Health inspection·August 15, 2025

Code of Federal Regulations, Title 42, Section 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. California Code of Regulations, Title 22, Section 72311. Nursing Service- General (a) Nursing service shall include, but not limited to, the following: (1) Planning of patient care, which shall include at least the following: (C) 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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (F) Any error in the administration of a medication or treatment to a patient which is life threatening and presents a risk to the patient. (G) The facility’s inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the patient. California Code of Regulations, Title 22, Section 72313, Nursing Service- Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. California Code of Regulations, Title 22, Section 72355, Pharmaceutical Service-Requirements. (a) Pharmaceutical service shall include, but not limited to, the following: (1) Obtaining necessary drugs including the availability of 24-hour prescription service on a prompt and timely basis as follows: (B) Anti-infectives and drugs used to treat severe pain, nausea, agitation, diarrhea or other severe discomfort shall be available and administered within four hours of the time ordered. California Code of Regulations, Title 22, Section 72523, Patient Care Policies and Procedures. (a) Written patient care and policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. It was determined that the facility failed to ensure the following: 1. An IV (intravenous – administered into a vein) antibiotic (medication to treat infection) for septic arthritis (a serious joint infection, often caused by bacteria, that can lead to significant joint damage and sepsis [infection in the blood or tissues] if left untreated) was administered in accordance with the physician’s order and the orthopedic surgeon’s (OS - a medical doctor specializing in the diagnosis, treatment, and prevention of musculoskeletal system injuries and diseases) recommendation for Patient 1, when the orthopedic physician ordered for Patient 1 to start on Rocephin (antibiotic medication to treat infection) on May 23, 2025, for septic arthritis. The IV Rocephin was not administered to Patient 1 from May 23, 2025, to June 27, 2025 (35 days). 2. Arrange a follow-up appointment with the OS in three weeks after the appointment on May 23, 2025. 3. The OS was consulted when Patient 1 missed receiving the IV Rocephin as prescribed for septic arthritis, on May 23, 2025. These failures resulted in delayed provision of care and treatment for Patient 1’s septic arthritis which could lead to severe and permanent joint damage, chronic pain, and life-threatening conditions such as sepsis; and up to death. On June 19, 2025, at 10 a.m., an unannounced visit was conducted at the facility to investigate a complaint on quality of care. A review of Patient 1’s General Acute Care Hospital (GACH) “Orthopedic Operative Report,” dated May 8, 2025, indicated, “...POSTOPERATIVE [the period of time following a surgical operation] DIAGNOSES: Left knee large effusion [excess fluid accumulation within or around the knee joint], questionable septic arthritis [a painful joint infection, usually caused by bacteria, that can damage cartilage and bone] with lateral meniscus [cartilage – a strong connective tissue found in joints, ear, nose] and medial meniscus tear [a common knee injury involving damage to the cartilage that acts as a shock absorber and stabilizer in the knee joint], popliteal cyst [a fluid-filled swelling that develops behind the knee]...large 30 ml [milliliter – unit of measurement] of turbid [cloudy, opaque, or thick with suspended matter] viscous [thick, sticky consistency] fluid is evacuated and is sent for Gram stain [a laboratory technique used to differentiate bacteria into two main groups: Gram-positive and Gram-negative]...explained to her regarding the operation findings and the need for several weeks of IV antibiotics as consulted to infectious disease...IV midline is recommended. IV Rocephin 1 g (gram) daily for 6 (six) weeks and IV Flagyl [antibiotic to treat infection] 500 mg (milligram – unit of measurement) every 6 (six) hours recommended...” A review of Patient 1’s “Admission Record,” at the skilled nursing facility (SNF) indicated the patient is a 48 year old female admitted to the facility on May 12, 2025, with diagnoses which included left elbow fracture (broken bone), left knee ORIF (open reduction with internal fixation - a surgical procedure used to treat fractures, particularly those that are severely displaced or unstable), and lupus (a chronic autoimmune disease where the body's immune system mistakenly attacks healthy tissue which could lead to inflammation and damage in various parts of the body, including the skin, joints, kidneys, heart, lungs, and blood cells). A review of Patient 1’s physician’s orders, date ordered May 16, 2025, indicated, “...RESIDENT HAS F/U [follow up] ORTHO APPOINTMENT ON 5/23 [May 23, 2025] AT 8:30 AM (a.m.) WITH [name of orthopedic surgeon] AT [address of orthopedic clinic]...” A review of Patient 1’s orthopedic consultation notes, dated May 23, 2025, indicated, “...Pt doesn’t have IV access...Left knee septic arthritis...Plan...IV midline (a type of IV access)...IV Rocephin 1 gm q (every) daily x 6 weeks...” A review of the document titled, “Progress Record,” documented by the OS, sent with Patient 1 when she came back from the appointment, dated May 23, 2025, indicated, “...ordering IV midline and IV Rocephin 1 [one] gram QD [daily] x 6 wks. [weeks] w/ [ with] [name of home health agency]...RTC (return to clinic) in 3 [three] weeks [around June 13, 2025]...” A review of Patient 1’s physician order, date ordered May 23, 2025, “...ORDER FOR IV MIDLINE AND IV ROCEPHIN 1 [one] GRAM [unit of measurement] DAILY X [times] 6 [six] WEEKS WITH [name of home health agency]...” A review of Patient 1’s “Progress Notes,” at the SNF dated May 23, 2025, at 10:51 a.m., documented by RN (Registered Nurse) 1, indicated the order from the orthopedic appointment for IV Rocephin, IV midline, and return to clinic in 3 weeks. Further review of Patient 1’s physician orders and progress notes indicated no documented evidence that the facility staff verified the start date of the IV antibiotic and the indication for the IV antibiotic with the orthopedic surgeon. A review of the Medication Administration Records (MAR) did not indicate documented evidence that the physician’s order for IV midline and IV Rocephin were carried out as ordered since May 23, 2025. A review of Patient 1’s physician order, date ordered June 11, 2025, indicated, “...Send to ER (Emergency Room) for IV Midline insertion...” (19 days from the order date) A review of Patient 1’s GACH records, dated June 11, 2025, at 1:28 p.m., indicated, “...Chief Complaint: midline placement...pt (patient) sent to er (Emergency Room) from (name of skilled nursing facility) for midline placement...” A review of Patient 1’s “Progress Notes,” at the SNF dated June 13, 2025, at 8:35 p.m., documented by RN 2 indicated, “...Patient arrived at 2035 (8:35 p.m.) from (name of GACH)...MD made aware...” Further review of the progress notes did not indicate documentation of the presence of an IV access on Patient 1 or if there were any IV orders. Further review of Patient 1’s SNF records from June 13, 2025, to June 27, 2025, indicated there was no documented evidence that the physician or orthopedic surgeon was consulted regarding the IV midline not done in the GACH and if the IV Rocephin was still needed to be given to Patient 1 (no IV access and no Rocephin given since the order date of May 23, 2025 - total of 35 days). During an interview on June 26, 2025, at 4:20 p.m., RN 1 stated she was the RN on duty when Patient 1 came back from an orthopedic appointment on May 23, 2025, and the orthopedic surgeon ordered IV midline and IV Rocephin daily for six weeks.  RN 1 stated IV midline was not being done at the facility and the patient would need to be scheduled at the hospital for IV midline placement. RN 1 stated she was not able to clarify with the orthopedic surgeon when the IV Rocephin should be administered. RN 1 stated she got busy and did not endorse it to the next shift RN. RN 1 stated she did not start a peripheral line (a type of IV access) so the IV Rocephin could be started on May 23, 2025. In addition, RN 1 stated she was not aware Rocephin may also be given through intramuscular (IM – through the muscles) injection (if ordered as such by a licensed practitioner). During an interview on June 26, 2025, at 5:47 p.m., the Administrator (ADM; who also possessed a California issued RN license) stated the following: a. The RN should have clarified with the OS the order for IV midline and IV Rocephin. b. The RN should have clarified with the OS when the IV antibiotic should be started, and if the IV antibiotic could be administered via a different route. c. He found out about the OS orders on June 13, 2025, when he did chart review with the Case Manager (CM), Social Services Director (SSD), and the Infection Preventionist (IP) and then discussed it with the previous DON. d. He instructed the previous DON to clarify the OS orders. e. The CM told him that the IV Rocephin should have been started on May 23, 2025. f. The Rocephin could be given through the IV peripheral line while waiting for an IV midline to be placed. During a concurrent observation and interview on June 27, 2025, at 9:28 a.m., Patient 1 was observed, in the patient’s room, sitting at the edge of the bed wearing a short sleeve shirt and was observed without IV access. Patient 1 stated the following: a. She had MRI (Magnetic Resonance Imaging-medical imaging technique used in radiology to create detailed pictures of the inside of the body) and was found to have septic arthritis which she was treated with IV antibiotics while at the GACH and she thought it would be continued in the skilled nursing facility. b. She had a follow up appointment with the OS on May 23, 2025, and had ordered for IV antibiotic; but until this date, have not received any IV antibiotics. c. She had inquired with the licensed nurses about the IV antibiotic, but did not get a clear response from anyone of them. d. She went to the GACH on June 11, 2025, to have an IV midline placed, but did not know why it was not placed while she was at the GACH. e. She did not know if she had a follow up appointment with the OS. During an interview on June 27, 2025, at 10:15 a.m., the CM stated her responsibility was to oversee the care and services being provided to the patients who received skilled services, from admission to discharge planning. The CM stated she would also arrange necessary appointments and transport services and would review consultant notes after appointments. During a concurrent review of Patient 1’s record on June 27, 2025, at 10:15 a.m., the CM stated the following: a. Patient 1 was admitted to the facility on May 12, 2025, for rehabilitation after left knee surgery; b. Patient 1 had a follow-up appointment with the OS on May 23, 2025, with an order for IV Rocephin daily for six (6) weeks via IV midline; c. She was not aware of the IV orders from the OS appointment on May 23, 2025, not until the previous DON discussed it with her on June 11, 2025. d. The previous DON called the OS to clarify the order for IV Rocephin and the previous DON was informed IV Rocephin should have been initiated on May 23, 2025; e. There was no documentation the licensed nurses followed up with the OS to clarify the order for IV midline and IV Rocephin; f. The RN should have clarified with the OS regarding the need for the IV Rocephin and when it should be administered; g. RN 1 told CM that a peripheral line was attempted but unable to get one on May 23, 2025. However, there was no documentation, a peripheral line was attempted to be inserted on Patient 1 and was not successful; h. The DON told the CM she would handle the issue on Patient 1’s IV order and that the patient was sent out to the GACH for IV midline placement on June 11, 2025; i. Patient 1 returned to the facility on June 13, 2025, without IV access and no further recommendations for IV antibiotics; j. There was no documentation the facility communicated to the OS that IV Rocephin was not administered to Patient 1 since the patient came back from GACH on June 13, 2025, and if the IV Rocephin would still be needed to be administered to the patient; k. The facility should have clarified with the OS regarding the IV Rocephin order if still needed even after coming back from the GACH on June 13, 2025; and l. There was no follow up appointment scheduled with the OS after it was ordered on May 23, 2025, for RTC in three (3) weeks (around June 13, 2025). The CM stated a follow up appointment with the OS should have been scheduled in accordance with the physician’s order. During an interview on June 27, 2025, at 11:11 a.m., the OS Medical Assistant (MA) stated the previous DON called the orthopedic clinic on June 11, 2025, to clarify regarding the IV Rocephin ordered by the OS on May 23, 2025, and the previous DON was advised that the IV Rocephin should have been initiated on May 23, 2025. The MA stated the IV Rocephin was ordered by the OS for septic arthritis. The MA stated there was no schedule made by the facility for a follow up appointment with the OS after May 23, 2025. During a concurrent interview and record review on June 27, 2025, at 1:32 p.m., the Infection Preventionist (IP), she stated she was not aware Patient 1 had an order for IV Rocephin when the patient returned from the orthopedic follow up appointment on May 23, 2025. The IP stated she should have reviewed Patient 1’s record to evaluate the appropriateness of the antibiotic since the patient was also on Levaquin (medication to treat infection). During an interview on July 2, 2025, at 11 a.m., the OS stated the following: a. Left knee surgery was done on the patient (Patient 1) on May 8, 2025, due to fluid buildup on her left knee joint with differential diagnosis (a systematic process used by healthcare professionals to identify the most likely cause of a patient's symptoms by distinguishing between various conditions that share similar characteristics) of septic arthritis. b. During surgery, there was turbid viscous fluid-like pus from the knee joint indicative of septic arthritis, and he recommended for the patient to receive IV Rocephin for 6 weeks while at the skilled nursing facility. c. The patient (Patient 1) had a follow up appointment with him on May 23, 2025, and he ordered for the patient to have IV Rocephin after the appointment on May 23, 2025, for septic arthritis. d. He was not aware the IV Rocephin was not administered to the patient since May 23, 2025. The IV Rocephin could be given via IV midline or peripheral line, whatever IV access was available. e. The facility should have clarified with