Health inspection·December 19, 2025

§ 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: 42 CFR §483.10(g)(14) Notification of Changes (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention. (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) 22 CCR § 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: . . . (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies, or services as prescribed under conditions which present a risk to the health, safety, or security of the patient. 22 CCR § 72523(a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 10/22/2025, the California Department of Public Health (CDPH) received a complaint and facility reported incident (FRI) alleging that Resident 1 had an acute right proximal femoral fracture with soft tissue swelling from unknown origin. On 11/5/2025, CDPH conducted an unannounced visit at the facility to investigate the complaint and FRI allegation. The facility failed to: 1. Notify Resident 1's physician promptly after receiving an order for right hip and right femur x-ray results on 10/22/2025 at 1:22 a.m. indicating an acute proximal femoral fracture with soft tissue swelling. The physician was not notified until 8:35 a.m., over seven hours later. 2. Follow Resident 1's care plan titled, "Resident 1 has the potential for alteration in comfort due to pain related to proximal femoral fracture, soft tissue swelling" dated 10/22/25, that included to notify the physician of abnormal x-ray findings and any change in condition (physician was not notified until 10/23/2025 at 8:35 a.m.). 3. Implement its policy and procedure titled, "Change in a Resident's Condition or Status" dated 2/2021, which requires prompt notification of the attending physician and resident representative upon significant changes in the resident's medical condition. These failures resulted in Resident 1 experiencing unmanaged right hip pain rated 9/10 on a non-verbal pain scale from zero to ten (0 to 3-mild pain, from 4 to 6- moderate pain, from 7 to 9-severe pain, and 10- the worse pain possible) and increased swelling. On 10/22/2025, Resident 1 was transferred to a GACH, approximately 10 hours after the initial signs of injury, and underwent a Girdlestone (removal or resection of the head and neck of the femur. Girdlestone is usually performed when the patient has a severely painful hip, and a total hip replacement [surgical procedure to replace a damaged hip] cannot be done) procedure with hip disarticulation (separation of two bones at a joint) on 10/24/2025. A review of Resident 1's Admission Record, indicated Resident 1 was initially admitted to the facility on 11/21/2011 and readmitted on 10/30/2025. Resident 1's diagnoses include chronic respiratory failure dependence on ventilator, age-related osteoporosis with current pathological fractures, quadriplegia and contracture. A review of Resident 1's Minimum Data Set (MDS- a resident's assessment tool) dated 8/19/2025 indicated Resident 1 had severe impairment in cognitive skills for daily decision making. The MDS indicated Resident 1 was dependent with bed mobility, oral hygiene, toileting hygiene, personal hygiene, shower and upper/lower body dressing. The MDS indicated no indicators of pain or possible pain in the last five days of assessment (8/19/2025). A review of Resident 1's Physician's Order dated 10/21/2025, at 3:30 p.m., indicated to have a Stat X-ray of Resident 1's right hip and right femur. During an observation on 11/5/2025, at 10:55 a.m., Resident 1 was observed lying down on a low bed. Resident 1 was observed with both legs contracted drawn toward the chest. The right hip area was observed with multiple stitches due to Girdlestone surgery done on 10/24/2025. During a concurrent observation and interview on 11/5/2025, at 11:00 a.m. in Resident 1's room, Licensed Vocational Nurse (LVN 1) stated Certified Nursing Assistant (CNA) 1 observed Resident 1 on 10/21/2025 at approximately 1:45 p.m. making facial grimaces and noted Resident 1's right hip appeared unstable "wobbling," indicating an abnormal range of motion compared to the resident's usual contracted position. LVN 1 stated CNA 1 reported to her (LVN 1) and she informed Registered Nurse (RN) 1. RN 1 assessed Resident 1 but opted not to perform a more extensive physical assessment to "avoid more complication." RN 1 noted the resident's right hip area was "hot to touch." During a telephone interview on 11/5/25, at 11:34 a.m., CNA 1 stated she was not certain of what happened to Resident 1's right hip. The splint applied on both lower extremities around the knees may have been too tight or pulled. CNA 1 stated that she began caring for Resident 1 on 10/21/2025, at the start of her shift (7:00 a.m. to 3:00 p.m.). She ( CNA 1) did not observe abnormalities during routine morning care on 10/21/2025, at approximately 10 a.m. On 10/21/2025, around 1:45 p.m., when she checked Resident 1, she observed the resident making facial grimaces. She (CNA 1) noted Resident 1's right leg appeared "loose" and the right hip unstable. CNA 1 stated she notified the charge nurse (LVN 1). Resident 1 wears a splint, with her legs typically positioned together drawn toward the chest with ankles overlapping. The Restorative Nursing Assistant (RNA) worked with Resident 1 on 10/21/2025 at approximately 10:45 a.m. During the interview on 11/5/25 at 11:40 a.m., RNA 1 stated she provides residents with range of motion ( ROM ) and splinting. RNA 1 stated Resident 1 had an order for knee splints for both lower extremities. RNA 1 stated she spread apart both Resident 1's knees and applied splints on 10/21/2025. Resident 1 was very contracted on both lower extremities and fragile. On 10/21/2025, she performed ROM to Resident 1 after Resident 1 was premedicated with Tylenol and cleaned by CNA 1. When she performed ROM and applied knee splints to Resident 1 at 10:45 a.m., the resident was fine and tolerated the treatment. At approximately 2:45 p.m., RN 1 asked her why Resident 1's legs were "loose." RNA 1 stated she does not know what happened to Resident 1's leg as "it was okay" when she did ROM and applied knee splints on 10/21/2025 at 10:45 a.m. During an interview on 11/5/25, at 1:05 p.m., RN 1 stated LVN 1 reported to her regarding Resident 1's "wobbly" leg. When she assessed Resident 1's leg, she did not observe any swelling, but the right hip area was "hot to touch." RN 1 stated she called Resident 1's medical doctor (MD) 1 and received an order on 10/21/2025, at 3:30 p.m., for Stat x-ray to right hip and right femur. LVN 1 gave Resident 1 Tylenol 500 milligrams (mg) two tablets for pain rated 7/10. During an interview on 11/5/2025, at 2:55 p.m., LVN 1 stated pain assessment was based on Resident 1's facial expression, which was the reason Resident 1 was medicated with Tylenol. Resident 1 received Tylenol 500 mg (2 tablets) on 10/21/2025, at 2:14 p.m. and at 4:17 p.m. LVN 1 stated during the night shift (11 p.m. to 6 a.m.) Resident 1 received Norco ( narcotic pain medication used to manage moderate to severe pain) 5/325 mg one tablet on 10/22/2025 at 5:12 a.m., and 9:11 a.m. Resident 1 was transferred to a GACH on 10/22/2025 at approximately 11 a.m. Resident 1's hip and femur x-ray results were received on 10/22/2025 at 1:22 a.m. Resident 1's x-ray results were faxed to MD 1 at that time (1:22 a.m.). MD 1 was notified of Resident 1's x-ray results on 10/22/2025, at 8:35 a.m., and an order was received to transfer Resident 1 to the GACH. During an interview on 11/5/2025, at 3:10 p.m., LVN 2 stated he received orders from Resident 1's physicians on 10/22/2025 at approximately 9 a.m., to transfer Resident 1 to the GACH. LVN 2 stated RN 3 called the ambulance, and the ambulance arrived around 11 a.m. During a telephone interview on 11/6/25, at 10:50 a.m., RN 2 stated she received the faxed x-ray results indicating Resident 1 had a femoral fracture on 10/22/2025 at 1:22 a.m. RN 2 stated she faxed the results to Resident 1's MD 1 and informed the Assistant Director of Nursing (ADON). She (RN 2) called Resident 1's MD 1 on 10/22/2025 at 6:00 a.m. and spoke with the receptionist. RN 2 stated she did not receive an order to transfer Resident 1 to the GACH until the end of her shift (11 p.m. to 7 a.m. shift) on 10/22/2025. During her initial rounds on 10/21/2025, at approximately 11:30 p.m., she observed Resident 1 sleeping. At around 12:30 a.m., she noted Resident 1 had swelling of the right hip. She (RN 2) did not contact the medical director when she received Resident 1's x-ray results because she received an order from MD 2, who was covering for MD 1, to wait until a.m. RN 2 stated she assumed a.m. meant 6 a.m. since there was no specific instruction to call at a particular time in the morning and her understandings that "morning" referred to 6:00 a.m. RN 2 stated she typically expects a physician to call-back within 15 to 20 minutes, but with Resident 1' s positive x-ray results for a fracture she was unable to follow up with the MD 2. A review of Resident 1's Medication Administration Record (MAR) dated 10/21/25, at 2 p.m., indicated Tylenol Extra Strength 500 mg two tablets were given to Resident 1 for pain level of 7/10, and Tylenol 500 mg two tablets were given to Resident 1 on 10/21/25, at 4:17 p.m. for pain level of 5/10 rated based on the resident's facial grimacing. A review of Resident 1's Nursing Progress Note dated 10/21/2025, at 2:20 p.m., indicated LVN 1 informed RN 1 regarding Resident 1's right leg "appeared wobbly and loose" with swelling. The Nursing Progress Notes indicated Resident 1 was observed with facial grimacing indicating the resident had 4/10 pain based on the resident's a facial expression. The Nursing Progress Notes indicated Resident 1was administered Tylenol 500 mg two tablets via gastrostomy tube (GT). A review of Resident 1's Nursing Progress Note dated 10/21/2025, at 3:17 p.m., indicated CNA 1 reported Resident 1 was observed with increased facial grimacing during care and repositioning. The Nursing Progress Notes indicated Resident 1 had an increase in pain each time Resident 1 was repositioned. A review of Resident 1's Physician's Order dated 10/21/2025, at 8:56 p.m., indicated an order for Norco tablet 5-325 mg one tablet to be given through GT every four hours as needed for severe pain. A review of Resident 1's Nursing Progress Note dated 10/21/2025, at 9:21p.m., indicated that on 3 p.m. to 11 p.m. shift Resident 1 was observed restless with facial grimacing. Resident 1was in severe pain with swelling on the right thigh, warm and tender to touch with redness, abnormal rotation of right thigh extending to the femur/knee. The Nursing Progress Note indicated Resident 1 was given Tylenol Extra Strength two tablets. for pain. RN 1 received an order from MD 2 on 10/21/2025, at 3:30p.m., to conduct an x-ray of the right hip and right femur. RN 2, paged MD 2 for an order for stronger pain medication. On 10/21/2025, at 8:56 p.m., received order from MD 2 for Norco 5/325 mg every four hours as necessary (PRN) for pain for seven days. Resident 1 received Norco 5/325 mg on 10/21/2025, at 10 p.m. MD 2 ordered to call MD 1 in a.m., if x-ray results were positive for fracture to get order to transfer Resident 1 to GACH. A review of Resident 1's Nursing Progress Note dated 10/22/2025, at 12:10 a.m., indicated Resident 1 was observed with swelling to the right leg and right knee, and it was very warm to touch. Resident 1 had increased facial grimacing with "beads of sweat". Resident 1's right leg swelling had doubled in size. A review of Resident 1's Radiology (x-ray) Report dated 10/21/2025, indicated right femoral fracture with soft tissue swelling. The Radiology Report was electronically signed by the radiologist on 10/22/2025, at 12:31 a.m. A review of Resident 1' s MAR dated 10/22/25, at 5:12 a.m., indicated that Norco one tablet 5-325mg was given to Resident 1 for severe pain of 6/10 rated based on the resident's facial grimacing, moaning, and groaning. Norco one tablet 5-325mg was administered to Resident 1 on 10/22/25, at 9:17 a.m. for severe pain level of 9/10 rated based on the resident's facial grimacing and crying. A review of Resident 1's Nursing Progress Note dated 10/22/2025, at 5:29 a.m., indicated Resident 1 had a swelling on the right thigh with facial grimacing when touched. A review of Resident 1' s Nursing Progress Note dated 10/22/2025, at 8:15a.m., indicated Resident 1 was monitored for status post-acute right proximal femoral fracture. Resident 1 was observed awake and alert resting in bed with episodes of facial grimacing. Resident 1 had pain level assessed of 7/10 based on non-verbal scale. Resident 1 had short periods of hyperventilation, ventilator alarming, occasional moaning/groaning, facial grimacing, rigidity and clenched fists. Resident 1's right leg appeared with moderate swelling, slight yellow tinged discoloration, and flaccidity with increased ROM. A review of Resident 1's Care Plan titled, "Resident 1 has the potential for alteration in comfort due to pain related to proximal femoral fracture, soft tissue swelling" dated 10/22/25, indicated the interventions included to monitor signs and symptoms of pain, flinching, moaning, crying, grimaced facial expression and inform physician promptly, provide nursing comfort measures, assess characteristics of pain, location, duration, quality, aggravating and alleviating factors, pain radiation and intensity, document, administer medication as ordered, monitor effect of medication, and provide pain medication prior to planned expected activities. A review of Resident 1's Nursing Progress Notes dated 10/22/2025, at 9:05 a.m., indicated Resident 1 was resting in bed with facial grimacing. Resident 1's non-verbal pain scale score was documented as 9/10. Resident 1 exhibited a short period of hyperventilation, ventilator alarms, crying, facial grimacing, rigidity, clenched fists, and was unable to be consoled by voice or touch. Resident 1 was given Norco 5/325 mg on 10/22/2025 at 9:11 a.m. The Nursing Progress Notes indicated, during a room check at 10:00 a.m., Resident 1 continued to display signs of distress, incl