Health inspection·August 21, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review, the facility failed to notify the physician when one of two sampled residents (Resident 1) had blue discoloration to his left foot. This failure resulted in the facility being unaware of Resident 1's nondisplaced (bone fragments are in their original position) fracture (break in the bone) proximal (closer to the center) aspect proximal phalanx (toe bone) left first digit and a delay in care.Findings:During a review of the Progress Notes (PN) dated 8/11/25 at 10:26 p.m. (documented by Licensed Vocational Nurse (LVN) 3), the PN indicated, Resident is being monitored for s/s (signs and symptoms) of edema (swelling that occurs when fluid builds up in the body's tissues) to BLEs (bilateral lower extremities), will encourage resident to elevate legs. Denies pain and discomfort at this time. Resident has bluish discoloration noted on left foot.During a review of the PN dated 8/12/25 at 12:03 p.m. (documented by LVN 2), the PN indicated, Resident has bluish discoloration noted on left foot.During a review of the PN dated 8/12/25 at 8:26 p.m. (documented by LVN 2), the PN indicated, Resident has bluish discoloration noted on left foot.During a review of the PN dated 8/13/25 at 3:12 a.m., the PN indicated, .blueish discoloration to the left foot. Will cont. (continue) to observe and evaluate for acute changes.During a review of the PN dated 8/13/25 at 12:38 p.m. (documented by LVN 1), the PN indicated, Edema noted to bilateral extremities and reddish in color. Discoloration also noted to toes on LLE (left lower extremity).During a review of the PN dated 8/13/25 at 5:49 p.m., the PN indicated, Resident's daughter in to visit. Requesting resident be sent to (hospital name) for evaluation of lower extremity edema and discoloration. MD notified and received order to send to ER (emergency room) for further evaluation and treatment as indicated.During a review of the Imaging Report (IR-from the acute hospital) dated 8/13/25, the IR indicated, .suspicious for nondisplaced (bone fragments that are in their original position) fracture (break in the bone) proximal (closer to the center) aspect proximal phalanx (toe bone) left first digit.During a review of Resident 1's emergency room Note (ERN) dated 8/13/25 at 6:39 p.m., the ERN indicated, Patient does have 2+ (swelling where the affected area retains fluid and leaves a visible indentation when pressed) bilateral lower extremity edema. Along with bruising on the right third toe and left 2-43 (sic) toe.Patient's foot x-ray that showed a nondisplaced proximal left great toe fracture.During an interview on 8/21/25 at 12:43 p.m. with LVN 1, LVN 1 stated the discoloration to Resident 1's left foot was noticed a couple of days before she returned to work from her days off. LVN 1 stated Resident 1 was monitored at the time it was discovered and then sent to the hospital.During a concurrent interview and record review, on 8/21/25 at 1:15 p.m. with Assistant Director of Nursing (ADON), Resident 1's PN's were reviewed. ADON stated bluish discoloration was documented to Resident 1's left foot on 8/11/25, 8/12/25 and 8/13/25. ADON was unable to provide documentation the physician was notified of the discoloration until 8/13/25. ADON stated when the discoloration was noted the physician should have been notified.During an interview on 8/21/25 at 2:20 p.m. with LVN 2, LVN 2 stated she did not recall notifying the physician of the Page 1 of 2 555658 555658 08/21/2025 River Walk Care Center 1100 West Morton Avenue Porterville, CA 93257

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few discoloration to Resident 1's foot. LVN 2 stated when the discoloration was discovered the physician should have been notified. During an interview on 8/21/25 at 2:34 pm with LVN 3, LVN 3 stated she was aware of the discoloration to Resident 1's foot on 8/11/25 and did not notify the physician.During a review of the facility's policy and procedure (P&P) titled, Notification of Changes dated 2024, the P&P indicated, The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification.Circumstances requiring notification include.significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.clinical complications. 555658 Page 2 of 2