Complaint·September 3, 2025

Per interviews and medical records, a Dr's Order was placed for R1 to obtain lab work, to see if there was anything that could be causing the resident's change in condition. Facility staff, S1, stated they don't have and/or never received a Dr's Order for R1 to obtain lab work. S1 stated that there was a never a response from the Physician/medical office on the faxed notification on 8/18/25. Staff S1 was not able to provide any follow-up to the resident R1's Physician regarding the 8/18/25 notification of change in condition, from 8/18/25 through to 8/24/25,10:20am. Per record review, there was a fax document regarding R1's change in condition dated 8/24/25, faxed at 10:20am to resident R1's Physician. R1 continued to be declined with confusion from their baseline as known, per review of records. Before 8/24/25 at 10:20am, there was no follow-up contact made by the facility to the Physician regarding R1's change in condition of 8/18/25. Per file reviews and interviews, Home Health Nurse (HHN) contacted Physician's office and notified them of R1's change in condition, and crackles in lungs, on 8/26/25. Per record reviews, HHN was told by staff on 8/25/25 when seeing R1, that R1 was more confused than their baseline. Per record reviews, there was no documentation of resident's responsible party (RP) being notified of resident R1's change in condition back on 8/18/25 or the next day, on 4/19/25; There was a mention of responsible party being aware when resident R1 was sent out 911 due to Physician's request, on 8/28/25. Per interviews and obtained documentation, reporting party was notified on 8/28/25 the need of R1 to be seen for lab work related to change of condition since 8/18/25, R1 needed to be evaluated by a medical professional regarding change in condition, including Home Health Nurse hearing crackles in resident's lungs. Per interviews, RP and reviewed obtained documentation, RP was notified by the facility on 8/27/25 that resident had a change of condition; Rp had no notification/information regarding 8/18/25, when Physician was faxed about change in R1's condition. There was sufficient information obtained to support violations had occurred regarding the allegations, "facility staff did not appropriately address resident's change in condition and seek medical attention in a timely manner, and required partiy (s) not notified timely of resident's change in condition". Deficiency will be cited, 87466 Observation of the Resident , see LIC9099D. The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed. Exit interview conducted with Gao Yang, Memory Care Director. Appeal Rights Provided.