Health inspection·October 22, 2025

§483.10(g)(14) 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— (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); §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. On 8/26/2025 and 9/2/2025, the California Department of Public Health (CDPH) received two complaints alleging a resident (Resident) 1 complained of difficulty breathing, coughing and congestion and no one came to assess his condition. When instructions were given to send Resident 1 to a General Acute Care Hospital (GACH) he was not transferred for over 24 hours and at the GACH he was diagnosed with COVID 19 and pneumonia. On 9/8/2025, CDPH conducted an unannounced visit to the facility to investigate both complaint allegations. During the investigation, CDPH determined Resident 1, who had a history of amyotrophic lateral sclerosis ([ALS] a progressive disease that leads to muscle weakness and eventual loss of the ability to move, speak, swallow, or breathe) complained of difficulty breathing on 8/20/2025 and felt he might choke. The facility failed to: 1. Follow up with Resident 1’s physician and/or the facility’s Medical Director when Resident 1’s physician did not respond for greater than eight hour to Licensed Vocational Nurse (LVN) 1’s text message on 8/20/2025 informing him of Resident 1’s change of condition (COC). 2. Ensure Resident 1’s COC relayed by LVN 1 to Resident 1’s physician, via text message, was transmitted in its entirety and documentation of the interaction with the physician, including time of the text message, method of communication and endorsement to other staff, was completed in accordance with the facility’s Policy and Procedure (P/P), titled, “Change of Condition Notification, dated 10/1/2023, which indicated “…The licensed nurse will document the time the attending physician was contacted, the method by which he/she was contacted, response time and whether orders were received.” 3. Ensure Resident 1’s physician was available, responded, and gave instructions for care when text messages were sent to him concerning Resident 1’s COC. 4. Follow the facility’s P/P, titled, “Change of Condition Notification, dated 10/1/2023, that indicated “…. The Licensed Nurse will immediately call the attending physician, if the LVN is unable to reach the attending physician or the physician on call during emergency situations, she will notify the facility’s medical director. The licensed nurse will document the time the attending physician was contacted, the method by which he/she was contacted, response time and whether orders were received. 5. Follow the facility’s P/P, titled, “Physician Services and Visits” dated 10/1/2023, that indicated the facility provides residents with care under an Attending physician. The physician services include ……providing consultation or treatment when called by the facility and provision for alternate physician coverage in the event the Attending physician is not available. These deficient practices resulted in Resident 1 feeling increased anxiety due to his shortness of breath (SOB) and feeling like he was choking. These deficient practices resulted in a delay in Resident 1’s care and treatment and the inability to ascertain, via documentation, the sequence of events related to the contact with Resident 1’s physician’s and the physician’s response. Resident 1 was eventually transferred to a GACH for difficulty breathing. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was initially admitted to the facility on 4/28/2025 and readmitted on 9/1/2025 with diagnoses including ALS, diabetes type 2 (DM) and major depressive disorder. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 8/8/2025, indicated Resident 1 was cognitively intact and had the ability to understand and be understood by others. A review of Resident 1’s Nurses Notes, dated 8/20/2025 and timed at 12:45 a.m., indicated at the beginning of the shift (11 a.m. to 7 a.m.). Resident 1 complained of a headache and requested to have his blood pressure (B/P) checked which was 117/86 (reference for normal B/P is 120/80 - 129/84). Resident 1 then complained of a cough and congestion. The Nurses Note indicated Resident 1 was administered Ibuprofen ([Motrin] a medication used to treat mild pain) at 12:11 a.m., for a headache and at 2:15 a.m., Cepacol (a medication used to treat a sore throat) for a sore throat. The Nurses Note indicated Resident 1 wanted to lie down but voiced fear of choking and wished to remain sitting for the remainder of shift. The Nurses Note indicated Resident 1’s physician was notified of Resident 1’s complaints of congestion and cough via text messages at 12:22 a.m. and 3:40 a.m., only, and not about that the resident feeling he might choke or his B/P. A review of Resident 1’s Change of Condition (COC) form, dated 8/20/2025 and timed at 3:41 a.m., indicated Resident 1 had a cough and congestion. A review of the Charge Nurse’s Cell Phone Log, dated 8/20/2025, indicated LVN 1 sent text messages to Resident 1’s physician related to Resident 1’s symptoms of a cough and congestion on 8/20/2025 at 12:22 a.m. and again at 3:40 a.m. The Charge Nurse’s Cell Phone Log indicated Resident 1’s physician responded via text message on 8/20/2025 at 8:56 a.m. (over eight hours after the first text message was sent to him). A review of Resident 1’s Nurses Notes dated 8/21/2025 and timed at 7:10 a.m., indicated Resident 1’s family called 911 because Resident 1 was not feeling well The Nurses Note indicated on 8/21/2025 paramedics arrived at the facility (8/21/2025) and transferred Resident 1 to the GACH. A review of the GACH’s Face Sheet, indicated Resident 1 was admitted to GACH on 8/21/2025 at 11:14 a.m., with diagnoses including pneumonia, secondary to the Covid 19 virus, and hypoxia (low levels of oxygen in body tissue causing symptoms like restlessness and difficulty breathing). During an interview on 9/8/2025 at 10:30 a.m., Resident 1 stated on 8/20/2025 shortly after 12 a.m., he was feeling short of breath and was afraid to lie down in bed because he was afraid he might choke. Resident 1 stated he asked LVN 1 to call his physician to inform the physician that he (Resident 1) was having difficulty breathing and was SOB. Resident 1 stated for the majority of the 11 p.m. – 7 a.m. shift on 8/20/2025, he sat up on the edge of his bed or in a wheelchair because it helped him breathe. Resident 1 stated LVN 1 gave him pain medicine for his headache and cough drops for his throat which really didn’t help. Resident 1 stated he felt increasingly anxious and nervous and thought the nursing staff did not believe he was having difficulty breathing. Resident 1 stated his family called 911 on 8/21/2025 and he was transferred to the GACH on 8/21/2025 at approximately 7 a.m. During a telephone interview on 9/9/2025 at 12:10 a.m., LVN 1 stated on 8/20/2025 at approximately 12 a.m., she observed Resident 1 with a cough and congestion, he was restless and agitated but did not appear to be SOB. LVN 1 stated Resident 1 did not want to lay in bed because he thought he might choke. LVN 1 stated this was the first time she observed Resident 1 in this condition, so she initiated a COC by texting Resident 1’s physician via the nurse supervisor’s cell phone to notify him that Resident 1 had a cough and congestion. LVN 1 stated she did not notify Resident 1’s physician that Resident 1 felt like he was choking. LVN 1 stated Resident 1’s physician did not respond during her shift (11 p.m. - 7 a.m.) so she endorsed Resident 1’s care to the oncoming nurse (7 a.m. – 3 p.m.). LVN 1 stated she should have followed up with Resident 1’s physician when he did not respond to the text messages, notified the Medical Director and/or the Director of Nursing (DON). During an interview on 9/10/2025 at 1 p.m., Resident 1’s physician stated he received text messages from the facility nursing staff at approximately 12:30 a.m., and 3:30 a.m., on 8/20/2025 regarding Resident 1’s cough and congestion but he was not informed that Resident 1 felt like he was choking. Resident 1’s physician stated he did not know why he did not respond to the text messages until almost 9 a.m., same day. Resident 1’s physician stated if the nursing staff had reported that Resident 1 felt like he was choking, he would have ordered different interventions, such as an Xray and/or transferred Resident 1 to the GACH. During an interview on 9/10/2025 at 2:20 p.m., the DON stated physicians should be available to respond to calls or text messages from the nursing staff 24 hours a day to meet the needs of the residents. The DON stated when LVN 1 did not receive a response from Resident 1’s physician she should have called her (DON) or the Medical Director. A review of the facility’s P/P, titled, “Change of Condition Notification” dated 10/1/2023, indicated the purpose of the policy is to ensure residents, family, legal representative and physicians are informed of changes in the resident’s condition in a timely manner. The P/P indicated the attending physician will be notified in a timely with a resident’s change in condition, the notification to the attending physician will include a summary of the condition change and an assessment of the resident’s vital signs and system review focusing on the condition and or signs and symptoms for which the notification is required, in emergency situations (resident is experiencing unexpected shortness of breath, intense pain, unexpected bleeding, serious abnormal labs or x-ray), the Licensed Nurse will immediately call the attending physician, if the LVN is unable to reach the attending physician or the physician on call during emergency situations, she will notify the facility’s medical director. The P/P indicated the licensed nurse will document the time the attending physician was contacted, the method by which he/she was contacted, response time and whether orders were received. A review of the facility’s policy, and procedure (P/P) titled, “Physician Services and Visits” dated 10/1/2023, the P/P indicated the purpose of the policy is to ensure that the facility provides residents with care under an Attending Physician. The P/P indicated physician services include ……providing consultation or treatment when called by the facility and provision for alternate physician coverage in the event the Attending physician is not available. The facility failed to: 1. Follow up with Resident 1’s physician and/or the facility’s Medical Director when Resident 1’s physician did not respond for greater than eight hour to LVN 1’s text message on 8/20/2025 informing him of Resident 1’s COC. 2. Ensure Resident 1’s COC relayed by LVN 1 to Resident 1’s physician, via text message, was transmitted in its entirety and documentation of the interaction with the physician, including time of the text message, method of communication and endorsement to other staff, was completed in accordance with the facility’s P/P titled, “Change of Condition Notification, dated 10/1/2023, which indicated “…The licensed nurse will document the time the attending physician was contacted, the method by which he/she was contacted, response time and whether orders were received.” 3. Ensure Resident 1’s physician was available, responded, and gave instructions for care when text messages were sent to him concerning Resident 1’s COC. 4. Follow the facility’s P/P, titled, “Change of Condition Notification, dated 10/1/2023, that indicated “…. The Licensed Nurse will immediately call the attending physician, if the LVN is unable to reach the attending physician or the physician on call during emergency situations, she will notify the facility’s medical director. The licensed nurse will document the time the attending physician was contacted, the method by which he/she was contacted, response time and whether orders were received. 5. Follow the facility’s P/P, titled, “Physician Services and Visits” dated 10/1/2023, that indicated the facility provides residents with care under an Attending physician. The physician services include ……providing consultation or treatment when called by the facility and provision for alternate physician coverage in the event the Attending physician is not available. These deficient practices resulted in Resident 1 feeling increased anxiety due to his SOB and feeling like he was choking. These deficient practices resulted in a delay in Resident 1’s care and treatment and the inability to ascertain, via documentation, the sequence of events related to the contact with Resident 1’s physician’s and the physician’s response. Resident 1 was eventually transferred to a GACH for difficulty breathing. These failures had direct or immediate relationship to the health, safety, or security of Resident.