Health inspection·August 22, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the residents responsible party (RP- an individual who has the authority to act on behalf of the patient)/family/emergency contact of a change in condition for two of three sampled residents (Resident 1, 6) when Resident 1 experienced seizures (abnormal electrical activity in the brain) and Resident 6 reported chest pain and were transferred to acute care hospital. This failure had the potential to result in Resident 1 and Resident 6's RP/family/emergency contact being unaware of the acute health conditions, hospital transfers, and treatment decisions, which could negatively impact continuity of care and right to have their representatives involved in care decisions. During a concurrent interview and record review on 8/22/25 at 1:41 p.m. with the Director of Nursing (DON) in the DON office, Resident 1's Situation Background Assessment Recommendation Form (SBAR-a tool used to improve the clarity and efficiency of information exchange) form dated 8/17/25 was reviewed. The SBAR indicated Resident 1 had active seizures lasting 3 to 4 minutes. The physician was notified on 8/17/25 at 5:30 a.m. and ordered to send Resident 1 to the acute hospital for further evaluation. The SBAR indicated on 8/17/25 at 5:30 a.m. Resident 1 was notified he was being transferred to the acute care hospital. The DON stated the RP should have been notified when a resident had a change of condition and transferred to the acute hospital. The DON stated the facility did not notify Resident 1's RP when he had changed of condition and was transferred to acute care hospital. The DON stated the license nurse should have called Resident 1's RP unless Resident 1 does not want his RP to be notified. The DON stated the documentation did not indicate Resident 1 declined to have his family notified of the acute care hospital transfer. During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 8/22/25, the AR indicated Resident 1 was a [AGE] year old male, admitted to the facility on [DATE] with diagnoses: left middle cerebral artery infarction (a blood clot to a major blood vessel on the left side of the brain that control the ability to use ones senses, move and language), muscle weakness, dysphagia (difficulty swallowing), type 2 diabetes mellitus (DM2- a condition where your body does not use a hormone that helps move sugar from your blood into your cells for energy properly), hallucinogen (drugs used for their ability to alter human perception and mood) abuse, cerebral edema (swelling of the brain), essential hypertension (abnormally high blood pressure that's not the result of a medical condition), and atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart and increase the risk of stroke and heart failure). During a concurrent interview and record review on 8/22/25 at 1:58 p.m. with the DON in the DON office, Resident 6's SBAR Communication Form dated 8/5/25 and the AR dated 8/22/25 were reviewed. The SBAR indicated on 8/5/25 at 11:30 a.m. Resident 6 had chest pain. The physician was notified on 8/5/25 at 11:30 a.m. and ordered the nurse to administer medication and transfer Resident 6 to the acute care Page 1 of 2 055454 055454 08/22/2025 Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hospital if the medication was not effective. Resident 6 received two medication doses for chest pain without effect and Resident 6 was transferred to the acute care hospital. Resident 6 was his own RP, and his mother was the emergency contact. The DON stated the facility did not have to notify Resident 6's emergency contact of the transfer to the acute care hospital because Resident 6 was his own RP. During a review of Resident 6's AR, dated 8/22/25, the AR indicated Resident 6 was a[AGE] year old male, admitted to the facility on [DATE] with diagnoses: anemia in chronic kidney disease (a condition in which your blood has a lower-than-normal amount of red blood cells that carry oxygen from your lungs to the rest of your body), severe protein-calorie malnutrition a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), atherosclerotic ( hardening of your arteries) heart disease without angina pectoris (chest pain), ischemic cardiomyopathy ( the heart's decreased ability to pump blood properly), other pulmonary embolism (a blood clot that blocks and stops blood flow to an artery in the lung), asthma (a chronic lung disease caused by inflammation and muscle tightening around the airways making it hard to breathe), pleural effusion (the buildup of excess fluid between the layers of the pleura outside your lungs), and end stage renal disease (permanent kidney failure that requires a regular course of dialysis or a kidney transplant).During an interview on 8/22/25 at 1:20 p.m. with the Administrator (ADM) in the ADM office, the ADM stated the RP or Emergency Contact should have been notified when residents have a change of condition and transferred to the acute care hospital regardless of resident's mental status. During a phone interview n 8/27/25 at 8:52 a.m. with the Licensed Vocational Nurse (LVN), the LVN stated the RP/family/emergency contact should have been notified when a resident had a change of condition and transferred to the acute care hospital. The LN stated it was important to notify the RP/family/emergency contact so they would know of the resident's change of condition and allow the ability to visit or contact the residents at the hospital. The LN stated the risk of not notifying the RP/family/emergency contact could result in delayed care or worsened medical condition if the hospital required consent for procedures and the RP/family/emergency contact were unaware resident had a change of condition and in the hospital. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2/2021, the P&P indicated, .4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: .b. there is a significant change in the resident's physical, mental, or psychosocial status; e. it is necessary to transfer the resident to a hospital/treatment center.5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.During a review of the facility's P&P titled, Transfer and Discharge (including AMA), dated 12/17/24, the P&P indicated, .12. Emergency Transfers/Discharges-initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified) .g. Provide a notice of transfer.to the resident and representative as indicated. 055454 Page 2 of 2