Health inspection·July 24, 2025

42 CFR §483.12: Freedom from Abuse, Neglect, and Exploitation (c) 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. HSC § 1418.91 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. (b) A failure to comply with the requirements of this section shall be a class “B” violation. 22 CCR § 72541 - Unusual Occurrences Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility should furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. 22 CFR § 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 On 6/4/2025, the California Department of Public Health (CDPH) received a complaint indicating Resident 57 had an unexplained broken bone. On 6/10/2025, the CDPH conducted an unannounced visit at the facility to investigate Resident 57’s unexplained broken bone. The facility failed to: 1. Implement its policies and procedures (P&P) titled “Unusual Occurrence Reporting," dated 8/27/2021, which indicated the facility will follow all applicable state and federal laws and regulations regarding the reporting of unusual occurrences within 24 hours. As a result, there was a delayed investigation by the CDPH. Resident 57 was a 68- year-old female, originally admitted to the facility on 11/4/2024 and readmitted on 6/5/2025. Resident 57’s diagnoses included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the hip, end stage renal disease (ESRD -irreversible kidney failure), and dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). A review of Resident 57's Minimum Data Set ([MDS]- a resident assessment tool), dated 5/7/2025, indicated Resident 57 was cognitively intact (ability to reason, understand, remember, judge, and learn) and had impairments of the lower extremities (related to the legs). The MDS, indicated Resident 57 required moderate assistance with bathing and transferring from bed to chair. A review of Resident 57's Situation, Background, Assessment, and Recommendation form (SBAR -a communication tool used by healthcare workers when there was a change of condition among the residents) dated 5/28/2025, indicated Resident 57 had severe pain in her lower back, bilateral hips and down her lower extremities more to right than the left side. The SBAR indicated Resident 57 had limited movement on the right lower extremity, and the doctor ordered a Radiology ([x-ray] process of talking pictures of bones and inner body structures to diagnose and treat diseases and or conditions) of the right thigh and hips. A review of Resident 57's SBAR dated 5/29/2025, indicated Resident 57's x-ray result indicated right femur (the thigh bone) fracture. A review of Resident 57's x-ray report of the right femur, dated 5/30/2025, indicated Resident 57 had an acute horizontal fracture through the base of the right femoral neck (the narrow part of the femur (thigh bone) that connects the femoral head [ball] to the femoral shaft [long bone]) with cortical bone irregularity (an abnormal or uneven appearance of the outer layer of a bone) at the fracture margins (cannot rule out an underlying lytic bone lesion [an area of bone tissue that has been destroyed or weakened] with a pathological fracture [a fracture that occurs in a bone weakened by an underlying disease, such as a tumor, infection, or metabolic disorder, rather than by a direct injury]). A review of Resident 57's History & Physical (H&P), dated 6/6/2025, indicated Resident 57 had the capacity to make decisions and had a good understanding of her health condition. During an interview on 6/10/2025 at 10:49 a.m., with Resident 57, Resident 57 stated she had no idea how the fracture happened. Resident 57 stated she woke up one day and her right leg was hurting more than usual. During an interview on 6/13/2025 at 10:58 a.m., with the Administrator (ADMN), the ADMN stated Resident 57’s fractured femur was not reported to the state agency as an unusual occurrence or an injury of unknown origin. The ADMN stated Resident 57’s primary care physician had determined that Resident 57's fractured femur was pathological. The ADMN stated she was content with her decision not to report this incident as an unusual occurrence. A review of the facility's policy and procedure (P&P) titled "Unusual Occurrence Reporting", dated 8/27/2021, indicated the facility will follow all applicable state and federal laws and regulations regarding the reporting of unusual occurrences within 24 hours. The facility failed to: 1. Implement P&P titled “Unusual Occurrence Reporting," dated 8/27/2021, which indicated the facility would follow all applicable state and federal laws and regulations regarding the reporting of unusual occurrences within 24 hours. As a result, there was a delayed investigation by the CDPH. This violation had a direct or immediate relationship to the health, safety, or security of 57 Resident and other residents in the facility.