report, dated 9/4/2025, indicated to obtain an X-Ray of Resident 1's left humerus (upper arm bone), and left shoulder to rule out a fracture, and to transfer Resident 1 to a GACH for further evaluation. A review of Resident 1's X-Ray Report date 9/4/2025, indicated Resident 1 had moderate joint osteoarthritis ) and a dislocation at the glenohumeral joint (a ball and socket joint that connects the upper end of the humerus to the glenoid cavity [socket] of the scapula [shoulder blade]). During an interview on 9/12/2025 at 10:53 a.m., and a subsequent interview on 9/15/2025 at 9 a.m., the Director of Nursing (DON) stated she did not report Resident 1's injury of unknown origin to CDPH because Resident 1 had a shoulder issue from previous hospitalizations a long time ago. The DON stated they considered Resident 1's shoulder dislocation a chronic issue not an acute (develops suddenly) issue. During an interview on 9/17/2025 at 1:13 p.m., the Administrator (ADM) stated Resident 1's left shoulder dislocation was not reported to CDPH because it was considered a "chronic issue." The ADM stated the facility had a 24-hour window to report injuries from an unknown origin, and the facility found out why Resident 1's left shoulder was dislocated during their investigation and before 24 hours had surpassed. A review of the facility's P/P titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating" dated 9/2022, indicated the facility will report all resident abuse, including injuries of unknown origin to local, State and Federal agencies (as required by current regulations). The facility failed to: 1. Ensure an injury of an unknown origin was reported when the facility was made aware of Resident 1's left shoulder dislocation. 2. Ensure the facility followed their P/P titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating" dated 9/2022, which indicated the facility will report all resident abuse including injuries of unknown origin to local, State and Federal agencies (as required by current regulations). This deficient practice resulted in the inability of CDPH to investigate the injury of unknown injury in a timely manner and had the potential for facts related to Resident 1's injury to be lost and/or forgotten. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 1.