Health inspection·December 23, 2025

LOS ALTOS POST ACUTE The following reflects the findings of the California Department of Public Health during the investigation of a complaint. Complaint Number: CA00971144 (IQIES 2365405) Representing the Department, HFEN 50855 Citation B was written. REGULATORY VIOLATIONS: California Code of Regulations, Title 22 §72303. Physician Services - General Requirements. (b) Physician services shall mean those services provided by physicians responsible for the care of individual patients in the facility. Physician services shall include but are not limited to: (7) Provision for alternate physician coverage in the event the attending physician is not available. Based on observation, interviews and record reviews, the facility failed to follow its policies and procedure when the nursing staff did not contact the medical director for additional guidance and consultation when they did not get a timely or appropriate response from an Attending Physician (AP) regarding a change of condition (COC) of swelling of right thigh and shortness of breath on 6/30/25 for Patient 1. This failure resulted in Patient 1 not receiving medical care in a timely manner. Patient 1 was sent to Acute Hospital on 7/2/25 for other reasons (nausea and fever) but was also found with new acute displaced comminuted (bone that is broken in at least two places.) right proximal femoral shaft (the portion of the femur [thigh bone] that is closest to the hip joint) fracture and had surgery on 7/3/25. This failure had the potential to compromise the safety of the patients or residents in the facility. FINDINGS: The clinical record of Patient 1 was reviewed. Patient 1 was admitted to the facility on 8/23/13 and readmitted on 9/10/24 with diagnoses including paraplegia (condition characterized by the loss of voluntary movement and sensation in the lower half of the body, typically from the waist down). During an interview with Patient 1 on 7/8/25 at 2:50 p.m., Patient 1 stated he told Licensed Nurse (LN) A, about his right thigh swelling. Patient 1 further stated they did not do anything about his right thigh swelling. During an interview on 7/8/25 at 2:01 p.m., with LN D, she stated they did an Xray of Patient 1's Right knee on 6/27/25 due to the popping sound heard during treatment. Review of Patient 1's progress notes dated 6/27/25 indicated, "After providing tx (treatment) care in the morning time for pt (patient)., pt. was requesting to reposition legs so he can trim his toenails. After feeling a bit of resistance in bending leg in a position where his leg can sit above opposite knee, a 'popping' noise was heard after bending leg. Concerned pt. may have had an injury due to the popping. Notified pt. M.D. (Medical Doctor) [AP], and he ok'ed for pt. to have STAT (immediately) x-ray (form of electromagnetic radiation that uses a small amount of energy to create images of the inside of your body, like bones and organs.) done. X-ray (was) done about 30mins ago. Awaiting result. Will continue to monitor." Review of Patient 1's Xray result dated 6/27/25 indicated, CONCLUSION: Right Knee no acute fracture. During a review of Patient 1's progress note dated 6/30/25 by LN A indicated, "...The resident was having shortness of breath that has resolved since calling. Unable to get O2 (oxygen) sat (saturation) off any digit or extremity, applied 2L (two Litter) O2 via NC (nasal cannula, a medical device that delivers supplemental oxygen through a flexible tube with two prongs that rest in the nostrils.) to resident, resident reported effectiveness. [ HOSP Staff - B] stated he will make this a "high-priority call" and to expect a call back within 24hrs. St. [station] 3 fax and facility phone numbers given. This LN (Licensed Nurse) attempted to call [hospital] at the end of shift if any updates in relation to patient, spoke to [HOSP Staff C], this LN told [HOSP Staff C] that resident reported effectiveness of 2L O2 via NC and removed NC by himself, currently on Room Air. No further updates from [Hospital, HOSP] as of 5PM, [HOSP Staff C] stated to continue to expect call back with orders." During review of Patient 1's Change in Condition Evaluation (COC) dated 6/30/25 indicated: "1.a List the other changes "Swelling in R (right) thigh" Section 3. Review & Notify B Provider Notification and Feedback 3. Recommendation of Primary Clinicians(s): "Called back [hospital] at 5PM, no new orders as of yet. [HOSP Staff C], w/ [hospital] stated will call back w/ orders when signed by MD." During an interview on 7/9/25 at 11:27 a.m., with LN A, she stated she remembered the COC dated 6/30/25 for Patient 1's right thigh swelling and SOB she stated she did the measurement of Patient 1's right thigh. LN A stated she called HOSP and spoke to [HOSP Staff B]. LN A stated she did not receive a reply, and she called back again before end of the shift. She stated she expected a call back with orders, but LN A further stated she did not receive a call back from the Doctor [AP]. LN A also stated the next shift should follow up, that's why she endorsed it to the next shift. Review of Patient 1's Facility Face Sheet (FS, document that summarizes a person's information such as medical history) indicated, Name of Attending Physician (AP) with phone number. During the interview on 7/9/25 at 11:27 a.m., with LN A she confirmed that this was the AP of Patient 1 who she was calling at HOSP. During a concurrent interview and record review on 8/28/25 at 1:50 p.m., with the Assistant Director of Nursing (ADON), the ADON reviewed Patient 1's progress notes from 6/30/25 to 7/2/25, the ADON stated he did not see anything documented that the doctor (AP) called back. During a follow-up interview on 8/28/25 at 2:09 p.m., with the ADON, the ADON stated he did not see documentation that the next (shift) nurse followed up with the doctor (AP) for Patient 1. ADON further stated Patient 1 was sent out to hospital on 7/2/25 for nausea and fever. During a review of Patient 1's Acute Hospital Records: History and Physical (H&P) CT (computed tomography, a type of medical imaging) Abdomen Pelvis (the basin-shaped structure in the lower part of the torso that connects the spine to the legs) w (with) IV Contrast (special medication injected into a vein that enhances the visibility of organs, blood vessels, and tissues during medical imaging like CT scans) result dated 7/3/25 IMPRESSION: "...4. New acute displaced comminuted (bone that is broken in at least two places.) right proximal femoral shaft (the portion of the femur [thigh bone] that is closest to the hip joint) fracture..." During a review of Patient 1's Acute hospital records: H&P printed date 7/8/25 indicated, "Neurological: General: No focal deficit present. Mental Status: He is alert and oriented to person, place, and time." During a review of Patient 1's Acute Hospital Records: H&P Summary of Hospitalization with printed date 7/8/25 indicated, "Patient was also found to have a femur fracture, s/p (status post) ORIF [Open Reduction and Internal Fixation, a surgical procedure used to repair broken bones) with ortho (short for orthopedic doctor or orthopedist, a medical specialist who diagnoses and treats conditions of the musculoskeletal system], post-op course unremarkable." ... date of surgery 7/3/2025. Patient 1 was discharged back to the facility on 7/6/25. During further review of Patient 1's clinical records, there was no documentation that the Facility Medical Director was notified that the AP did not respond to the calls made regarding the COC. Furthermore, there was no documentation that any other physician was called. During a review of facility's policy and procedure (P&P) titled, "Acute Condition Changes-Clinical Protocol" undated, the P&P indicated, "...7. The Nursing staff will contact the physician based on the urgency of the situation. 8. The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. 9. The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response..." This failure resulted in Patient 1 not receiving medical care in a timely manner. Patient 1 was sent to Acute Hospital on 7/2/25 for other reasons (nausea and fever) but was also found with new acute displaced comminuted (bone that is broken in at least two places.) right proximal femoral shaft (the portion of the femur [thigh bone] that is closest to the hip joint) fracture and had surgery on 7/3/25. This failure had the potential to compromise the safety of the patients or residents in the facility. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents. 2