Health inspection·December 16, 2025

The following citation reflects the findings of the California Department of Public Health investigation of complaint number 2645428. The inspection was limited to the specific complaint and does not represent the findings of a full inspection of the facility. The facility was found to be not in compliance with 42 CFR 483.5-483.75 - Subpart B - Requirements for Long Term Care Facilities and 22 CCR sections 72523 and 72301. State Class A citation 230022792 was issued for complaint number 2645428 at Title 42 CFR § 483.25 and Title 22 CCR 72523 and 72301. 22 CCR § 72523: 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. 22 CCR § 72301: Required Services. (f) The facility shall ensure that all orders written by a person lawfully authorized to prescribe shall be carried out unless contraindicated. § 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 On 10/21/25 at 7:45 am, the Department conducted an unannounced visit to the facility to investigate the quality of care and treatment provided to Resident 1. The facility failed to: 1. Record or report a change in Resident 1’s condition to the Medical Director when Resident 1 experienced a decrease in the frequency of urine output in her daily brief (type of adult disposable underwear) changes—a significant indicator of decreased urine output as required by the facility’s policies and procedures; 2. Ensure laboratory tests were performed as ordered by the facility’s Medical Director on 9/26/25. These failures to identify and report Resident 1’s change in condition, failure to ensure the lab tests were performed caused Resident 1 from receiving appropriate medical assessments and treatment, which ultimately resulted in her death on 10/10/25. Findings: A review of the facility’s policy titled “Change in a Resident’s Condition or Status”, revised 11/2015, the policy indicated that: The facility will promptly notify the Resident, their attending physician, and their representative of any changes in the Resident’s medical or mental condition and/or status. The Charge Nurse (CN) will notify the Resident’s attending or on-call physician of significant changes in the Resident’s physical, emotional, or mental condition, or if there is a need to transfer the resident to a hospital or treatment center. A “Significant Change” is defined as a decline or improvement in the resident’s status that will not resolve without staff intervention or standard clinical interventions and impacts more than one area of the Resident’s health. Before notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant information, including using the SBAR communication tool (Situation, Background, Assessment, and Recommendation. It provides a structured, concise, and standardized way for healthcare professionals to communicate important patient information.) The CN will document changes in the resident’s medical or mental condition in the resident’s medical record. If a significant change occurs, a comprehensive assessment of the resident’s condition will be conducted, and any changes will be reported to the Director of Nursing Services to ensure the resident’s medical record is updated accordingly. A review of Resident 1’s admission record, dated 10/21/25, indicated that Resident 1 was admitted on 2/12/24 with diagnoses that included type 2 diabetes (high blood sugar), unspecified dementia (a progressive state of decline in mental abilities), hypertensive chronic kidney disease (a condition where high blood pressure damages the kidneys, causing them to lose function over time), and need for assistance with personal care. Resident 1 was not her own healthcare decision maker. A review of Resident 1’s record titled “Bladder Elimination”, dated 9/22/25 – 10/1/25, documentation showed a significant reduction in the number of daily brief changes. On most days during this period, Resident 1 received only one to four brief changes per day. Specifically, she had four changes on 9/22, one on 9/23, three on 9/24, four on 9/25, two on both 9/26 and 9/27, two again on 9/28, three on 9/29, two on 9/30, and one on 10/1. During an interview with Certified Nursing Assistant (CNA) D on 10/22/25 at 9:40 am, CNA D stated that Resident 1 was a “heavy wetter” and usually had “a lot of brief changes.” During an interview with CNA E on 10/22/25 at 9:50 am, CNA E stated, “[Resident 1] usually received 15-20 brief changes every 24 hours.” CNA E confirmed Resident 1 was a “Heavy wetter.” CNA E explained that facility staff were generally aware that Resident 1 was “Very incontinent.” CNA E added, “It would be strange for [Resident 1] to receive only 2-4 brief changes in a 24-hour period.” During an interview with CNA F on 10/22/25 at 10:03 am, CNA F confirmed she worked the night shift on 9/28/25, 9/29/25, and 9/30/25. She stated Resident 1 was a “Heavy wetter” and receiving 15–20 brief changes in a 24-hour period was “Normal” for her. During an interview with CNA G on 10/22/25 at 11:06 am, CNA G confirmed that 2–4 brief changes in a 24-hour period for Resident 1 was “Not enough. Because [Resident 1] was always incontinent.” During an interview with Licensed Nurse (LN) H on 10/22/25 at 11:14 am, LN H stated that “[Resident 1] needed multiple brief changes a day, and 2-4 brief changes a day was not like her elimination baseline.” During an interview with Director of Nursing (DON) on 10/22/25 at 12:19 pm, DON stated he was not aware there was a decrease in the number of brief changes for Resident 1. He confirmed this was considered a change in condition and both the MD and DON should have been notified of this, especially since Resident 1 had a history of Urinary tract infection (UTI – an infection in any part of the urinary system). A review of Resident 1’s clinical record titled “Blood Sugar Summary”, dated 9/18/25 – 9/26/25, indicated between 9/18 and 9/21/25, Resident 1’s fasting blood sugar levels remained relatively stable, ranging from 238 to 274 mg/dL. However, beginning on 9/22, her levels rose sharply, reaching dangerously high readings between 320 and 434 mg/dL over the next five days. On 9/25, her blood sugar peaked at 434 mg/dL and remained critically elevated at 408 mg/dL the following day. This change of condition was not reported to Resident 1’s physician. According to the Centers for Disease Control and Prevention (CDC) website, accessed 10/25/25, Resident 1’s sustained blood sugar levels above 300 mg/dL that do not respond to the prescribed treatment are considered life-threatening and require immediate medical intervention. This sustained elevation marked a significant change in condition that warranted urgent clinical attention. https://www.cdc.gov/diabetes/about/diabetic-ketoacidosis.html During a review of Resident 1’s clinical record titled “SBAR”, dated 9/25/25 at 12:44 pm, indicated LN H notified MD and wrote, “Nurse called MD for Resident 1 having high fasting blood glucose (FBG - the level of glucose (sugar) in the blood after fasting for at least 8 hours) before breakfast 434 mg/dL and before lunch 353 mg/dL. New order received for Complete Blood Count (CBC- a common blood test that measures various components of the blood to assess overall health and detect potential medical conditions)/ Comprehensive Metabolic Panel (CMP- a routine blood test that provides an overview of the body's chemical balance and metabolism)/ Hemoglobin A1C (Hb A1C - a blood test that measures the average blood sugar levels over the past two to three months) one time only for one day.” MD recommended to “Monitor and new order for labs.” During a review of Resident 1’s physician orders, dated 9/26/25 at 12:30 pm, indicated “CBC/CMP/HbA1C one time only for one day” During a review of Resident 1’s clinical record titled “Laboratory Result”, dated 9/26/25 at 12:54 pm, indicated LN A documented “Notified by lab that Resident 1 refused ordered labs today. MD notified and gave order to try again tomorrow. Lab slip placed in lab book per policy. Lab will attempt again tomorrow morning.” During a review of the facility’s lab requisition binder, a local phlebotomist (a healthcare professional who specializes in drawing blood from residents) documented “no labs” on the lab draw log on 9/26/25, the date Resident 1’s lab draw was ordered to be done. During an interview with LN H on 10/22/25 at 11:14 am, LN H reported that the night shift nurse, LN A, told her Resident 1 refused the lab draw on 9/26/25. LN H stated, “it was not the nurse’s job to ask a resident if they wanted lab work.” She added, “it was the job of the phlebotomist to ask the resident.” LN H explained that after she notified MD of Resident 1’s high blood glucose levels on 9/25/25, he gave her a verbal order for labs to be drawn on 9/26/25. She entered the order electronically and completed a lab slip. She then placed the lab slip into the facility lab binder. LN H confirmed she did not work on 9/27/25 and did not follow up to ensure Resident 1’s lab order was fulfilled as ordered. During an interview with CNA D on 10/22/25 at 9:40 am, CNA D stated that Resident 1 was not someone who routinely refused medications or care. During an interview with CNA E on 10/22/25 at 9:50 am, CNA E stated Resident 1 only refused care to new staff but accepted care if new staff took their time and spoke with her. During an interview with DON on 10/21/25 at 1:56 pm, the DON stated, “if a lab order is refused by a resident, the lab slip would be placed back into the lab requisition binder for the next day and notify the MD.” The DON also stated he could not remember if LN H told him about Resident 1’s change in condition on 9/25/25. During a concurrent interview and record review with LN A on 10/21/25 at 2:10 pm, the facility’s lab requisition binder was reviewed. LN A confirmed, “if the phlebotomist wrote ‘no labs’ in the lab requisition binder, then there were no lab slips for the phlebotomist to reference for that day.” LN A confirmed the phlebotomist wrote “no labs” in the lab requisition binder on 9/26/25. She stated she could not remember if she put a lab slip in the binder for 9/26/25 and confirmed there was not one in the binder. LN A stated, “after Resident 1 refused the lab draw for 9/26/25, she forgot to enter the verbal lab order received from MD for 9/27/25.” She stated, “a new lab order was needed in order for Resident 1 to successfully receive a lab draw on 9/27/25.” During an interview with the supervisor of a local lab company (S LAB) on 10/21/25 at 3:30 pm, S LAB stated, “no labs” written on the lab requisition log indicated no lab slips were in the binder for the phlebotomist to reference. S LAB explained that if a resident refused a lab draw, the phlebotomist documented it in the lab draw log in the lab requisition binder with the resident’s name, type of lab ordered, and the word “refused.” S LAB confirmed “no labs” was documented in the lab draw log for 9/26/25 and that Resident 1’s name was not on the log. During a review of Resident 1’s progress notes, dated 10/1/25 at 7:09 am, by LN H, indicated “LN H received a report from night shift staff that [Resident 1] was calling out all night. [Resident 1] had FBG 258 mg/dL and pulse 40 (normal range 60-100 beats per minute) thready (a weak pulse), and SPO2 (Oxygen levels) was 87% on room air…. [Resident] 1 was transferred to the Emergency Room on 10/1/25.” During an interview with MD on 10/22/25 at 10:42 am, MD stated staff notified him on 9/26/25 that Resident 1 refused the lab drawing, and he gave a verbal order for the lab to attempt the draw on 9/27/25. He stated he was not notified that the labs were never drawn. MD stated, “he would have expected to be notified that labs were not drawn as ordered.” He also stated, “he expected the facility to follow up to ensure the labs were drawn if the first attempt was not successful.” MD stated he was not notified that Resident 1 cried out for help on 9/28/25, 9/29/25, or 9/30/25. He stated, “this would be considered a change in condition for Resident 1 and that facility should have notified him because he would have sent Resident 1 ‘Out immediately for evaluation.’” During an interview with DON on 10/22/25 at 12:19 pm, the DON confirmed, “an increase in blood glucose levels would be considered a change in condition that the MD and the DON should be notified of immediately.” The DON confirmed LN A should have entered a new lab order electronically for 9/27/25. He confirmed it was his responsibility to follow up on lab work for residents and ensure it was completed as ordered. The DON confirmed he did not follow up on Resident 1’s lab work. During an interview with CNA G on 10/22/25 at 11:06 am, CNA G stated “[Resident 1] would not scream out or cry out for help at her baseline. CNA G stated Resident 1 was “Generally a quiet person.” During an interview with CNA F on 10/22/25 at 10:03 am, CNA F confirmed she worked the night shift on 9/28/25, 9/29/25, and 9/30/25. She stated, “[Resident 1] screamed out ‘Help me! Lord, help me! Help me!’ during her shift all three nights.” CNA F reported that Resident 1’s roommate pressed the call light one night to get staff to help calm Resident 1. She stated she reported Resident 1’s calling out to LN C on 9/28/25, 9/29/25, and 9/30/25 during their shift. CNA F stated she did not see LN C leave the nurse’s station to assess Resident 1 during the shifts when she reported Resident 1 screaming. During an interview with LN C on 10/22/25 at 2:20 pm, LN C confirmed he worked the night shift on 9/28/25, 9/29/25, and 9/30/25. He stated he couldn’t recall whether Resident 1 called out for help. He confirmed he did not assess Resident 1 for a change in condition. LN C stated Resident 1 appeared more “Confused” on 9/30/25, and he called MD, but MD did not answer. He confirmed he did not call MD again, nor notify the DON or Administrator (Admin) of the change in condition. During a review of Resident 1’s clinical record titled “Hospitalist: History and Physical,” dated 10/1/25, at 9:56 AM, by Hospital MD, Resident 1 was admitted to the hospital with the following diagnoses: Septic shock: A life-threatening condition that occurred when an infection spread throughout the body and caused a severe drop in blood pressure. Acute respiratory failure with hypoxia: A life-threatening condition where the lungs could not adequately provide oxygen to the body. Profound hyperkalemia: A life-threatening condition where blood potassium levels were dangerously high, potentially causing fatal abnormal heart rhythm. Acute kidney injury with anuric renal failure: A condition where the kidneys suddenly lost their ability to function properly, resulting in no urine output. Resident 1’s BUN was profoundly elevated at 287, and emergent hemodialysis (a life-saving treatment for acute kidney failure) was performed. Hypovolemic hypernatremia: A condition where there was a loss of both water and sodium, but more water was lost than sodium, resulting in a higher concentration of sodium in the blood and a decrease in overall body fluid volume. Metabolic acidosis/Lactic acidosis: A condition where there was too much acid in the blood, occurring when the body either produced too much acid or the kidneys could not remove enough of it. Lactic acidosis, a specific type of metabolic acidosis, was caused by an excess buildup of lactic acid in the blood, often due to insufficient oxygen delivery to the body's tissues. The hospital MD also indicated in the assessment and plan, “Septic shock, admit to intensive care unit, will be a miracle if this patient survives.” During a review of Resident 1’s physician order, Resident 1 was placed on hospice care (Hospice care is a type of specialized medical care focus