Health inspection·September 18, 2025

§483.10(g)(14) Notification of Changes (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) §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 - (i) The services that are to be furnished to attain or maintain the resident's highest §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. §72311. Nursing Service-General. (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. On 7/28/2025, the California Health Department of Public Health (CDPH) received a complaint alleging two residents were sent to an Intensive Care Unit ([ICU] due to the facility's neglect. On 7/29/2025, CDPH conducted an unannounced visit at the facility to investigate the complaint allegation. During the investigation, CDPH determined the facility failed to notify the attending physician when Residents 1, 2, 3, and 4 had a change of condition (COC). The facility failed to: 1. Notify the attending physician of Resident 1, Resident 3, and Resident 4's electrocardiogram ([EKG/ECG] a test that measures the electrical activity of the heart) results. 2. Notify the attending physician when Resident 2 reported lightheadedness, weakness and feeling dizzy when ambulating to the bathroom on 6/20/2025. 3. Ensure the facility's staff followed the facility's Policy and Procedure (P/P), titled, "Change in a Resident's Condition or Status" dated 2/2021, that indicated the nurse will notify the resident's attending physician on call when there has been a significant change in the resident's physical/emotional/mental condition. 4. Ensure the facility's staff followed the facility's P/P titled, "Lab and Diagnostic Test Results- Clinical" dated 11/2018, that indicated a physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent. The facility staff should document information about when, how, and to whom the information was provided and the response. The documentation should be done in the progress notes section of the medical record and not on the lab results report, because the test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directives, and prognosis. These failures resulted in: 1. Resident 2 experiencing an altered level of consciousness (ALOC) on 6/24/2025 of bradycardia (a slow HR, reference range 60-100 bpm) of 48 bpm, hypotension (low blood pressure, below 90/60 mmHg) of 86/40, bradypnea (slow breathing, below 12 breaths per minute) of 14 breaths per minute, and a critically high Potassium level of 7.3 millimoles ([mmol] per liter ([L] (reference range 3.5 to 5.2 mEq/L) leading to his transfer to a General Acute Care Hospital (GACH) on 6/24/2025 where he was admitted to the Intensive Care Unit (ICU) and received STAT dialysis. 2. Resident 1's physician not being aware of Resident 1's abnormal EKG results until two days after the EKG was conducted. 3. Resident 3 and Resident 4's physicians not being aware of Resident 3 and Resident 4's EKG results for over two months after their EKGs were conducted. Cardiology consultations for follow up related to Resident 3 and Resident 4's abnormal EKG results were ordered on 7/13/2025. a. A review of Resident 2's Admission Record (Face Sheet) indicated Resident 2, a 47 year old male, was admitted to the facility on 2/11/2025 with diagnoses including type 2 diabetes mellitus (DM) and diabetic chronic kidney disease (CKD). A review of Resident 2's Minimum Date Set ([MDS] a resident assessment tool) dated 7/15/2025 indicated Resident 2's cognition was intact. A review of Resident 2's untitled Care Plan dated 5/26/2025 indicated Resident 2 had anemia and was at risk for weakness, fatigue and dizziness. The goal of this care plan was to minimize the signs and symptoms (s/s) and complications related to anemia. The Care Plan's interventions included monitoring Resident 2 for s/s of anemia including dizziness, syncope (a temporary loss of consciousness and muscle control, commonly known as fainting), and weakness, and to report to Resident 2's physician as needed. A review of Resident 2's untitled Care Plan dated 5/26/2025 indicated Resident 2 was on diuretic therapy related to hypertension (HTN). The goal of this Care Plan was for Resident 2 to be free from discomfort or adverse reactions related to diuretic use. The Care Plan's interventions included monitoring Resident 2 and observing for possible side effects such as dizziness, fatigue, falls, and reporting to Resident 2's physician. A review of Resident 2's Untitled Care Plan dated 2/11/2025 indicated Resident 2 had DM. The goal of the Care Plan was to minimize Resident 2's risk for complications related to DM. The Care Plan's interventions included monitoring/documenting/reporting as needed s/s of hyperglycemia (increased b/s) including increase in thirst, headaches, trouble concentrating, blurred vision, frequent urination, fatigue, and weight loss and s/s of hypoglycemia (low blood sugar [b/s]) including sweating, tremors (shaking), increased heart rate (HR), pallor (pale skin), nervousness, confusion, slurred speech, lack of coordination, and a staggering gait. A review of Resident 2's Nursing Progress Note dated 6/20/2025 and timed at 3:49 p.m., indicated Resident 2 experienced an episode of lightheadedness and weakness while using the restroom, verbalizing, "I feel dizzy and weak." The Nursing Progress Note contained no information or comment indicating that Resident 2's complaints of lightheadedness, dizziness and weakness were reported to Resident 2's physician. A review of Resident 2's Change of Condition (COC) form dated 6/22/2025 and timed at 1:40 p.m., indicated Resident 2 had three episodes of loose stool, he felt weak and requested to have labs (laboratory tests) drawn. The COC form indicated Resident 2's physician ordered a complete blood count ([CBC] a blood test that measures parts of the blood), a comprehensive metabolic panel ([CMP] a blood test that measures a variety of substances in the blood), and a urinalysis ([UA] a test that analyzes the urine's chemical contents and the types and amounts of cells it contains). A review of Resident 2's Physician's Order dated 6/22/2025 indicated to obtain a CBC, CMP, and UA. A review of Resident 2's Nursing Progress Note dated 6/22/2025 and timed at 3:46 p.m., indicated Resident 2 was withdrawn (socially detached and unresponsive) and reported he felt weak. A review of Resident 2's Nursing Progress Note dated 6/22/2025 and timed at 11:20 p.m., indicated Resident 2 appeared to be sleepy and reported he felt weak. A review of Resident 2's Lab Results Report dated 6/23/2025 indicated the following: 1. Blood Urea Nitrogen ([BUN] a waste product that forms in the liver when the body breaks down protein) - 132 milligrams ([mg]- metric unit of measurement, used for medication dosage and/or amount)/per deciliter ([dl] a unit of measurement) (reference range 6-20 mg/dl) indicating a critical result (a laboratory value that indicates a potentially life-threatening patient condition, requiring immediate notification to a responsible healthcare professional). 2. Potassium 7.3 mmol/L indicating a critical result. 3. Carbon Dioxide (a waste product produced when the body breaks down food for energy) - 6 mEq/L (reference range 23-29 mEq/L) indicating a critical result. Continued review of Resident 2's Lab Results Report indicated the laboratory called the facility and relayed the critical lab values to Licensed Vocational Nurse (LVN) 2 on 6/23/2025 at 11:22 p.m. A review of Resident 2's Nursing Progress Note dated 6/24/2025 and timed at 4:45 a.m., indicated at 12:02 a.m., Resident 2 was assessed with an ALOC, bradycardia, hypotension, bradypnea, and a critically high potassium level at 7.2 mmol/L. The Nursing Progress Note indicated emergency services were called and Resident 2 was transferred to the GACH. A review of the Ambulance Record dated 6/24/2025 indicated emergency services were called because Resident 2 was hypotensive and bradycardic and staff were unable to wake him. The Ambulance Record indicated Resident 2 was lethargic with generalized weakness and was slow in answering questions. The Ambulance Record indicated Resident 2's blood pressure (BP) was 82/40 (normal BP 120/80) and his HR was 49 beats per minute (bpm) (reference range 60-100 bpm). A review of the GACH's Face Sheet indicated Resident 2 was admitted to the GACH on 6/24/2025 at 12:24 a.m. A review of the GACH's History and Physical (H&P) dated 6/24/2025 indicated Resident 2 was lethargic with a HR of 47 bpm and a BP of 92/41. The H&P indicated Resident 2 had severe hyperkalemia (high potassium), metabolic acidosis (the buildup of acid in the body due to kidney disease or kidney failure) and acute renal failure (a sudden and rapid loss of the kidneys' ability to filter waste and maintain proper fluid and electrolyte balance in the body). The H&P indicated Resident 2 was admitted to the ICU and STAT dialysis was conducted. During an interview on 7/31/2025 at 2:35 p.m., the Clinical Mentor (CM) stated if a resident experiences a change from their usual state, the COC should be reported to the physician. The CM stated when a COC is reported to the physician, the facility staff should document the physician's response/instructions in the resident's medical record. The CM stated failure to report a resident's COC could result in a delay of care and treatment. During an interview on 7/29/2025 at 2:34 p.m., Resident 2 stated ten days before he was transferred to the GACH, he was feeling tired and was not eating well but he thought it was normal because of his diabetes. Resident 2 stated he was told by facility staff to wait for the physician to come and see him, but the physician did not come. During an interview on 7/31/2025 at 3:39 p.m., LVN 1 stated on 6/20/2025 Resident 2 reported he felt weak and was dizzy when he walked to the restroom. LVN 1 stated his report of being weak and dizzy was not normal for Resident 2, so she assessed his vital signs, which were stable, so she did not notify Resident 2's physician that Resident 2 was complaining of feeling weak and dizzy. Registered Nurse (RN) 2 also assessed Resident 2 and advised her (LVN 1) to monitor Resident 2 throughout the shift. RN 2 did not instruct her to notify Resident 2's physician. During an interview on 7/31/2025 at 4:33p.m., Resident 2's Physician stated lab tests were ordered on 6/22/2025 due to the facility staff reporting Resident 2's COC of feeling weak. Resident 2's Physician stated he was not aware of Resident 2's COC on 6/20/2022. A review of the facility's Job Description, titled "Charge Nurse" the Job Description indicated one of the duties and responsibilities of the charge nurse included coordinating with the resident's physician in the care of the resident including notification upon change of condition. 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 the nurse will notify the resident's attending physician on call when there has been a significant change in the resident's physical/emotional/mental condition. A "significant change" of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. b. A review of Resident 1's Admission Record (Face Sheet), indicated a 74 year old female, was admitted to the facility on 1/16/2025 with the diagnoses including CKD and DM. A review of Resident 1's MDS dated 5/5/2025 indicated Resident 1's cognition was intact. A review of Resident 1's untitled Care Plan, dated 4/15/2023 indicated Resident 1 had gastroesophageal reflux disease (GERD). The goal of the Care Plan was to minimize the complications related to GERD as manifested by nausea and vomiting, stomach pain, vomiting blood, and tarry stools. The Care Plan's intervention included obtaining and monitoring laboratory/diagnostic work as ordered, report results of the labs/diagnostic work to the physician and follow up as indicated. A review of Resident 1's Physician's Order dated 6/10/2025 indicated to conduct a 12 lead EKG due to Resident 1's intermittent chest discomfort. A review of Resident 1's EKG results dated 6/11/2025 and timed at 7:30 a.m. indicated a diagnosis of an abnormal heart rhythm, low voltage QRS (the electrical signals generated by the heart are weaker than what is typically considered normal), consider pulmonary (lung) disease, possible anterior myocardial infarction ([MI] heart attack), and age undetermined. During an interview on 7/30/2025 at 3:34 p.m., Registered Nurse (RN) 1 stated EKG results were usually sent to the physician via text message. RN 1 checked the facility's mobile phone's message history and could not find any message sent to Resident 1's physician regarding Resident 1's EKG results on 6/11/2025, nor could she find documentation in Resident 1's clinical record to indicate Resident 1's physician was notified of Resident 1's EKG results. During an interview on 8/8/2025 at 12:39 p.m., Resident 1's physician stated he reviewed Resident 1's EKG results one to two days after the EKG was conducted and he did not remember how he received the EKG results. c. A review of Resident 3's Admission Record (Face Sheet), indicated a 80 year old male, was admitted to the facility on 5/15/2025 with diagnoses including atherosclerotic heart disease and the presence of a cardiac pacemaker. A review of Resident 3's MDS dated 5/30/2025 indicated Resident 3's cognition was moderately intact. A review of Resident 3's untitled Care Plan dated 5/8/2025 indicated Resident 3 had a low battery in his pacemaker. The Care Plan's goals indicated Resident 3 would have a normal BP, a normal HR and heart rhythm. The Care Plan's interventions included assessing Resident 3's cardiac function and for Resident 3's HR to be above 60 bpm. A review of Resident 3's Physician's Order dated 5/8/2025 indicated to conduct an EKG on Resident 3 related to Resident 3's pacemaker. A review of Resident 3's Nursing Progress Note dated 7/31/2025 and timed at 12:54 p.m. (two months, three weeks and two days after the order for an EKG was placed) indicated Resident 3's EKG results, which were completed in 5/2025, were relayed to Resident 3's physician on 7/31/25. A review of Resident 3's Nursing Progress Note dated 7/31/2025 and timed at 1:15 p.m. indicated Resident 3's physician ordered a cardiology consultation to follow up on Resident 3's pacemaker. A review of Resident 3's Physician's Order dated 7/31/2025 indicated a cardiology consultation for Resident 3's pacemaker follow up. During an interview on 7/31/2025 at 1:31 p.m., LVN 3 stated after reviewin