Health inspection·April 22, 2025

§483.12(c) Reporting of Alleged Violations 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)(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. 22CCR §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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. HSC 1418.91 (a) 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. On 02/27/2025, the California Department of Public Health (CDPH) received a Facility-Reported Incident (FRI) indicating Resident 1 had an injury of unknown origin. On 03/13/2025 at 8:00 a.m., the CDPH conducted an unannounced visit for investigation. The facility failed to: 1. Report an injury of unknown origin to the CDPH for Resident 1. As a result, there was a delay in the investigation by the CDPH. Resident 1 was a 93-year-old female, admitted on 08/17/2023 with diagnoses which included age-related physical debility (a decline in physical function that can occur with aging), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), difficulty in walking and lack of coordination. A review of Resident 1’s Minimum Data Set (MDS- a federally mandated resident assessment tool) indicated Resident 1’s cognitive skills was severely impaired. The MDS indicated Resident 1 required moderate supervision with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 1’s nursing notes, dated 2/21/2025 at 10:16 p.m., indicated Resident 1 had a bump on the back of her head. A review of Resident 1’s nursing notes, dated 2/22/2025, at 11:00 a.m., indicated Resident 1 was noted with purple and blue discoloration and an elevated bump to the back of her head. During a telephone interview on 3/13/2025, at 9:36 a.m., with Certified Nurse Assistant 1 (CNA) 1, CNA 1 stated on 2/21/2025 at 5:00 p.m., she observed Resident 1 had a reddish discoloration and bump to the back of her head. CNA 1 stated she reported Resident 1’s bump to Registered Nurse (RN) 1 on the 3:00 p.m. to 11:00 p.m. shift. CNA 1 stated after dinner, she asked RN 1 if Resident 1’s bump was reported. CNA 1 stated the RN 1 stated, “I took care of it.” During an interview on 3/13/2025 at 10:24 a.m., with LVN 1, LVN 1 stated on 2/22/2025 at 10:30 a.m., he was informed by CNA 2 of Resident 1’s bump to the back of her head. LVN 1 stated on 2/22/2025 he reported Resident 1’s bump to RN 2. LVN 1 stated the time frame for reporting allegations of an injury of unknown origin was within 2 hours after discovering the injury. During a telephone interview on 3/13/2025 at 11:29 a.m., with RN 2, RN 2 stated on 2/22/2025, LVN1 informed her of Resident 1’s bump on the head. RN 2 stated on 2/22/2025 she reported Resident 1’s bump to the Director of Nursing. RN 2 stated the risk of not reporting in a timely manner could result in complications from a head injury or potential abuse. During an interview on 3/13/2025 at 12:40 p.m., with the Director of Nursing (DON), the DON stated on 2/22/2025 she was informed of Resident 1’s bump. The DON stated Resident 1’s bump should have been reported on 2/21/2025. The DON stated the risk of not reporting an unknown injury in a timely manner could result in impeding a resident’s care. During an interview on 3/13/2025 at 1:03 p.m., with the Administrator (ADM), the ADM stated the time frame for reporting unknown injuries was within two hours. The ADM stated Resident 1’s bump was not reported to the CDPH because he was not aware of the incident. The ADM stated the risk for not reporting an unknown injury could result in a health decline and potential abuse. A review of the facility’s policy and procedures, titled “Injury of Unknown Origin (Abuse),” revised 3/2024, indicated “The management and staff, with the support of the physicians, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations.” The facility failed to: 1. Report an injury of unknown origin to the CDPH for Resident 1. As a result, there was a delay in the investigation by the CDPH. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1 and other residents in the facility.