Health inspection·November 25, 2025

§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. §483.50(a)(2)(ii) The facility must- (ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders. §72301(d) Written arrangements shall be made for obtaining all necessary diagnostic and therapeutic services prescribed by the attending physician, podiatrist, dentist, or clinical psychologist subject to the scope of licensure and the polices of the facility. If the service cannot be brought into the facility, the facility shall assist the patient in arranging for transportation to and from the service location. § 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 10/3/2025, the California Department of Health (CDPH) received a complaint alleging facility staff waited days to follow up on laboratory (lab) results that indicated a resident (Resident 1) had a urinary tract infection ([UTI] an infection in the bladder/urinary tract). On 10/16/2025, CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. Upon investigation, CDPH determined Resident 1 had an order for a STAT (immediate) comprehensive metabolic panel ([CMP] a blood test that measures the overall health including metabolism, liver and kidney functions and electrolyte levels), a complete blood count ([CBC] a blood test that measures various components of the blood to assess overall health and detect potential medical conditions) and a urinalysis ([UA] a lab test that examines a urine sample to detect and assess various health conditions) with a culture and sensitivity ([C&S] a test that identifies the specific germ(s) causing an infection and determines which medication will be most effective in treating it) on 9/24/2025. The final lab results were completed on 9/26/2025 at 7:19 p.m., but the lab results were not reported to Resident 1's physician until 9/28/2025. The facility failed to: 1. Ensure Resident 1's lab results were promptly reported to Resident 1's physician. 2. Ensure facility staff implemented Resident 1's Care Plan, dated 10/8/2024 and revised 2/5/2025, that indicated to notify Resident 1's physician of signs and symptoms (s/s) of a UTI. 3. Ensure the facility followed their Policies and Procedure (P/P), titled "Diagnostic Test Results Notification" revised 4/2025, that indicated the facility shall promptly notify the ordering physician of the residents' laboratory results and such effort shall be documented in the resident's clinical record. As a result of these deficient practices, Resident 1 did not receive medication to treat the reported UTI until 9/28/2025, two days after the lab results were reported to the facility and had the potential for Resident 1's infection to worsen and cause more serious complications, such as a kidney infection and/or a life-threatening bloodstream infection. A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1, a 77-year-old female, was admitted to the facility on 7/29/2025 with a diagnosis of a UTI. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 8/6/2025, indicated Resident 1 was able to make decisions that were reasonable and consistent and required a one person assist to complete her activities of daily living ([ADLs] routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 1's Care Plan, dated 10/8/2024 and revised 2/5/2025, indicated Resident 1 was at risk for a UTI and urinary retention (inability to empty the bladder completely or partially). The goal of the Care Plan was for Resident 1 to be able to urinate adequate amounts of urine with no discomfort or abdominal distention (swelling of the abdomen due to buildup of gas, fluids or digestive contents). The Care Plan's interventions included notifying Resident 1's physician of signs and symptoms (s/s) of a UTI. A review of Resident 1's Change of Condition (COC) form dated 9/24/2025 and timed at 2:20 p.m., indicated Resident 1 experienced a runny nose and headache and the physician ordered a CBC, CMP and UA with a C&S. A review of Resident 1's Order Summary (Physician's Order) dated 9/24/2025, indicated to obtain a STAT CBC, CMP, UA and C&S. A review of Resident 1's Laboratory Test Results, dated 9/26/2025 indicated Resident 1's labs were collected on 9/24/2025 at 3:56 p.m., and the results were reported to the facility on 9/26/2025 at 7:21 p.m. The Laboratory Test Results indicated the following abnormal values: a. Anion gap (determines the blood acidity) - 6 millimoles (mmol)/per liter(L) (reference range 7 to 15 mmol/L. b. Calcium (a mineral in the body) - 8.6 milligrams (mg)/ per deciliter(dl) (reference range 8.7 to 10.4 mg/dl. c. Glucose (blood sugar [b/s]) - 67 mg/dl (reference range 74 to 106 mg/dl) d. Potassium (a mineral in the body) - 5.4 mmol/L (reference range 3.5 to 5.1 mmol/L e. Immunoglobulin percentage (a protein produced to fight infection) - 0.3% (reference range 0.0 to 0.1%) f. Mean corpuscular hemoglobin concentration (a measurement of the average amount of hemoglobin [a protein found in red blood cells]) - 30.6 grams per deciliter (g/dl) (reference range 32.2 to 35.5 g/dl) g. Mean corpuscular volume (a blood test that measures the average size of the red blood cells) - 98.70 femtoliters (fl) (reference range 79.40 to 94.80 fl. h. Absolute monocyte count (a test that measures the number of monocytes [a type of white blood cell]) - 0.69 (reference range 0.24 to 0.26) i. Red blood cell (specialized cells in the body that carry oxygen from the lungs to the tissues) - 3.87 (reference range 3.93 to 5.22) j. Red cell distribution width (a measurement of the variation in size of red blood cells) - 15.4% (reference range 11.7 to 14.4%) k. Urinalysis test result indicated the following: 1.Trace amount of blood in the urine (reference range negative) 2. Turbid (cloudy, not clear) (reference range clear) 3. Leukocytes (white blood cells) 3+ (reference range negative). k. C&S - over a hundred thousand Citrobacter Freundii organisms (a bacteria found in the intestines of human beings and animals that causes various infections such as UTI and sepsis) and the list of antibiotics compatible to treat the UTI. A review of Resident 1's Nursing Progress Notes, dated 9/28/2025 indicated Resident 1's physician was notified of Resident 1's lab results on 9/28/2025 at 3:26 p.m. (two days after the facility was made aware of the lab results on 9/26/2025). The Nursing Progress Note indicated Resident 1 was prescribed an antibiotic for a UTI on 9/28/2028. During an interview on 10/16/2025 at 11:44 a.m., Resident 1 stated she was having urinary discomfort when she urinated the previous month (9/2025), and her physician ordered lab tests and a urine exam. Resident 1 stated she continued to feel weaker and uncomfortable when urinating, so she asked the licensed nurses to follow up with the results of her lab tests. During an interview on 10/16/2025 at 12:36 p.m., Registered Nurse Supervisor (RNS) 1 stated she checked for Resident 1's lab results during the 7 a.m. to 3 p.m. shift on 9/26/2025 and they were not available, so she endorsed that the labs were pending to Licensed Vocational Nurse (LVN) 2 and asked her to follow up and call the physician once the lab results were available. During a telephone interview on 10/16/2025 at 1:24 p.m., LVN 2 stated she worked on 9/26/2025 during the 7 a.m. to 3 p.m. shift as well as the 3 p.m. to 11 p.m. shift. LVN 2 stated RNS 1 reported to her that Resident 1's lab results were still pending and when they were available, RNS 1 asked her to report the results to Resident 1's physician. LVN 2 stated she did not check Resident 1's lab results during her shift (3 p.m. to 11 p.m.) but she did ask LVN 3, who worked during the 11 p.m. to 7 a.m. shift to follow up. During a subsequent interview on 10/17/2025 at 12:28 p.m., LVN 2 stated on 9/27/2025 Resident 1's Family Member (FM 1) asked her about Resident 1's lab results and she (LVN 2) texted Resident 1's physician to ask if he had received Resident 1's lab results. LVN 2 stated Resident 1's physician responded to her text, asking "what lab results?" LVN 2 stated she did not remember to send the lab results to Resident 1's physician. LVN 2 stated she could not remember if she reported to the incoming shift (11 p.m. to 7 a.m.) nurses (LVN 4 or RNS 2) to follow up with the results of Resident 1's labs and if they were available to send the lab results to Resident 1's physician. LVN 2 stated she should have checked to see if Resident 1's lab results were available on 9/26/2025 and if they were available, she should have notified Resident 1's physician so there was no delay in Resident 1's care. During a telephone interview on 10/17/2025 at 7:15 a.m., RNS 2 stated she worked on 9/26/2025 and 9/27/2025 during the 11 p.m. to 7 a.m. shift but she received no report from LVN 2, LVN 3 or LVN 4 regarding Resident 1's labs. During a telephone interview on 10/17/2025 at 8:37 a.m., LVN 4 stated she was not given a verbal report by LVN 2 on 9/27/2025 related to Resident 1's lab results nor was there any written endorsement in the communication book. During a telephone interview on 10/17/2025 at 1:11 p.m., LVN 5 stated RNS 4 obtained Resident 1's lab results on 9/28/2025 during the 7 a.m. to 3 p.m. shift and she (RNS 4) texted the lab results to Resident 1's physician. LVN 5 stated after Resident 1's physician received the lab results he ordered antibiotics for Resident 1 because the lab results indicated Resident 1 had a UTI. During a telephone interview on 10/17/2025 at 2:04 p.m., Resident 1's physician stated he was not notified of Resident 1's lab results until 9/28/2025. Resident 1's physician stated the licensed nurses were expected to notify him of lab results, especially ones that were abnormal so there would be no delay in the residents' care and treatment. Resident 1's physician stated Resident 1 was at risk for worsening symptoms because she was not given prompt treatment for her UTI. During an interview on 10/17/2025 at 3:16 p.m., the Director of Nursing Services (DON) stated LVN 2 should have checked to see if Resident 1's lab results were available on 9/26/2025 when they were sent to the facility and sent the results to Resident 1's physician to obtain an order for treatment. The DON stated it was important for all licensed nurses in the facility to be aware of residents' pending labs and to report the results of the labs to the physician promptly so there would be no delay in the resident's care. A review of the facility's P/P titled, "Diagnostic Test Results Notification" revised 4/2025, indicated the facility shall promptly notify the ordering physician of the residents' laboratory results and such effort shall be documented in the resident's clinical record. The facility failed to: 1. Ensure Resident 1's lab results were promptly reported to Resident 1's physician. 2. Ensure facility staff implemented Resident 1's Care Plan, dated 10/8/2024 and revised 2/5/2025, that indicated to notify Resident 1's physician of s/s of a UTI. 2. Ensure the facility followed their P/P, titled "Diagnostic Test Results Notification" revised 4/2025, that indicated the facility shall promptly notify the ordering physician of the residents' laboratory results and such effort shall be documented in the resident's clinical record. As a result of these deficient practices, Resident 1 did not receive medication to treat the reported UTI until 9/28/2025, two days after the lab results were reported to the facility and had the potential for Resident 1's infection to worsen and cause more serious complications, such as a kidney infection and/or a life-threatening bloodstream infection. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 1.