Health inspection·April 9, 2026

The following reflects the findings of the California Department of Public Health during an Abbreviated Standard Survey Complaint # 2714350. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. A deficiency was written for Complaint # 2714350 at F-Tag 684-G. § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, including but not limited to the following: (d) Accidents. The facility must ensure that- (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR § 72523 (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 22 CCR 72707 (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated...Patients shall have the right: (3) To receive all information that is material to an individual patient's decision concerning whether to accept or refuse any proposed treatment or procedure. On 1/22/26 an unannounced visit was conducted at the facility to investigate a complaint incident regarding a patient who sustained a fracture. Resident 1 is a 51-year-old female who was admitted to the facility on 7/14/2025 with diagnoses including lupus (autoimmune disease where the immune system mistakenly attacks healthy cells, causing inflammation and potential damage to joints and other organs) and history of steroid treatment (can cause weak bones), diabetes (high blood sugar levels) with multiple ulcers and history of prior fractures following a motor vehicle accident, abnormal posture, need for assistance with personal care. Based on interview and record review the facility failed to: 1. Ensure one sampled resident's (Resident 1's) environment remains as free of accident hazards as is possible when on 1/3/26 while the resident was out on a day pass visiting with family Resident 1, who required extensive assistance with bed mobility, transfer, and dressing, has risk factors for poor bone density and used a wheelchair, sustained a likely low energy rotational injury resulting in a nondisplaced distal left femur fracture while toileting in her room unassisted. 2. Provide treatment and care in accordance with professional standards of practice when the physician failed to provide a clear or appropriate medical order when she responded to Registered Nurse (RN) 1's report of Resident 1's acute injury and request for a diagnostic X-ray with a non-clinical "thumbs up" emoji reaction, and RN 1 failed to seek clarification of the non-standard form of communication, which jointly contributed to a substantial probability of serious harm to Resident 1 due to the resulting delay in diagnostic evaluation. 3. Provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, when the facility staff failed to timely obtain appropriate diagnostic evaluation for the resident's acute left lower extremity injury after Resident 1 reported pain and swelling, and requested an X-ray resulting in a 6-day delay in diagnosis of her femur fracture. 4. Ensure Resident 1 received all information material to her decision concerning whether to accept or refuse treatment when, despite her wishes, it did not timely obtain a medically appropriate diagnostic X-ray for six days to evaluate for the possibility of a leg fracture following her acute rotational injury. 5. Implement written care policies and procedures, when the facility failed to implement its P&P titled "Pain Assessment and Management", dated October 2022, which requires the facility "...to develop interventions that are consistent with the resident's goals and needs and that address the underlying cause of pain" when it failed to obtain a diagnostic X-ray consistent with Resident 1's goals and needs to address the underlying cause of her left lower extremity pain following her acute injury. Findings: During a review of Resident 1's "Admission Record" (AR), undated, the AR indicated Resident 1 was admitted to the facility on 7/14/25 with diagnoses of abnormal posture and need assistance with personal care. During a review of Resident 1's Minimum Data Set (MDS) (a comprehensive assessment tool) dated 11/14/25, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a mental capacity assessment) with a range of scores from 0-15, with higher scores indicating different levels of cognition) score of 15. The MDS indicated Resident 1 used a wheelchair and needed assistance with movement and activities of daily living (eating, dressing, hygiene). During a review of Resident 1's "Nurse's Note" (NN) dated 1/3/26 at 6:21 p.m., the NN indicated Resident 1 had been out of the facility on a family outing day pass on 1/3/26 and returned at 5 p.m. The NN indicated, "[Resident 1] came back to facility with family at 5 p.m. VS [vital signs] obtained were normal. No pain or discomfort noted." During a review of Resident 1's "SBAR Communication Form" (Situation, Background, Assessment and Recommendations - a standard form used to document change in conditions of residents) (SBAR), dated 1/3/26 at 8:05 p.m. (three hours later), the SBAR indicated "[Resident 1] reported PAIN to nurse, pt [patient/Resident 1] reported while she was with family, on wheel chair her left leg got twisted, nurse assessed, mild swelling noted on left knee and provided PRN [as needed] pain medication for pain, vitals were recorded within normal range. Family/RP [Responsible Party] DR [Doctor] made aware, dr [Doctor] prescribed 5% lidocaine patch [a topical pain medication] for moderate pain and Norco 5mg [milligrams] [a narcotic pain medication] every 6 [hours] as needed..." There was no documentation of physician's order to send resident to the hospital. During a review of Resident 1's Care Plan titled "Pain" (Pain Care Plan), dated 1/3/26, the Pain Care Plan indicated the intervention of, "Assess pain every shift and as indicated." During a review of Resident 1's Medication Administration Record (MAR), dated January 2026, the MAR indicated order dated 7/14/25 indicating, "Monitor and Record pain assessment level Q [every] shift, -No pain, 1-3 Mild pain, 4-6 Moderate pain, 7-10 Severe pain... 1/4/26: Pain Level of 7." The MAR also contained order dated 12/2/25 for "Hydrocodone-Acetaminophen [a pain medication] Oral Tablet 5-325 mg [milligrams]... Give 1 tablet as needed for pain." The pain medication was given on: 1/3/26: Pain Level of 8 1/4/26: Pain Level of 7 1/5/26: Pain Level of 7 1/6/26: Pain Level of 7 1/7/26: Pain Level of 8 1/8/26: Pain Level of 7 During a review of Resident 1's NN dated 1/6/26 at 1:36 p.m., the NN indicated, "[Resident 1] is complaining of pain left knee." During a review of Resident 1's physician's orders (PO) dated 1/8/26, the PO indicated to obtain an "X-ray to left knee D/T [due to] Pain. . ." During a review of Resident 1's "Radiology Results Report" (RR), dated 1/8/26 at 4:31 p.m. (five days later), RR indicated, "KNEE EXAM... LEFT... Reason for Study: PAIN IN LEFT KNEE... Conclusion: Nondisplaced [a stable break where the bone cracks but remains properly aligned] distal [away from body center] femur fracture appears acute [happened recently]..." Medical Doctor (MD) 1 sent a text message to Registered Nurse (RN) 1 on 1/3/26 (five days ago) with a thumbs up (indicating approval) emoji to order X-Ray. During a review of Resident 1's SBAR, dated 1/9/26 at 10:44 a.m., the SBAR indicated, "X-Ray results came, [Resident 1] has nondisplaced [a bone break where the fragments remain in their proper alignment] distal femur fracture appears acute... notified dr [doctor]/rp [responsible party/family], [Resident 1's son] told his dad was rolling the wheel chair while [Resident 1] got twisted her leg underneath the wheelchair... [Resident 1 sent out to hospital]." During a review of Resident 1's hospital record "History and Physical" (H&P), dated 1/9/26 at 9:53 p.m. (six days later), the H&P indicated, "Pt [patient] BIB [brought in by ambulance] EMS [emergency medical services] from [facility] complaining of left knee pain for x6 [six] days... Complains of moderate pain and swelling... XR [x-ray] and CT [computerized tomography, diagnostic imaging procedure that uses rotating X-rays and computer technology to produce detailed, cross-sectional, 3D "slices" of bones, blood vessels, and soft tissues] scan of the left knee performed on arrival to ED showing new nondisplaced fracture of distal femur... Assessment/Plan: Fracture of the distal end of left femur... occurred six days ago. Ortho surgical repair [procedure performed by specialists to fix, reconstruct, or replace damaged components of the bones]." During an interview on 2/4/26 at 11:57 a.m. with RN 1, RN 1 stated he was the nurse in charge on 1/3/26 during the afternoon shift (3 p.m. to 11 p.m.). RN 1 stated Resident 1 was out of the facility on a day pass on 1/3/26 and returned around 5-6 p.m. RN 1 stated at around 8 p.m. he went to Resident 1's room to check on her. RN 1 stated Resident 1 reported pain in her left knee. RN 1 stated he assessed Resident 1's left knee and noticed it was swollen. RN 1 stated he took pictures of Resident 1's knees using the "Nursing Phone" and sent the pictures via a text message to MD 1. RN 1 stated the Nursing Phone was a facility cell phone used to communicate with physicians. RN 1 showed the text message and pictures he sent MD 1. RN 1 showed a text message sent to MD 1 on 1/3/26 at 8:05 p.m. as follows, "Hey dr, [Resident 1], her left knee hurts and its little swollen. Because she said her leg got twisted on wheelchair when she was out with her family. She didn't report anything after coming back but she is in pain now. She also requesting for X-ray for her knee." Attached to this text message were pictures of Resident 1's knees, showing swelling of her left knee. RN 1 said MD 1 replied with a "thumbs up" emoji and the following text message, "We can do a lidocaine patch [patch with medication for pain] too, 5% q [every] 24 prn [as needed] ... if severe can give Norco 5 [mg/milligram] q [every] 6 [hours] prn." RN 1 stated MD 1's response was for him to enter the two pain medication orders and treat Resident 1's pain. RN 1 stated that MD 1 did not order x-rays or for Resident 1 to be sent out to the hospital for evaluation of her leg. During an interview on 2/4/26 at 1:25 p.m. with Resident 1, Resident 1 was alert and oriented and stated she broke her left leg in the facility on 1/3/26 at around 6 p.m. Resident 1 stated on 1/3/26 at around 6 p.m. she was in her room and was going to the bathroom in her wheelchair when she accidently twisted her left leg and felt her left knee "pop". Resident 1 stated she felt a sharp pain in her left knee and reported it to her nurse. Resident 1 stated thereafter she had a constant, sharp, moderate intensity pain in her left knee daily until she was taken to the hospital six days later on 1/9/26. Resident 1 asked why it took so long to take her to the hospital to check on her leg. Resident 1 stated she should have been taken to the hospital the same day she had injured her leg on 1/3/26. During an interview on 2/4/26 at 2:40 p.m. with MD 1, MD 1 stated she was contacted by RN 1 on 1/3/26 at night via text message. MD 1 stated RN 1 sent her a text message on 1/3/26 at 8:05 p.m. reporting Resident 1 had left knee pain and requesting an x-ray of her left knee. MD 1 stated she replied to RN 1's text message with a "thumbs up" emoji and a text message with pain medication orders. MD 1 stated the "thumbs up" emoji meant she approved of Resident 1's request for a left knee x-ray. MD 1 stated her expectation was for RN 1 to send Resident 1 out to the ER that night or the next morning for evaluation and treatment of her left leg pain and swelling. During an interview on 2/4/26 at 3 p.m. with Director of Nursing (DON), DON stated there was a miscommunication between RN 1 and MD 1 on 1/3/26 regarding Resident 1's left leg injury. DON stated emojis were not a professional way for MD 1 to communicate with RN 1 concerning the care of Resident 1. DON stated emojis had the potential for confusion and misunderstanding. DON stated the fact Resident 1 was Spanish speaking only may have contributed to a misunderstanding amongst nursing staff about how Resident 1 injured her leg. DON stated Resident 1 should have been sent earlier to the hospital for evaluation and treatment of her leg pain and injury. DON stated the facility had no policy and procedure on proper communication between the licensed nurse and the doctor. During a review of facility policy and procedure (P&P) titled "Quality of Care/Accommodation of Needs", Revised March 2021, the P&P indicated, "Our facility's environment and staff behavior are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being... The resident's individual needs and preferences are accommodated to the extent possible..." During a review of facility P&P titled "Pain Assessment and Management", dated October 2022, the P&P indicated, "...to develop interventions that are consistent with the resident's goals and needs and that address the underlying cause of pain." During a review of facility P&P titled "Change in a Resident's Condition or Status", Revised February 2021, the P&P indicated, "The nurse will notify the resident's attending physician or physician on call when there has been a(an):...(a) accident or incident involving the resident... (g) need to transfer the resident to a hospital/treatment center..." In violation of the above cited, the facility failed to send Resident 1 to the hospital promptly for evaluation and treatment of a left leg injury after Resident 1 reported she had injured her left leg and requested to be taken to the hospital for X-rays and treatment. This failure resulted in Resident 1 experiencing continued severe pain in her left leg which required hospitalization and surgical intervention. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and represents a Class A citation.