Health inspection·December 30, 2025

The following reflects the findings of the California Department of Public Health during the investigation of a complaint #: 2617905 and Facility Reported Incident (FRI) #: 2618013. Event ID: 1D718E-H1 State Citation (A) was written 483.10(g)(14)(i)(B) 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- (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).  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 needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. (B) 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. (C) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (2) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: ... (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. On 9/17/2025 at 9:18 a.m., an unannounced visit was conducted at the facility to investigate complaint 2617905 and facility reported incident 2618013. The complaint alleged that on 9/14/25, Resident 1's grandson (GS) arrived at the facility between 3-4 p.m. Upon arrival, the GS observed Resident 1 to be unresponsive and warm to the touch. The GS notified nursing staff and requested Resident 1 be transferred to an acute care hospital (ACH). Nursing staff declined the initial request, indicating Resident 1 would continue to be monitored at the facility. The GS reported he continued to request transfer to the ACH. Following the GS continued request, the facility arranged for Resident 1 to be transferred to ACH. The facility records indicated Resident 1 was transferred from the facility to the ACH on 9/14/25 at 4:25 p.m. The ACH records indicated Resident 1 arrived at approximately 4:45 p.m., on 9/14/25. The facility failed to recognize and appropriately act on the clinical change in condition for Resident 1 when: 1)Nursing staff did not notify the physician on 9/12/25 of abnormal blood lab results. 2)Nursing staff did not notify the physician on 9/13/25 for Resident 1's low blood pressure of 91/55 millimeters of mercury (mmHg- unit of measurement), (normal BP 120/80), elevated heart rate (HR) 116 beats per minute (bpm), (normal range 60-100 bpm). 3)Nursing staff did not recognize and act on the clinical decline of Resident 1 on 9/14/25 when Resident 1 had altered mental status, was weaker than normal, had declined in communication, exhibited shortness of breath and distress, with a BP 86/64 mmHg, HR 118 bpm, temperature 99.2 Fahrenheit (F-unit of measurement) and Oxygen saturation (amount of oxygen in the blood) 75% (normal range 95%-100%). As a result of these failures, the grandson (GS) of Resident 1 notified nurses of Resident 1's decline in medical status two days after a change of condition first presented itself. This delayed recognition of a change of condition led to an avoidable emergency transport to the local acute care hospital (ACH) emergency department and an admission from September 14th through October 3, 2025, totaling 20 days of hospitalization. [AB1][DH2]During the hospitalization, Resident 1 was diagnosed with potentially avoidable sepsis (life-threatening condition cause by the body's overreaction to infection) and acute kidney injury (AKI -sudden inability of the kidneys to filter waste from the blood), which required admission to the intensive care unit (ICU-specialized hospital unit providing close monitoring and critical care) for management of septic shock (life-threatening drop in blood pressure following an infection). Resident 1 was discharged October 3, 2025, to the family home with home health services arranged. During a review of Resident 1's "Admission Records (AR)" [AB3] the AR indicated Resident 1 was admitted to the facility on 9/8/25 with diagnoses including hemiplegia (total paralysis of the arm, leg and trunk on the same side of the body), hemiparesis (weakness on one side of the body), cerebral infarction (stroke-when part of the brain was damaged, because it did not get enough blood and oxygen), dysphagia (when a person had trouble using language because of brain damage, often from a stroke) and diabetes mellitus (a disease where the body had trouble controlling the amount of sugar (glucose) in the blood. During a review of Resident 1's "Minimum Data Set" (MDS-resident assessment tool which indicates physical and cognitive abilities), the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 11 out of a range of scores from 0-15, indicating Resident 1 had moderate cognitive impairment (0-7 is severe cognitive impairment, 8-12 is moderate cognitive impairment, 13-15 is no cognitive impairment). During an interview on 9/16/25 at 10:04 a.m., with Adult Protective Services Representative (APS- a public social program services that receives and investigates reports of abuse, neglect, in vulnerable adults), the APS Representative stated she received a call from Resident 1's grandson (GS) on 9/15/25. The APS Representative stated GS reported on 9/14/25, that the GS visited the facility and found Resident 1 warm to touch, and unresponsive. GS requested staff to check Resident 1's temperature which was recorded at 99 F (Fahrenheit-a temperature [normal range 97.7-98F] scale). The APS Representative stated the staff told GS since the temperature was only 99 F, there was no need to call 911. During an interview on 9/16/25 at 12:54 p.m., with the GS, the GS stated Resident 1 was admitted in the facility for acute rehabilitation (an intensive, goal-oriented therapy that begins soon after a severe injury or illness to help patients regain function and independence) after hospitalization for a stroke (occurs when blood flow to the brain is interrupted). The GS stated, on 9/14/25, between 3 and 4 p.m., he arrived at the facility and observed Resident 1 sitting up in bed with her head tilted back in an uncomfortable position, unresponsive, unable to speak, and felt hot to touch. The GS stated he requested assistance to check Resident 1's temperature. The GS stated the charge nurse took Resident 1's temperature, which was 99 F, but dismissed the findings, stating it was "only 99". The GS stated he requested staff to call 911 three times while staff obtained Resident 1's oxygen saturation, which was 75%. The GS stated Resident 1 was transferred to an acute care hospital and later diagnosed with sepsis secondary to urinary tract infection (UTI- infection in the bladder). During an interview on 9/17/25 at 9:18 a.m. with the Director of Nursing (DON), the DON stated the GS of Resident 1 had visited the facility on 9/14/25. The DON reported GS was very upset and requested Resident 1 be sent to the hospital. The DON confirmed Resident 1 was sent to the hospital following his request. During a record review of Resident 1's Acute Care Hospital document titled "ED [Emergency Department] Provider Notes (EPN)" dated 9/14/25 at 4:46 p.m., the "EPN" indicated, "Chief Compliant: Altered Mental Status (AMS hot and tachycardic [elevated HR]...)... 70 year old Spanish speaking female with a medical history of CVA [cerebrovascular accident - blood flow to the brain is interrupted, causing brain cells to die] with left side deficits [weakness on the left side of the body], HTN [hypertension- high blood pressure]... BIBA [brought in by ambulance] due to AMS .... At 1600 [4p.m.] today... patient was coming from SNF [skilled nursing facility] where grandson stated he noted patient being altered. EMS [emergency medical services] states that nursing staff last rounded at 1430 [2:30 p.m.] and did not report that patient is altered... HR was 118... BP was 86/64... the patient was hot to touch... Patient was placed on O2 [oxygen] en route [on the way] ... Sepsis: Per my clinical assessment, patient has sepsis..." During a record review of Resident 1's Acute Care Hospital document titled "ED [Emergency Department] Provider Notes (EPN)" dated 9/14/25 at 4:46 p.m., the "EPN" indicated, "Critical Care... Performed by: [name of hospital physician] Critical care provider statement... Critical care time exclusive of: Bedside assessment... Due to the patient's unstable presentation, the patient required my immediate attention and intervention. I had to stop attending other patients to immediately assess the patient... Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: Sepsis (AKI [Acute Kidney Injury, Hyperkalemia [a condition where the potassium level in the blood is too high] ..." During a record review of Resident 1's Acute Care Hospital document titled "Critical Care Progress Notes (CCPN)" dated 9/16/25 at 9 a.m., the "CCPN" indicated, "... This patient is critically ill...On admission, patient was diagnosed with pyelonephritis (an infection of the upper urinary tract, caused by bacteria that ascend from the bladder) in the ED. Despite administration of three liters of crystalloid fluids (an intravenous [IV-into the veins] solution containing water, and electrolytes that can easily pass from the blood stream into the tissues), the patient's hemodynamic status failed to improve... and acute kidney injury with elevated BUN [blood urea nitrogen-waste product when the body breakdowns protein] (62 mg/dl[milligrams per deciliter-unit of measurement]) and creatinine (a normal waste product of the body) (1.89 mg/dl). Urinalysis consistent with urinary tract infection...Admitted to the intensive care unit for further management of septic shock (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection) secondary to pyelonephritis [infection of the kidneys] ..." During an interview on 9/17/25 at 11:59 a.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated she was familiar with Resident 1, having provided care to her when she was initially admitted to the facility on 9/8/25. CNA 2 described Resident 1 as a Spanish-speaking resident who had been unable to use her left side and often experienced pain in her left arm due to a skin tear. Although Resident 1 had required assistance with mobility, she had typically been able to assist with turning onto her right side. CNA 2 reported she had worked the P.M. (2:00 p.m.-10:30 p.m.) shift on 9/14/25. At the beginning of her shift, she had checked Resident 1 and observed that Resident 1 had been asleep. Later during the shift, Resident 1's GS arrived. CNA 2 observed GS speaking to Resident 1 and repositioning her in bed. CNA 2 stated the GS had then left the room, gone to the nurse's station, and expressed concern, stated that Resident 1 had not been like that the day before. CNA 2 stated Resident 1's vital signs had been obtained, with a temperature of 99.2F and an oxygen saturation level of 75%. Oxygen had been applied, and her oxygen level had improved to 96%. CNA 2 stated Resident 1 had appeared weaker than her normal baseline, had shown changes in her communication, had appeared to be in distress, and had experienced shortness of breath. CNA 2 also stated Resident 1 had been unable to assist with turning, as she normally would have. CNA 2 reported the GS had appeared very concerned and had repeatedly requested that 911 be called. Although the nursing staff had initially indicated they would continue to monitor Resident 1, 911 had ultimately been contacted. During an interview on 9/17/25 at 12:32 p.m., with License Vocational Nurse (LVN) 1, LVN 1 stated on 9/14/25 she worked the p.m. shift (2 p.m.-10:30 p.m.) and was assigned to Resident 1. LVN 1 stated she had cared for Resident 1 previously. LVN 1 stated Resident 1was normally alert with mild confusion, Spanish speaking, able to communicate, able to engage, make eye contact, and was able to use the call light. LVN 1 stated on 9/14/25 during the handoff (the real-time process of a nurse giving detailed, essential patient-specific information, responsibility, and authority to another nurse or team for the purpose of ensuring patient safety and care continuity) from the day shift nurse, Resident 1 was asleep, and no concerns were reported. LVN 1 stated at around 4 p.m., she heard a nurse call for her, reporting Resident 1's family was at the nurse's station and had concerns. LVN 1 stated she went to Resident 1's room. LVN 1 stated when she assessed Resident 1 her oxygen saturation was low and improved to 96%-97% after oxygen was applied. LVN 1 stated Resident 1 was not at her baseline (BIMS of 11) when first assessed, appeared weaker than usual, and had impaired alertness. LVN 1 stated the GS was upset and requested 9-1-1 to be called three to four times. LVN 1 stated Resident 1 was transported to ACH and was not alert at the time of transport. During an interview on 9/17/25 at 2:24 p.m. with CNA 3, CNA 3 stated on 9/14/25, during the day shift (6:00 a.m. to 2:30 p.m.) she was assigned to Resident 1. CNA 3 stated during the first few rounds after breakfast, Resident 1 was quiet and slow to respond, and appeared to be in pain. CNA 3 stated before lunch, Resident 1 requested to call her daughter. CNA 3 stated Resident 1 spoke with her daughter and reported she did not feel well, and her arm hurt. CNA 3 stated she informed the nurse Resident 1 was requesting pain medication. During a concurrent interview and record review on 9/17/25 at 3:21 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's "Progress notes" (PN) were reviewed. The "PN" indicated, on 9/10/2025 Resident 1's vital signs were BP 101/59 mmHg, T 98.4, HR 114 bpm, Resp [respiratory- the number of breaths a person takes in one minute] 19. No resident assessments were conducted 9/11/25 or 9/12/25. On 9/13/25 vital signs were BP 91/55 mmHg, T 97.3F, HR 116 bpm, resp 18; Resident 1 was oriented to person, breathing normally, with redness to the perineal area (part of the body between the thighs). On 9/14/25 at 9:15 a.m. vital signs were BP 105/63, T 97.4 F, HR 64, resp 18, and oxygen saturation 95% on room air; Resident 1 was alert to self, breathing normally, with redness to the perineal area. Later, on 9/14/25 at 4:38 p.m., Resident 1 exhibited altered mental status (AMS), difficulty speaking, elevated temperature 99.2 F, and oxygen saturation dropped to 75%, prompting transfer to the ACH. During a concurrent interview and review of Resident 1's electronic health record on 9/17/25 at 3:21p.m. with LVN 1, LVN 1 stated the facility protocol was to complete a resident assessment daily. LVN 1 stated Resident 1's daily assessment was not completed on 9/11/25 and 9/12/25 and should have been done to detect subtle or sudden changes in resident condition to ensure timely medical interventions. LVN 1 stated Resident 1's low blood pressure of 91/55 and a HR of 116 on 9/13/25, should have been communicated to the physician by the nurse to ensure timely interventions. During a concurrent interview and record review on 9/17/25 at 3:40 p.m., with LVN 1, Resident 1's "Lab Result Report (LRP)" dated 9/12/25 was reviewed. The "LRP" indicated, "WBC 17.930 H [high].... BUN 45 mg/dl H [high-indicates that the kidneys may not be functioning properly] ..." LVN 1 stated part of the facility's standard protocol for new admissions was to collect basic laboratory (lab) after 3 - 4 days of admission. LVN 1 stated the lab results were received on 9/12/25 at 12:31 p.m., showing an elevated WBC of 17.930 cells per microliter (reference range 4,500-11,000 cells per mi