Health inspection·June 27, 2025

§483.10(g)(14)(i)(A)(B)(C) Notification of Changes (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications). (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D)A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). §483.21(b) Comprehensive Care Plans §483.21(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 §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. On 5/13/2025, the California Department of Public Health (CDPH) received a Complaint alleging that a resident (Resident 2) bumped his head trying to look at a photo. Upon admission to the General Acute Care Hospital (GACH) Resident 1 was diagnosed with a brain bleed, and a fall was suspected. On 5/13/2025, the CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. Upon investigation CDPH determined the facility failed to notify Resident 2's physician when Resident 2 had a change in condition (COC) after sustaining a head injury on 5/4/2025. The facility failed to: 1. Notify Resident 2's physician when Resident 2, who was receiving Aspirin (ASA) a blood thinner to prevent stroke and Clopidogrel Bisulfate ([Plavix] a medication used to prevent blood clots), sustained a head injury on 5/4/2025, that resulted in an abrasion, a laceration, and a small bump with substantial bleeding to his head. 2. Notify Resident 2's physician following Resident 2's head injury and obtain an order for the discontinuance of ASA and Plavix to prevent bleeding in the resident's brain. Resident 2 continued to receive blood thinners from 5/4/2024 through 5/9/2025 daily. 3. Notify Resident 2's physician following Resident 2's head injury (5/4/2025), when Resident 2 exhibited noticeable changes in behavior that included decrease in appetite, drowsiness, and less talkative, which were not his typical behaviors. 4. Follow Resident 2's untitled Care Plan dated 4/25/2025, that indicated to monitor, document and report adverse reactions of anticoagulant therapy to include lethargy, loss of appetite, and sudden changes in mental status. 5. Follow their Policy and Procedure (P/P), titled, "Change in Resident's Condition of Status" indicating the nurse will notify the attending physician or physician on call within 24 hours (except in medical emergencies) when there has been an accident, a significant change in the resident's physical/emotional/mental condition, and the need to transfer to the hospital. These deficient practices resulted in a delay in evaluation and treatment for Resident 2 following an injury to his head with bleeding on 5/4/2025. Resident 2 was transferred to a GACH on 5/9/2025 (five days after the injury to his head) via 911 when he was found lethargic and unarousable by Resident 2's Family Member (FM) 1. Resident 2 was diagnosed with a subarachnoid hemorrhage (a life threatening condition where bleeding occurs in the space between the brain and the tissue covering the brain) and was transfused (a procedure where blood or blood components are administered through an intravenous line) with one unit of platelets. These deficient practices had the potential for Resident 1 to suffer more severe injuries and death. A review of Resident 2's Admission Record (Face Sheet) indicated Resident 2, a 93-year old male, was admitted to the facility on 4/25/2025 with a diagnosis including Alzheimer's disease (a progressive disorder that affects memory, thinking, and behavior), and a history of falling. A review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 5/2/2025, indicated Resident 2 had moderate cognitive impairment (noticeable but mild memory and thinking problems) and required maximum assistance with toileting hygiene, and substantial assistance with dressing, and personal hygiene. A review of Resident 2's Physician's Order, dated 4/25/2025, indicated to administer the following medications and to monitor for signs and symptoms (s/s) of bleeding such as hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) every shift, and notify the physician if s/s occur: 1. ASA 81 milligrams (mg) once a day to prevent a cerebral vascular accident ([CVA] a stroke] loss of blood flow to a part of the brain) 2. Plavix 75 mg once a day for CVA prevention. A review of Resident 2's Medication Administration Record (MAR), dated 4/2025 and 5/2025, indicated Resident 2 received ASA 81 mg and Plavix 75 mg once a day from 4/26/2025 through 5/9/2025. A review of Resident 2's untitled Care plan, dated 4/25/2025, indicated Resident 2 was on antiplatelets ([ASA and Plavix). The Care Plan's goal indicated Resident 2's risk for adverse reactions related to the medications use would be minimized. The Care Plan's interventions indicated to monitor, document and report adverse reactions of anticoagulant therapy to include lethargy, loss of appetite, and sudden changes in mental status. A review of Resident 2's SBAR ([situation, background, assessment, recommendation] a communication tool used by healthcare workers when there is a change of condition among the residents), dated 5/4/2025 and timed at 7 p.m., indicated Resident 2 hit his head on a shelf. The SBAR indicated Resident 2 was sitting at the edge of the bed, something hit him, but he (Resident 2) did not remember what it was. The SBAR indicated Resident 2 sustained a small cut and a small bump on the front of his head. A review of Resident 2's Nursing Progress Note, dated 5/9/2025 and timed at 1:50 p.m., indicated Resident 2's Family Member (FM) 1 was observed in Resident 2's room at 12:55 p.m., screaming and trying to wake up Resident 2. The Nursing Progress Note indicated Resident 2 was lethargic. A review of Resident 2's SBAR, dated 5/9/2025, indicated Resident 2 was lethargic and unarousable at 12:55 p.m., and was transferred to the GACH via 911. A review of Resident 2's Emergency Medical Services (EMS) form, dated 5/9/2025, indicated Resident 2's blood pressure (BP) upon arrival was 86/42 millimeters of mercury ([mmHg] a unit of pressure commonly used to measure BP, normal BP is typically between 90/60 mmHG and 120/80 mmHG) A review of the GACH's Admission record, dated 5/9/2025, indicated Resident 2 arrived at the GACH at 2:38 p.m., due to bleeding in the brain, altered mental status, low BP, and monitoring for long-term blood thinner use. A review of the GACH's Emergency Department's (ED) Provider Notes, dated 5/9/2025 and timed at 7:10 p.m., indicated Resident 2 had an abrasion to the front scalp with strips of surgical tape and a band aid in place. A review of the GACH's Assessment/Plan Note dated 5/9/2025, indicated Resident 2 received one unit of platelets for transfusion in the ED. A review of the GACH's Imaging Note, dated 5/10/2025 and timed at 5:26 a.m., indicated Resident 2 had a possible subarachnoid hemorrhage. A review of the GACH's Consult note, dated 5/10/2025 and timed at 7:47 a.m., indicated Resident 2 had a left parietal (on top of the head) traumatic subarachnoid hemorrhage. During an interview on 5/14/2025 at 9:27 a.m., and a subsequent interview at 9:40 a.m., FM 1 stated on 5/4/2025 (time unknown), she received a call from Registered Nurse (RN) 1 saying that Resident 2 scraped his head when bending over looking pictures, there was some bleeding, but he did not have to go to the GACH. FM 1 stated on 5/9/2025 around 1 p.m., she came to pick up Resident 2, he was sitting on his walker in the hallway and was having difficulty speaking. FM 1 stated Resident 2 pointed to his groin, letting her know he need to go to the bathroom, she took him to the bathroom and while walking he became very unstable, he began to slump over, and she had to brace him using her knee to prevent him from falling. FM 1 stated, Resident 2's eyes rolled back, and he stopped breathing, so she called for help and asked RN 1 to call 911. During an observation on 5/14/2025 at 12:48 p.m., in Resident 2's room, Resident 3's (Resident 2's Roommate) shelf was observed on the floor at the foot of Resident 3's bed. The shelf was made of a flimsy plastic material and was approximately three feet high with four individual shelves. The edges of the shelf were ridged and corroded. During an interview on 5/14/2025 at 10:29 p.m., RN 1 stated on 5/4/2025 after dinner, he was informed by a staff member (unidentified) that Resident 2 had an accident. RN 1 stated he went to Resident 2's room and saw blood on the floor and observed Resident 2 sitting on his bed bleeding from his forehead. RN 1 stated Resident 2 told him something hit his face, but he (Resident 2) was not able to fully explain what it was. RN 1 stated he spoke to Resident 3, who witnessed some of the incident. RN 1 stated Resident 3 told him that Resident 2 bent down to look at pictures that were on Resident 3's shelf, and when Resident 2 stood up he was bleeding. RN 1 stated he called Resident 2's physician on 5/4/2025 (time unknown), left a voicemail and sent the physician a text message but he (RN 1) received no response from the physician. RN 1 stated he did not work the next day and was unsure if anyone followed up with Resident 2's physician. RN 1 stated he should have followed up with the physician or medical director when he received no response from Resident 2's physician. During an interview on 5/14/2025 at 12:13 p.m., Certified Nursing Assistant (CNA) 5 stated on 5/8/2025 she noticed Resident 2 was acting differently from the previous day (5/7/2025), he was sleepy all day, less talkative, only got up to eat meals then wanted to go back to bed. CNA 5 stated on 5/9/2025 Resident 2 did not want to eat breakfast or lunch, he was arousable but sleepy, he yelled and wanted to hit her when she tried to assist him back to bed. CNA 5 stated she notified licensed Vocational Nurse (LVN) 5 of Resident 2's sleepiness on 5/8/2025 and she notified RN 1 that Resident 2 did not want to eat on 5/9/2025 in the morning after breakfast. During an interview on 5/14/2025 at 12:31 p.m., LVN 4 stated on 5/4/2025 at approximately 7 p.m., she heard Resident 2 yelling for help, when she went to his room she observed him bleeding from his scalp. LVN 4 stated Resident 2 had an abrasion, a laceration and a small bump on his scalp. LVN 4 stated she did not call Resident 2's physician because RN 1 told her he would call the physician. LVN 4 stated she remembered receiving a report that Resident 2 had a fall on 5/4/2025. LVN 4 stated she was not told to withhold Resident 2's ASA and Plavix so she continued to administer both medications to Resident 2, as ordered, until 5/9/2025, when Resident 2 was transferred to the GACH. LVN 4 stated, typically when a resident falls, has a suspected head injury and was receiving blood thinners, an order for labs (a medical procedure where a sample of blood, urine, or other fluids or tissues are analyzed to help diagnose or monitor a health condition) and/or imaging diagnostics (use of various technologies to create visual pictures inside the body to help diagnose, treat, or monitor a health condition) is obtained to rule out possible bleeding to the brain. During an interview on 5/14/2025 at 2:34 p.m., the Director of Nursing (DON) stated the licensed nurses continued to administer blood thinners, Aspirin and Clopidogrel, to Resident 2 after the injury to his head on 5/4/2025. The DON stated the licensed nurses should have called Resident 2's physician to notify him of Resident 2's head injury and to obtain an order to hold the Aspirin and Clopidogrel. The DON stated blood thinners could cause excessive bleeding and a possible brain bleed. During an interview on 5/14/2025 at 4:44 p.m., LVN 3 stated on 5/4/2025 she worked 11p.m. to 7a.m., and was informed about Resident 2's accident by RN 1 and LVN 4. LVN 3 stated she did not call Resident 2's physician because she was told RN 1 already called him. During an interview on 5/14/2025 at 4:45 p.m., Nurse Practitioner (NP) 1 stated he did not remember any report about Resident 2. NP 1 stated if a Resident was on blood thinners, had an accident/head injury, he would have recommended sending Resident 2 out to the GACH for a CT scan (computed tomography, a diagnostic procedure that produces images inside of the body) to make sure there is no intracranial (inside the skull) bleeding. During an interview on 5/15/2025 at 9:32 a.m., the Physician Assistant (PA) 1 stated on 5/4/2025 he was on call covering for Resident 2's physician but did not receive any calls about Resident 2. PA 1 stated Resident 2 was receiving blood thinners and was 90% more likely to sustain a brain bleed than those who were not receiving blood thinners following a head injury. PA 1 stated had he been informed that Resident 2 had a head injury, he (Resident 2) would have been sent him to the hospital right away to get a CT scan to make sure he did not have a brain bleed. During an interview on 5/15/2025 at 2:50 p.m., Housekeeping (HK) 1 stated on 5/4/2025 he was asked by Certified Nursing Assistant (CNA) 6 to clean Resident 2's room. HK 1 stated he went to Resident 2's room and observed a shelf (at the foot of Resident 3/s bed), and approximately six inches in front of the shelf was a puddle of blood with a towel placed over it. HK 1 stated the blood on the floor was approximately the size of a baseball with little drops of blood scattered around the it. HK 1 stated he did not see blood on the shelf but stated he was not sure if anyone had already cleaned it from the shelf. A review of the facility's undated P/P titled "Change in Resident's Condition of Status" indicated the nurse will notify the attending physician or physician on call within 24 hours (except in medical emergencies) when there has been an accident, a significant change in the resident's physical/emotional/mental condition, and the need to transfer to the hospital. The P/P indicated prior to notifying the physician the nurse will make detailed observations and gather pertinent relevant information. During a review of the facility's P/P titled "Accidents and Incidents-Investigating and Reporting" dated 3/2018, the P/P indicated the nurse supervisor, charge nurse, or department director shall document the time of the injured person's attending physician being notified, as well as the time the physician responded and his or her instructions. The facility failed to: 1. Notify Resident 2's physician when Resident 2, who was receiving ASA and Plavix, sustained a head injury on 5/4/2025, that resulted in an abrasion, a laceration, and a small bump with substantial bleeding to his head. 2. Notify Resident 2's physician following Resident 2's head injury, to obtain an order for the discontinuance of ASA and Plavix to prevent bleeding in the resident's brain. Resident 2 continued to receive blood thinners from 5/4/2024 through 5/9/2025 daily. 3. Notify Resident 2's physician following Resident 2's head injury (5/4/2025), when Resident 2 exhibited noticeable changes in behavior that included decrease in appetite, drowsiness, and less talkative, which were not his typical behaviors. 4. Follow