Health inspection·July 9, 2025

The following reflects the findings of the California Department of Public Health during the investigation of Complaint #: CA00962328 State Citation A was written. Regulation: 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. 42 CFR 483.21 (b) (3) (i) Meet Professional Standards of Quality The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. (ii) Be provided by qualified persons in accordance with each resident's written plan of care. (iii) Be culturally-competent and trauma-informed. 22 CCR 72311(a)(1)(A) Nursing Services-General 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: (A)Identification of care based upon an initial written and continuing assessment of the patient's needs. 22 CCR 72523 (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 5/21/25, an unannounced visit was conducted at the facility to investigate complaint: CA00962328 which alleged a concern in the delay in care and treatment of the changes observed in Resident 1's legs. Resident 1 was transported to the acute care hospital on 5/9/25 and was diagnosed with a deep vein thrombosis (DVT- condition where a blood clot forms in one of the large veins [blood vessel that carries blood back to the heart], usually in the legs or arms), which required an admission to the hospital and surgical intervention. The facility failed to: 1. Ensure treatment and care in accordance with professional standards of practice was provided when Resident 1, who had hypertension (high blood pressure) and difficulty in walking, had changes to her legs that were assessed by nurses on 4/22/25 and 5/8/25. 2. Ensure nurses followed physician's orders to obtain a vascular consult ordered for Resident 1 on 4/23/25. 3. Ensure a Change in Condition (CIC- documentation completed when nurses identify a change from a resident's baseline condition) was completed when Resident 1's legs were discolored and one leg as swollen on 4/22/25 and on when Resident 1's left leg was more swollen than the right leg on 5/8/25. 4. Ensure a weekly head-to-toe assessment was completed on 5/4/25 according to facility policy. These failures resulted in a delay in acting on Resident 1's symptoms, delayed treatment and care and contributed to an acute change of pain and swelling on 5/9/25 for which Resident 1 was transported to an acute care hospital for higher level of care. Resident 1 was diagnosed with a deep vein thrombosis (DVT- condition where a blood clot forms in one of the large veins [blood vessel that carries blood back to the heart], usually in the legs or arms) of left leg and experienced a corrective surgical procedure and remained in the hospital from 5/9/25 through the date of the unannounced visit on 5/21/25. Resident 1 was a 73-year-old female who was admitted to the facility on 3/18/25. She had the following diagnoses: Acute Respiratory Failure with hypoxia (inadequate exchange of gases between the lungs and the blood which leads to low levels of oxygen in the blood and tissues), Chronic Obstructive Pulmonary Disease (COPD- a long-lasting lung disease causing difficulty in breathing), and abnormal posture. During a review of Resident 1's "Minimum Data Set (MDS- a standardized assessment and care screening tool)", dated 3/25/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation and memory recall) indicated a score of 13 (scores range from 0 to 15 with 0-7 meaning severe cognitive impairment (an intense inability to think, remember, use judgement and make decisions), 8-12 meaning moderate cognitive impairment (lessened ability to think, remember, use judgement and make decisions), and13-15 meaning no cognitive impairment), which indicated Resident 1 had no cognitive impairment. During a concurrent interview and record review on 5/21/25 at 9:57 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's "Progress Notes (PN)", dated 4/22/25 was reviewed. The PN indicated, on 4/22/2025 at approximately 11:04 p.m. a Duplex scan (type of ultrasound) was ordered by the physician for dependent edema (swelling from fluid which pools due to gravity in the hands, feet and legs). During a concurrent interview and record review on 5/21/25 at 9:57 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's "Weekly Summary Documentation (WSD- a head-to-toe assessment completed on each resident once a week)", dated 4/24/25 was reviewed. The WSD indicated, on 04/24/2025 Resident 1's current plan of care would continue as usual. LVN 1 stated, Resident 1 was able to make her needs known to the staff and answer the staff's questions appropriately. LVN 1 stated, a WSD for every resident was required to be completed every week. LVN 1 stated, a schedule was in a binder at the nurse's station and indicated which days and shifts each resident was to be assessed every week, according to room number. LVN 1 stated, Resident 1's last WSD was completed on 4/24/25 and there was no WSD completed on 5/4/25. LVN 1 stated, the WSD was important to assess for any new changes During an interview on 5/21/25 at 10:28 a.m. with LVN 2, LVN 2 stated, a WSD should have been completed on every resident once a week. LVN 2 stated, the WSD was a head-to-toe assessment performed by the nurse to assess for any changes or abnormalities to Resident 1. LVN 2 stated, if there was an issue identified with Resident 1, then the resident would have a nursing assessment performed every day. LVN 2 stated, the WSD was important to perform every week because the nurses could catch a change with Resident 1 like a skin change or other abnormality within the resident. LVN 2 stated, if a change was identified, a Change in Condition (CIC) form would be completed and Resident 1's physician, RP and the administrator would be notified. During a concurrent interview and record review on 5/21/25 at 11:10 a.m. with the DON, the "Station 1 Weekly Summaries and Skin Assessments (WSSA)", dated 4/17/25, and Resident 1's "Change in Condition Evaluation (CIC)", dated 5/9/25 were reviewed. The WSSA indicated, Resident 1's weekly summaries and body checks were to be completed on Sunday nights by the night shift nurses. The CIC indicated, on 5/9/2025 Resident 1 had a new onset of a dark spot to the left lower leg medial accompanied by moderate pain (5 on a scale of 0 to 10). The MD was notified and ordered to send out to hospital for further evaluation and treatment. The DON stated, Resident 1's physician ordered an ultrasound of her legs and was completed on 4/23/25. The DON stated, on 5/9/25, Resident 1's daughter was concerned about Resident 1's leg and Resident 1 was complaining of pain. The DON stated, the nurse noticed Resident 1's left lower leg had a dark spot on the medial area of the leg. The DON stated, Resident 1 went to the hospital on 5/9/25 and was still at the hospital. The DON stated, the final results of the ultrasound were faxed to the facility on the evening of 5/8/25 and had shown severe bilateral (both sides) arterial (pertaining to an artery) disease, no hemodynamically (how blood flows through your blood vessels) significant stenosis (abnormal narrowing) and a possible occlusion (blockage) of the left proximal (nearer to the center of the body or the point of attachment to the body) deep femoral artery (DFA- a blood vessel in the leg which supplies blood to the thighs and buttocks). The DON stated, a WSD was a head-to-toe assessment completed on each resident every week. The DON stated, the expectation was a WSD was completed to catch new abnormalities or changes with the residents. The DON stated, the WSD was important to ensure care of the Resident's problem before it gets worse. The DON stated, any changes identified during the WSD were reported to the MD, RP and DON. The DON stated, the WSD provided a way for those changes to the residents to be followed up on further. The DON stated, Resident 1's last WSD was completed on 4/24/25 and she left for the hospital on 5/9/25. The DON stated, the CIC on 5/9/25 showed Resident 1 had a new onset of a dark spot to her left lower leg accompanied by 5/10 (a pain level of 5 based on a based on a scale where 1 is the lowest pain and 10 is the most severe pain) pain. The DON stated, the nurse contacted Resident 1's MD, notified him of the final ultrasound results in addition to the current assessment. The DON stated, based on all the information, the MD ordered for Resident 1 to be sent to the hospital. The DON stated, according to the WSSA, Resident 1 should have had a WSD completed on 5/4/25 but it was not completed. During a concurrent interview on 5/21/25 at 12:02 p.m. with the DON, Resident 1's PN, dated 4/24/25, and "MD Progress Note (MDPN)" dated 5/2/25 was reviewed. The PN indicated, on 04/24/2025 the MD reviewed final results for the doppler study for Resident 1 and gave a new order for vascular consult (an appointment with a physician who specializes in the vessels that carry blood in the body) of both lower legs. The PN was written by LVN 4. The MDPN dated 5/2/25 indicated, Resident 1 remained at high risk for DVT due to Resident 1's age and comorbidities. The DON stated, the MD ordered a vascular consult to be made for Resident 1 and to elevate her legs based on the ultrasound results. The DON stated a vascular consult was never made for Resident 1. The DON stated, there was no documentation of any attempts made to obtain a vascular consult appointment. The DON stated During a phone interview on 5/22/25 at 2:32 p.m. with LVN 3, LVN 3 stated, she was Resident 1's nurse on 4/23/25 during the AM shift (the shift that facility staff work from 6:00 a.m. until 2:30 p.m.). LVN 3 stated, she received report from the NOC shift nurse on 4/23/25 who had cared for Resident 1 during the prior night. LVN 3 stated, the NOC shift nurse reported staff attempted to get Resident 1 up from bed and Resident 1's lower extremities had turned a purple color so they laid her back down. LVN 3 stated, because of Resident 1's lower extremity discoloration, the nurse had called Resident 1's MD and received an order to obtain an ultrasound of both lower legs. LVN 3 stated, Resident 1's ultrasound was completed during her AM shift on 4/23/25. LVN 3 stated, she had sent the MD a picture of Resident 1's preliminary ultrasound results to MD's cell phone on 4/23/25. LVN 3 stated, the MD did not respond to the message so she documented a PN indicating there were no new orders at the time. LVN 3 stated, a WSD was completed once a week for every resident in the facility according to the WSSA. LVN 3 stated, the WSD was important in order to get an update on the resident and assess for any changes from the resident's baseline, which were documented by the nurse. LVN 3 stated, a CIC would be completed if there was a change from baseline. LVN 3 stated, a CIC required the nurse to notify the resident's physician, RP and DON. LVN 3 stated, it was important to follow physician's orders to get the resident the care they needed regarding any underlying issues or new diagnoses they may have had. LVN 3 stated, if the physician gave an order for a vascular consult to be made for a resident, the nurse would have entered an order in the computer charting system, create a PN and notified the DON. LVN 3 stated, the DON, Assistant Director of Nursing (ADON) or a unit manager would have carried out the order and scheduled the consult, according to the physician's orders. During a phone interview on 5/22/25 at 2:53 p.m. with LVN 4, LVN 4 stated, a WSD was a head-to-toe assessment performed on each resident once a week. LVN 4 stated, a WSD was important to complete every week to assess for any changes which may have developed or progressed since the previous week. LVN 4 stated, she had texted the MD Resident 1's final ultrasound results on 4/24/25 at approximately 3:00 a.m. and the MD had responded back "they" already knew Resident 1 needed a vascular consult. LVN 4 stated, the MD did not specify who already knew about the vascular consult. LVN 4 stated, there was no order in the computer charting system so she put in the order for Resident 1's vascular consult on 4/24/25. LVN 4 stated, she gave report to the AM shift nurse on 4/24/25 and told her about the MD's response to the final ultrasound results and the AM shift nurse responded saying everybody knew about the vascular consult. LVN 4 stated, the former ADON was the staff member who normally handled all the resident's referrals and appointments. LVN 4 stated, she was not informed by management who was in charge of creating the appointments currently, but assumed the new ADON would make the appointments. LVN 4 stated, it was important to follow the physician's orders in order to prevent the resident's condition from getting worse and being overlooked. During a phone interview on 5/22/25 at 4:48 p.m. with RN, RN stated, she worked with Resident 1 on 5/8/25 during the PM shift (the shift that facility staff work from 2:00 p.m. until 10:30 p.m.). RN stated, Resident 1's daughter wanted RN to assess Resident 1's left lower leg on 5/8/25 because it appeared abnormally swollen. RN stated, she assessed Resident 1's left lower leg and noticed some increased swelling compared to Resident 1's right lower leg. RN stated, she searched in the computer charting system and saw PNs about an ultrasound which was completed for Resident 1, but could not find any results. RN stated, RN asked the DON about where she could find Resident 1's final ultrasound results and the DON instructed RN to call the diagnostic imaging company to obtain the results. RN stated, she received the final results from the 4/23/25 ultrasound on 5/8/25 via fax and RN stated she saw there may be a possible occlusion according to the ultrasound results. RN stated, she immediately sent the results to the MD but he did not reply that night. RN stated, she informed the 5/8/25 NOC shift nurse about the ultrasound results, the swelling to Resident 1's left lower leg and they were awaiting a reply from the MD. RN stated, the MD texted RN back on the morning of 5/9/25 and RN forwarded the message to the nurse working the 5/9/25 AM shift. RN stated, she worked the PM shift on 5/9/25 and around 2:30 p.m., she finished receiving report and went to check on Resident 1. RN stated, Resident 1 had a significant change with increased swelling and a dark-colored spot to the left lower medial leg with 5/10 pain. RN stated, this increased change to Resident 1's condition coupled with the ultrasound results showing a possible clot (clumps that occur when blood hardens from a liquid to a solid) made her contact the MD again. RN stated, the MD immediately ordered Resident 1 to be sent out to the hospital. RN stated, an Emergency room (ER) doctor from the hospital Resident 1 was sent to had called RN and informed her Resident 1 was diagnosed with a DVT. RN stated, a DVT can travel to the heart and cause a heart attack (occurs when blood flow to the heart is blocked, depriving the heart muscle of oxygen) or travel to the brain and cause a stroke (occurs when blood flow to the brain is disrupted, leading to damage or death of brain tissue). RN stated, a WSD was a head-to-toe assessment required to be completed on every resident in the facility and divided up evenly according to a schedule. RN stated, a WSD was completed to check for changes to the resident because often elderly residents would not tell you about their problems, so the nurse needed to complete an assessment to look for those changes. RN stated, a WSD helped identify changes to vital signs (measurements of the body's most basic