Health inspection·September 19, 2025

F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to recognize and appropriately act on the clinical change in condition for one of three residents, (Resident 1), when: Nursing staff did not notify the physician on 9/12/25 for abnormal blood lab results. 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). 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%). These failures resulted in the grandson (GS) of Resident 1 bringing a change in Resident 1's condition to the attention of the nursing staff. This led to avoidable emergency transport to the local acute care hospital (ACH) emergency department and an admission from September 14 through October 3, 2025. During the hospitalization, Resident 1 was diagnosed with potentially avoidable sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection) and acute kidney injury (AKI- when the kidneys suddenly are not able to filter waste products from the blood), which required admission to the intensive care unit (ICU-refers to specialized hospital unit that provides close monitoring and critical care to patients with life-threatening conditions). During a review of Resident 1's admission Record (a summary of important information regarding a patient, which include patient identification, past medical history, insurance status, care provider, family contact information and other pertinent information), the admission Record indicated, Resident 1 was admitted to the facility on [DATE] 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 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 1 had moderate 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, GS visited the facility and found Resident 1 warm to touch, and unresponsive. GS Page 1 of 5 056338 056338 09/19/2025 Morning Star Post Acute 111 Barstow Ave. Clovis, CA 93612

F 0580 Level of Harm - Actual harm Residents Affected - Few 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, the EPN indicated, Chief Compliant: Altered Mental Status (AMS hot and tachycardic [elevated HR].). [AGE] 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, the EPN indicated, Critical Care. Performed by: [name of 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, 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 056338 Page 2 of 5 056338 09/19/2025 Morning Star Post Acute 111 Barstow Ave. Clovis, CA 93612

F 0580 Level of Harm - Actual harm Residents Affected - Few 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. 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. (2:00p.m.-10:30p.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 the 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 inher 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 [EJ10] 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: On 9/10/2025 Resident 1's vitals signs were as follow: BP 101/59 mmHg, T 98.4, HR 114 bpm, Resp [respiratory- the number of breaths a person takes in one minute] 19. On 9/11/2025 no resident assessment (a medical check done for someone living in a care facility to understand their health and needs) was conducted. On 9/12/25 no resident assessment was conducted. On 9/13/25 Resident 1's vital signs were as follows: 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 056338 Page 3 of 5 056338 09/19/2025 Morning Star Post Acute 111 Barstow Ave. Clovis, CA 93612

F 0580 Level of Harm - Actual harm Residents Affected - Few (part of the body between the thighs). On 9/14/25 at 9:15 a.m. Resident 1's vital signs were as follows: BP 105/63, T 97.4 F, HR 64, resp 18, and O2 [oxygen] 95% on room air. Resident 1 was alert to self , breathing normal, with redness to the perineal area. On 9/14/25 at 7:38 p.m. Resident 1 had altered mental status (AMS), difficulty speaking, elevated temperature 99.2 F and Oxygen dropped to 75%. Resident 1 was sent to 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 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 as 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, indicating an infection process. LVN 1 stated the physician was not notified of the abnormal lab results and the delay could have contributed to Resident 1's decline on 9/14/25. LVN 1 stated the physician should have been notified of the elevated WBC. During a concurrent interview and record review on 9/17/25 at 4:19 p.m. with the Director of Nurses (DON), the facility's policy and procedure P&P titled Blood Pressure Measuring, revised 9/2010 was reviewed. The P&P indicated, hypotension is defined as blood pressure less than 100/60.hypotension [a condition where the BP is abnormally low] should be reported to the physician. Staff should record several readings throughout the day, including before and after meals. The DON stated the nurse should have notified the physician when Resident 1's BP was 91/55 mmHg with a HR of 116 on 9/13/25, and with an elevated WBC at 17.930, but it was not reported to the physician. The DON stated the nurse should have rechecked Resident 1's BP and HR to confirm accuracy and ensure a safe clinical decision to prevent serious adverse outcomes. The DON stated the daily resident assessment should have been completed to detect early changes in resident's condition and communicated promptly with the physician to ensure timely medical interventions and that was not done for Resident 1. During an interview on 9/19/25 at 11:28 a.m. with Registered Nurse (RN) 1, RN 1 stated she was the nurse assigned to Resident 1 on 9/12/25. RN 1 stated she did not complete Resident 1's daily assessment on 9/12/25. RN 1 stated she should have completed the daily assessment to detect early changes in Resident 1's condition. RN 1 stated she received Resident 1's elevated WBC result of 17.930 on 9/12/25 but did not notify the physician. RN 1 stated the delay of notifying the physician could have contributed to Resident 1's development of sepsis on 9/14/25. RN 1 stated sepsis was an infection process that spreads rapidly to organs in the body, especially in vulnerable residents like Resident 1. During an interview on 10/7/25 at 11:04 a.m. with the GS, the GS stated Resident 1 was discharged from the hospital with Home Health services (a medically necessary skilled care provided by qualified professional in a patient's residence). The GS stated Resident 1 had been hospitalized for approximately one month and was just recently discharged on 10/3/25. The GS stated Resident 1 was still recovering from the infection. During a review of R1's Acute Care Hospital document titled Progress Notes (PN) dated 9/30/25, the PN indicated, Patient is medically discharged . Septic shock, resolved. UTI . AKI, resolved. During a review of the facilities policy and procedure (P&P) titled, Change in a Resident's Condition or Status, revised 11/2015, the P&P indicated, 1. The Nurse Supervisor/Charge Nurse will notify the resident's attending 056338 Page 4 of 5 056338 09/19/2025 Morning Star Post Acute 111 Barstow Ave. Clovis, CA 93612

F 0580 Level of Harm - Actual harm Residents Affected - Few physician or on-call physician when there has been d. a significant change in the resident's physical/emotional/mental condition.2. A significant change of condition is a decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing disease-related clinical interventions b. impacts more than one area of the resident's health status, d. ultimately is based on the judgement of the clinical staff. During a review of the facilities policy and procedure (P&P) titled, Vital Signs, dated 2022, the P&P indicated, nurse aids may be assigned responsibility for obtaining routine vital signs and reporting abnormal findings to the nurse.licensed nurses are responsible for knowing the usual range of a residents vital signs, analyzing and interpreting routine vital signs and notifying the physician of abnormalfindings.4. Acceptable ranges for adults b. pulse 60-100 beats per minute d. blood pressure: average <120/ <80 . During a review of the facilities policy and procedure (P&P) titled, Laboratory Services and Reporting, revised 9/2022, the P&P indicated, promptly notify the ordering physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range. During a review of the facilities policy and procedure (P&P) titled, Resident Examination and Assessment, revised 2/2014, the P&P indicated, the purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan.Reporting 2. Notify the physician of any abnormalities such as, but not limited to a. abnormal vital signs, 3. Report other information in accordance with facility policy and professional standards of practice. During a review of a professional reference from https://pathwayhealth.com/change-of-condition-the-quiet-signal-that-demands-a-loud-response/ titled Change of Condition: The Quiet Signal That Demands a Loud Response dated 5/28/25, the professional reference indicated, In the fast-paced world of clinical care, it's often the quietest signs that speak the loudest. A resident who suddenly seems more withdrawn. A subtle shift in appetite. A new complaint of pain. These aren't just passing moments, they could be the first indicators of a Change of Condition (COC), and your clinical instincts are the first line of defense. As nurses, CNAs, and interdisciplinary team members , your ability to recognize and act on these changes is critical-not just for compliance with CMS and RAI guidelines , but for the safety, dignity, and outcomes of the people you care for. This article is your guide to understanding what qualifies as a COC, how to document it effectively, and why your role in this process is not just important, it's essential. Why Early Detection Matters. Early detection of a Change of Condition can be the difference between a manageable intervention and a medical emergency. When clinical staff identify subtle changes early-before they escalate into acute issues, residents benefit from faster treatment, fewer hospital transfers, and better overall outcomes. It also allows the care team to adjust care plans proactively, reducing stress for residents and families alike. During a review of a professional reference from https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmod1.html titled Improving Patient Safety in Long-Term Care Facilities the professional reference indicated, . A change in a resident's condition may mean that he or she is at risk. Action can be taken only if changes are noticed and reported, the earlier the better. Changes that are not reported can lead to serious outcomes, including medical complications, transfer to a hospital, or even death. In order to identify a change in condition and know when to report it, staff need to understand what is normal (baseline) for a particular resident's condition when he or she first comes into the nursing center, and over time after that. Armed with this information, staff will be able to identify changes and decide which ones need to be reported to others on the care team. 056338 Page 5 of 5