Health inspection·September 9, 2025

42 C.F.R. 483.21, subdivision (b) - Comprehensive Care Plans. (b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25, or 483.40; and (ii) Any services that would otherwise be required under 483.24, 483.25, or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv) In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. 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. 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. 22 CCR 72311(a)(1)(A), (a)(2) Nursing Services-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. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 5/19/2025, the California Department of Public Health (CDPH) received a complaint about Resident 1's hospitalization on 5/18/25 due to the facility's failure to monitor his blood sugar level and oxygen levels. On 6/6/25 at 11:35 a.m. an unannounced visit was conducted at the facility to investigate a complaint regarding Resident 1's hospitalization on 5/17/25 due to the facility's failure to monitor his blood sugar level and oxygen levels. The facility failed to: 1. Develop and implement a person-centered, comprehensive care plan for Resident 1's diagnoses of Diabetes Mellitus Type II as required by state and federal law when Resident 1's care plan did not include interventions to monitor Resident 1's blood glucose level. 2. Implement a person-centered, comprehensive care plan for Resident 1's diagnosis of Chronic Obstructive Pulmonary Disease as required by state and federal law when oxygen levels were not checked during every shift on 5/17/2025 as ordered by a physician and required by the care plan. These deficient practices resulted in Resident 1's admission to the GACH on 5/18/25 when Resident 1 was found unresponsive and Emergency Medical Services (EMS) was called. Resident 1 was sent to the General Acute Care Hospital (GACH) and was treated for altered mental status, tachycardia (faster heart rate), hypoxemia (low oxygen level), and hypoglycemia (low blood glucose). Resident 1 was hospitalized from 5/18/25 to 6/3/25. A review of Resident 1 ' s "Admission Record," dated 6/6/25, indicated Resident 1 was admitted to the facility on 5/4/25 with diagnosis that included Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Muscle Weakness, Hypertension (high blood pressure), Cervicalgia (neck pain) and Congestive Heart Failure (CHF- heart is unable to pump blood efficiently). A review of Residents 1 ' s Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated 5/9/25, Resident 1 was cognitively intact based in his Brief Interview of Mental status assessment (BIMS- assessment of cognitive status for memory and judgement) with the highest possible score (15 out of 15). During a concurrent interview and record review on 6/6/25, at 2:30 p.m. with Registered Nurse (RN) 1, RN 1 stated Resident 1 has a diagnosis of COPD, CHF and Type 2 DM. RN 1 confirmed she worked on 5/17/25 PM shift (afternoon shift, from 2:00 p.m. to 10:30 p.m.) and was the charge nurse for Resident 1. Resident 1's "Nursing Note," dated 5/17/25 at 6:39 p.m. was reviewed. The note indicated, Resident 1's oxygen saturation (O2) was 93% (normal range 95-100%) and was being delivered via nasal cannula (NC- oxygen provided through a thin flexible tube with two prongs into the nostrils). During a concurrent interview and record review on 6/6/25, at 2:33 p.m. with RN 1, Resident 1's "Order Summary Report (OSR)," dated 6/6/25 was reviewed. The "OSR" indicated, " ... Glipizide ER (medication to control Type 2 DM, use to lower blood glucose levels) Oral Tablet Extended Release 24 Hour 5MG (milligrams - unit of measurement). Give 1 tablet by mouth two times a day for DM type 2 ..." RN 1 stated Resident 1's record indicated he took the prescribed Glipizide from 5/4/25 to 5/17/25 twice a day. During a concurrent interview and record review on 6/6/25, at 2:37 p.m. with RN 1, Resident 1's "Food Intake," dated 5/17/25 was reviewed. The "Food Intake" indicated, " ... 5/16/25 Breakfast - 51% to 75%, Lunch - Refused, Dinner - 51% to 75% ... 5/17/25 Breakfast - Refused, Lunch - Refused, Dinner 51% to 75% ..." RN 1 stated Resident 1's intake from 5/16/25 to 5/17/25 were reduced compared to 5/15/25 (75% to 100%). During a concurrent interview and record review on 6/6/25, at 2:39 p.m. with RN 1, Resident 1's Diabetes Mellitus care plan dated 5/5/25 was reviewed. The care plan indicated, "... Focus ... [Resident 1] has Diabetes Mellitus, Glipizide ER Oral Tablet Extended Release 24 hour 5 MG ... Interventions ... Diabetes medication as ordered by doctor. Monitor/document effectiveness ... Educate regarding medications and importance of compliance ..." RN 1 stated the care plan interventions should have been individualized to meet Resident 1's needs and it was not. RN 1 stated the care plan did not include a blood glucose check or to hold glipizide administration during meal refusals. RN 1 stated taking glipizide without food intake could result to severe hypoglycemia (low blood sugar) and avoidable hospitalization. During a concurrent phone interview and record review on 6/12/25, at 8:45 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 has a diagnosis of COPD, CHF and Type 2 DM. LVN 1 confirmed she worked on 5/18/25 NOC (evening shift, from 10:00 p.m. to 6:30 a.m.) and was the charge nurse for Resident 1. Resident 1's "Nursing Note," dated 5/18/25 at 3:15 a.m. was reviewed. The note indicated, " ... CN (Charge Nurse) was informed by the CNA (Certified Nurse Assistant) that resident was coughing and was having difficulty expelling mucus (phlegm) to clear throat. CN immediately assess resident ... CN noticed that resident was not responding verbally to any commands. Multiple attempts for verbal response were ineffective. VS (Vital Signs) 154/63 (blood pressure), O2 (oxygen) sat [saturation] 86-88% via NC (nasal cannula) at 3L (liters- unit of measurement) ... [Ambulance] was call[ed] at 03:55 a.m. ... left resident via gurney at 04:15 a.m. ..." LVN 1 stated several paramedics came to the facility and checked Resident 1's vital signs, including oxygen level and blood glucose levels. LVN 1 stated she was informed by one paramedics who responded to the emergency call that Resident 1's initial blood glucose level was 53 mg/dl and was given D5W (dextrose, a liquid solution containing 5% dextrose [a type of sugar]). During a concurrent phone interview and record review on 6/12/25, at 8:49 a.m. with LVN 1, Resident 1's "Order Summary Report," dated 6/6/25 was reviewed. LVN 1 stated there was no order to check Resident 1's BS (blood sugar) every shift or daily. Resident 1's "Food Intake," dated 5/17/25 was reviewed. LVN 1 stated she was not aware of Resident 1's refusing meals while taking his Glipizide. Resident 1 ' s Diabetes Mellitus care plan dated 5/5/25 was reviewed. LVN 1 stated the careplan interventions should be resident specific and it was not. LVN 1 stated the care plan did not include monitoring of meal intake and blood glucose check. LVN 1 stated Resident 1's low level of blood glucose resulted to altered mental status and subsequent hospitalization. During a concurrent phone interview and record review on 6/12/25, at 8:45 a.m. with LVN 1, LVN 1 stated Resident 1 has a diagnosis of COPD, CHF and Type 2 DM. LVN 1 confirmed she worked on 5/18/25 NOC (evening shift, from 10:00 p.m. to 6:30 a.m.) and was the charge nurse for Resident 1. Resident 1's "Nursing Note," dated 5/18/25 at 3:15 a.m. was reviewed. The note indicated, " ... CN (Charge Nurse) was informed by the CNA (Certified Nurse Assistant) that resident was coughing and was having difficulty expelling mucus (phlegm) to clear throat. CN immediately assess resident ... CN noticed that resident was not responding verbally to any commands. Multiple attempts for verbal response were ineffective. VS (Vital Signs) 154/63 (blood pressure), O2 (oxygen) sat [saturation] 86-88% via NC (nasal cannula) at 3L (liters- unit of measurement) ... [Ambulance] was call[ed] at 03:55 a.m. ... left resident via gurney at 04:15 a.m. ..." LVN 1 stated several paramedics came to the facility and checked Resident 1's vital signs, including oxygen level and blood glucose levels. During a concurrent phone interview and record review on 6/12/25, at 8:55 a.m. with LVN 1, Resident 1's "OSR" dated 6/6/25 was reviewed. The "OSR" indicated, " ... Check oxygen saturation PRN every 8 hours as needed for Dyspnea/Cyanosis ... Order Date 5/5/25 ..." LVN 1 stated Resident 1's physician's order to check oxygen saturation was not followed by the previous shift. LVN 1 stated Resident 1's oxygen saturation level was not checked for more than 12 hours (from 9:07 a.m. to 2:20 am). LVN 1 stated Resident 1 was on continuous oxygen and checking the oxygen saturation level was part of the vital signs, and it was not done. During a concurrent phone interview and record review on 6/12/25, at 9:00 a.m. with LVN 1, Resident 1 ' s COPD and CHF care plan dated 5/5/25 was reviewed. The care plan indicated, oxygen therapy was necessary for Resident 1's diagnosis of CHF and COPD and the oxygen was to be administered continuously at 3ml via nasal cannula. The care plan indicated the staff was to monitor for signs and symptoms of respiratory distress including increased respirations (breathing), decreased pulse oximetry and cough. These symptoms if observed were to be reported to the MD. LVN 1 stated the care plan interventions should be implemented and it was not. LVN 1 stated the facility failed to follow Resident 1's care plan interventions and physician's order to monitor oxygen saturation level every shift,and resulted to altered mental status and subsequent hospitalization. During a concurrent interview and record review on 6/12/25 at 2:21 p.m. with the Director of Nursing (DON), the DON stated Resident 1 has a diagnosis of COPD, CHF, Cervicalgia and Type 2 DM. The DON stated Resident 1 was transferred to an acute care hospital (ACH) on 5/18/25 by EMS and did not return to their facility. The DON stated Resident 1 was previously admitted (4/20/23) to the facility and was on blood glucose monitoring and she was unsure why it was discontinued on his most recent readmission (5/4/25). The DON reviewed Resident 1 ' s Type 2 DM care plan dated 5/5/25 and stated the care plan intervention column was incomplete. The DON stated the purpose of a care plan was to guide staff for a resident's plan of care and the interventions in place to meet the resident goals. The DON stated Resident 1's care plan should be individualized and specific, without specific interventions, Resident 1 could experience a negative outcome, including hypoglycemia or hyperglycemia. The DON stated Resident 1 has a diagnosis of COPD, CHF, Cervicalgia and Type 2 DM. The DON stated Resident 1 was transferred to an acute care hospital (ACH) on 5/18/25 due to AMS, and did not return to their facility. The DON reviewed Resident 1's COPD and CHF care plan dated 5/5/25 and stated the care plan intervention to monitor oxygen saturation level every shift was not followed on 5/17/25. The DON stated the purpose of a care plan was to guide staff for a resident's plan of care and the interventions in place to meet the resident goals. The DON stated failure to follow the nursing care plan interventions could lead to a negative outcome, including low oxygen level and respiratory distress. During a review of Resident 1's "Acute Hospital History and Physical," dated 4/28/25, the record indicated, Resident 1 with a history of COPD, CHF, DM presented to the ER with shortness of breath and a blood glucose of 189. Resident 1 was admitted for insulin regimen and hypoglycemic precautions. A review of Resident 1's "Ambulance Service Record," dated 5/18/25, indicated, "... 04:00 [4:00 a.m.] ... Chief Complaint ... not acting like his usual self ... Vital Signs BP [blood pressure] 166/67 ... Oxygen Saturation 92% (percent- unit of measurement) ... Blood Glucose 53 mg/dl ... Comments: low blood sugar ... Narrative: Pt found semi fowlers ( a patient positioning technique where the head of the bed is elevated to an angle between 30 and 45 degrees, while the patient remains lying on their back)in bed at [Facility Name]. Family at scene. Staff states that pt (patient) is not his usual self. Usually converses more but this morning he just yells. Pt has history of COPD and is on 2 LPM (liters per minute - unit of measurement) via nasal cannula. Pt has an oxygen saturation of 88 %, EMS [Emergency Medical Staff] increased oxygen to 3 LPM this improved his oxygen saturation to 93%. Glucose check showed 53 mg/dl. Pt moved to gurney to unit ..." During a review of Resident 1's "Acute Hospital ED [Emergency Department] Physician Notes," dated 5/18/25 at 7:26 a.m., the note indicated, "... Patient presenting from the [Facility Name] for altered mental status .... male history of COPD, diabetes, hypertension presents for altered mental status. Vital signs with borderline tachycardia (faster heart rate) hypoxemia (low oxygen level) to the low 90s and high 80s on supplement