The incident at South Pasadena Care Center came to light during an August 27 state inspection triggered by a complaint. Resident 1's family first noticed the skin discoloration and swelling on August 14, two days after the resident had routine blood work drawn.
Nobody could explain how the injuries occurred.
RN 1 told inspectors she had no idea what caused the bruising and swelling. "There was no endorsement from previous shift regarding Resident 1's skin discoloration and swelling of left upper extremity," she said during the August 26 interview. The resident couldn't provide information about how the injuries happened.
Staff initially speculated the bruising might have resulted from the August 12 blood test or the resident's aspirin use. But RN 1 acknowledged there was "no documented evidence that Resident 1 sustained skin discolorations, bruising and swelling due to the blood draw."
The facility's Director of Nursing initiated a care plan on August 14 for "skin discoloration, swelling and pain to left hand and arm of unknown origin." The resident's doctor was notified and X-rays were ordered because staff didn't know how the injuries occurred.
RN 1 understood the reporting requirements. She told inspectors the Director of Nursing "should have reported it to CDPH, local law enforcement and ombudsman because we did not know how Resident 1 sustained those injuries."
But no reports were filed.
The Infection Preventionist confirmed during the August 26 interview that the facility never notified law enforcement, the California Department of Public Health, or the ombudsman about the unexplained injuries. "Since the DON did not know how Resident 1 sustained the left upper extremity injuries, the incident should have been reported to local law enforcement, CDPH and ombudsman for thorough investigation," the IPN told inspectors.
The failure violated the facility's own policies. South Pasadena Care Center's January 2025 policy on investigating resident injuries states that all resident injuries must be investigated. The policy defines an "injury of unknown source" as one where nobody observed what caused it and the resident can't explain it, particularly when the injury is suspicious due to its extent, location, or the number of injuries observed at one time.
A separate facility policy from March 2024 on abuse investigation and reporting is even more explicit. It requires that "all reports of mistreatment and/or injuries of unknown source shall be promptly reported to agencies as defined by current regulations and thoroughly investigated by facility management."
The policy mandates immediate reporting to three specific agencies: the ombudsman, law enforcement officials, and the state licensing agency responsible for surveying the facility. Reports must be made "immediately or as soon as practicable, but not later than two hours after the incident occurred."
None of these reports were filed for Resident 1's injuries.
During the interdisciplinary team discussion, social service staff suggested the bruising might have been from the resident's blood test two days earlier or aspirin use. But this speculation didn't change the fundamental problem: nobody knew for certain what caused the injuries, making them unexplained injuries requiring immediate reporting under federal regulations.
The August 14 care plan documentation explicitly acknowledged the injuries were "of unknown origin," meeting the facility's own definition of suspicious injuries requiring investigation and reporting. Staff recognized they couldn't explain how a resident sustained visible bruising and swelling on their left arm and hand.
RN 1's interview revealed the disconnect between staff understanding and facility action. She correctly identified that unexplained injuries should be reported to multiple agencies for proper investigation. She acknowledged the facility didn't know how the resident was injured. Yet the required reports were never made.
The Infection Preventionist emphasized the purpose behind reporting requirements: to ensure thorough investigation of how residents sustain unexplained injuries and to develop care plans preventing future incidents. Without proper reporting, these investigations don't happen.
Federal regulations require nursing homes to immediately report suspected abuse, neglect, or injuries of unknown origin to multiple agencies. The requirement exists because facilities cannot adequately investigate potential abuse or neglect on their own. Outside agencies have investigative resources and authority that nursing homes lack.
South Pasadena Care Center's policies aligned with federal requirements, mandating two-hour reporting timeframes for unexplained injuries. The facility's own infection preventionist and nursing staff understood these requirements. But when faced with an actual case of unexplained injuries, the facility failed to follow its own procedures.
The resident's family discovered the injuries themselves, raising questions about facility monitoring and assessment practices. The bruising and swelling were significant enough to prompt family concern, medical evaluation, and X-ray orders. Yet staff provided no satisfactory explanation for how the injuries occurred.
Resident 1's case illustrates a broader problem in nursing home injury reporting. Facilities sometimes attribute unexplained injuries to routine medical procedures or medication side effects without documentation supporting these explanations. This speculation can delay or prevent proper investigation of potentially serious incidents.
The inspection found the facility's failure to report unexplained injuries represented minimal harm with potential for actual harm to few residents. But the violation undermines the entire system designed to protect nursing home residents from abuse and neglect.
Without proper reporting, unexplained injuries go uninvestigated by authorities with expertise in elder abuse detection. Patterns of abuse or neglect may go unrecognized. Residents remain at risk when facilities fail to follow through on their own policies and federal requirements.
Resident 1's family likely expected the nursing home to thoroughly investigate and properly report their loved one's unexplained injuries. Instead, they discovered a facility that speculated about causes while ignoring its legal obligation to notify authorities when injuries couldn't be explained.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for South Pasadena Care Center from 2025-08-27 including all violations, facility responses, and corrective action plans.