Health inspection·July 2, 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: (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. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. CCR §72523 - Patient Care Policies and Procedures (a) 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 5/6/2025 the California Department of Public Health (CDPH) received a complaint regarding a resident (Resident 1) having an injury of unknown origin. On 5/15/2025 at 12:15 p.m., CDPH conducted an unannounced complaint investigation at the Skilled Nursing Facility (SNF) to investigate FRI allegation. Upon investigation CDPH determined the facility failed to report and investigate an injury of unknown origin to CDPH per the facility's policy and procedure (P/P) titled "Abuse, Neglect and Exploitation" for Resident 1 when Resident 1, who complained of right hip pain and experienced a decreased range of motion (ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point), was found to have a right hip fracture (broken bone). As a result of this deficient practice, Resident 1 was placed at risk for potential continued abuse, further injuries, delay in care and investigation into the cause of Resident 1's fractured right hip. Findings: A review of Resident 1's Admission Record indicated Resident 1, a 71-year-old-male, was originally admitted to the facility on 1/31/2019 and readmitted on 5/8/2025 with diagnoses of encounter for orthopedic aftercare, epilepsy and bipolar disorder. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 4/12/2025, indicated Resident 1 had moderate cognitive impairment for daily decision making. The MDS indicated Resident 1 had no functional limitations in range of motion for the upper (shoulder, elbow, wrist, hand) and lower (hip, knee, ankle, foot) extremities. A review of Resident 1's Nurses Note dated 4/28/2025, indicated Resident 1 complained of pain in the right hip radiating to the right knee. The Nurses Note indicated on the morning of 4/28/2025, Resident 1 had trouble performing activities of daily living (ADL) and required assistance from certified nursing assistant (CNA) 1 to complete the tasks. The note indicated Resident 1 was unable to perform ROM on the right leg and was complaining of pain level 6 out of 10 on the pain rating scale from 0 to 10. During a review of Resident 1's Nurses Note dated 4/28/2025, Resident 1 was transferred to a general acute care hospital (GACH) due to hypotension, unrelated to the right hip pain or limited ROM. A review of Resident 1's GACH Progress Note - Orthopedic Medicine dated 5/7/2025, indicated Resident 1 was initially admitted to the GACH on 4/28/2025 for right sided weakness and a stroke workup but was found to have a right hip fracture on 5/4/2025 requiring surgery. A review of Resident 1's Nurses Note dated 5/8/2025, indicated Resident 1 was admitted back to the facility from the GACH with a diagnosis of a (right) hip fracture. During an interview on 5/15/2025 at 1:31 p.m., CNA 1 stated Resident 1 was usually able to walk and get himself dressed but on 4/28/2025 he had a change in condition (COC). CNA 1 stated the morning of 4/28/2025 she noticed Resident 1 was not out of bed to go for a smoke so she went to check on him and he stated he could not move, which was a change from his baseline. CNA 1 stated it took two people to change him that morning when he could usually do it by himself. CNA 1 stated Resident 1 was unable to move his right leg, so she called the charge nurse, licensed vocational nurse (LVN) 1, to come and assess Resident 1. CNA 1 stated she was unsure how the patient became injured. During an interview on 5/15/2025 at 1:55 p.m., LVN 1 stated Resident 1 complained of right hip pain on the morning of 4/28/2025. LVN 1 stated CNA 1 informed her that Resident 1 required extra assistance for ADLs the morning of 4/28/2025. LVN 1 stated she assessed Resident 1 and did not see any bruising or swelling on the right leg, so she thought maybe he slept on his leg wrong causing the pain, so she gave him Tylenol (pain medication). LVN 1 stated Resident 1 was able to lift the right leg but not as much as the left leg and he was "signaling (patient hard to understand)" his right leg was in pain. LVN 1 stated the decrease in ROM of the right leg and the new pain was new for Resident 1. LVN 1 stated Resident 1 was hard to understand but she asked him if he hit himself or got hurt and he kept shaking his head "no". LVN 1 stated the director of nursing (DON) was the supervisor for the day, but she did not tell the DON about the COC for decreased ROM or new right hip pain for Resident 1. LVN 1 stated they usually tell the supervisors about COCs to get a second set of eyes assessing the resident, but she (LVN 1) did not tell the DON that day because Resident 1 was "just complaining of pain" and thought he would be better after the Tylenol. LVN 1 stated she did not think it was a "big problem." LVN 1 stated she did inform Resident 1's physician (MD) 1 about Resident 1's situation and he just ordered Ibuprofen but did not order an X-ray. During a concurrent interview and record review on 5/15/2025 at 3:28 p.m., with the DON, Resident 1's Nurses Note dated 4/28/2025 was reviewed. The DON reviewed Resident 1's Nurses Note dated 4/28/2025 and stated LVN 1 did not tell her Resident 1 was having right hip pain or decreased ROM of the right hip on 4/28/2025, the day he was transferred to the GACH. The DON stated if she was aware of Resident 1's right hip pain and decreased ROM she would have assessed Resident 1 herself and recommended a right hip X-ray be ordered by MD 1. The DON stated it was important that the supervisor was made aware of COCs so a comprehensive assessment could be done, appropriate interventions could be placed, and an investigation into the cause of the injury could be conducted. The DON stated Resident 1's right hip fracture was an injury of unknown origin because the pain and decreased ROM began while still at the facility prior to his discharge to the GACH, and they did not know how the injury occurred. The DON stated it was important to investigate and report injuries of unknown origin because the facility does not know how the injury occurred and there was a possibility it happened due to potential abuse or another unknown reason. During a concurrent interview and record review on 5/16/2025 at 10:50 a.m., with the DON the facility's undated P/P titled, "Abuse, Neglect and Exploitation" was reviewed. The DON stated Resident 1's right hip fracture (injury of unknown origin) should have been reported to the state department at the time of the incident on 4/28/2025. The DON stated she found out about the fracture on 5/8/2025 and the facility did not report the incident because she found out about the injury of unknown origin "after the fact." The DON reviewed the facility's P/P titled "Abuse, Neglect and Exploitation" and stated per the facility's policy the injury of unknown origin should have been reported to the state agency. The DON stated in the future injuries of unknown origin will be reported to the state agency as soon as they are discovered, even if it was "after the fact." During a review of the facility's P/P titled, "Abuse, Neglect and Exploitation" undated, the P/P indicated the facility must ensure all alleged violations including injuries of unknown source (injuries of unknown origin) must be reported immediately but not later than two hours after the allegation is made, if the events result in serious bodily injury, to the facility administrator and the State Survey Agency. During a review of the facility's P/P titled "Injury of Unknown Origin Policy" undated, the P/P indicated an injury of unknown origin was any injury where: the cause or circumstances are not witnessed or reported, the resident is unable to explain how the injury occurred, and the injury is not consistent with the resident's known condition or typical behavior. The facility failed to report and investigate an injury of unknown origin to CDPH per the facility's P/P titled "Abuse, Neglect and Exploitation" for Resident 1 when Resident 1, who complained of right hip pain and experienced a decreased ROM, was found to have a right hip fracture. As a result of this deficient practice, Resident 1 was placed at risk for potential continued abuse, further injuries, delay in care and investigation into the cause of Resident 1's fractured right hip. These violations presented a direct or immediate relationship to the health, safety, security, or welfare of the residents.