Health inspection·December 26, 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 resident's choices, including but not limited to the following: Code of Federal Regulations, Title 42, Section 483.50(a)(2) Laboratory services (2) The facility must: (iii) 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. California Code of Regulations, Title 22, Section 72311. Nursing Service--General. (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. California Code of Regulations, Title 22, Section 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 9/11/2025, the California Department of Public Health (CDPH) received a complaint with multiple allegations of care issues for a resident (Resident 1). On 9/24/2025, CDPH conducted an unannounced visit to the facility to investigate the complaint allegations. During the investigation it was determined Resident 1 had labs drawn on 9/9/2025, the results of those labs (which were abnormal) were reported to Resident 1's physician via a text message on 9/9/2025 with a response of "OK" from the physician but no instructions for care. The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN) 1 relayed the results of Resident 1's abnormal laboratory (lab) tests results to the Resident 1's physician by phone call instead of text message. 2. Ensure LVN 1 followed up with Resident 1's physician to obtain instructions for Resident 1's care after the physician responded "OK" to the text message with abnormal lab results. 3. Ensure LVN 1 endorsed the abnormal lab results to the oncoming shift nurses for continuity of care and follow up with Resident 1's physician. 4. Ensure the facility followed their Policy and Procedure (P/P), titled, Laboratory, Diagnostic and Radiology Services" dated 10/1/2023, that indicated the primary care physician will be notified of results that fall outside of the clinical reference or expected normal ranges. These deficient practices resulted in Resident 1's physician not being made aware of Resident 1's abnormal lab results until 9/10/2025, after the abnormal labs were reported to the facility on 9/9/2025, and a delay in transferring Resident 1 to the GACH (9/10/2025). At the GACH Resident 1 was assessed and treated for severe dehydration (a life threatening emergency where the body has lost critical amounts of water and electrolytes that can cause serious damage to the kidneys, heart and brain), hypernatremia (a condition where the concentration of sodium in the body is abnormally high), and hypotension (a medical condition caused by low blood pressure). This deficient practice had the potential for more serious consequences related to Resident 1's abnormal lab results and delay in evaluation and treatment to occur. A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on 9/4/2025 with diagnosis including acute kidney failure (a condition when the kidneys lose their ability to remove waste and help balance fluids and electrolytes in the body), cerebral infarction (a condition where blood flow to the brain Is interrupted, causing brain tissue damage) and congestive heart failure ([CHF] a heart disorder which causes the heart not to pump the blood efficiently, sometimes resulting in leg swelling). A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 9/9/2025, indicated Resident 1 was unable to make decisions that were reasonable and consistent. A review of Resident 1's Physician Order dated 9/6/2025, indicated to obtain a Complete Blood Count ([CBC] a common blood test that counts and examines the types and numbers of blood cells to check for health problems), a Comprehensive Metabolic Panel ([CMP] a blood test that measures the overall health including metabolism, liver and kidney functions and electrolyte levels), a Hemoglobin A1C (a blood test that shows the average sugar level in the body for the past three months), a Keppra level (a blood test that measures the amount of an anti-seizure medication in the body), a digoxin level (a blood test that measure the amount of medication digoxin in the body) and a lipid panel (a blood test that measure different types of fats in the blood) for Resident 1 on 9/9/2025. A review of the Resident 1's Laboratory Results, dated 9/9/2025, drawn at 5:06 a.m., and reported to the facility at 1:32 p.m. (9/9/2025) indicated the following abnormal results: a. White Blood Cell Count ([WBC] a blood cell that helps attack infection or injury in the body) 10.7 cells per microliter (cells/mcl). Reference range is between 4.0 cell/ul to 10.5 cells/ul. b. Red Cell Distribution Width ([RDW] a test that measures the size of the red blood cells) of 15.3%. Reference range is between 11.6% to 14.4%. c. Mean Platelet Volume ([MPV] a test that measures the average size of the blood cells that stop bleeding) of 12.0 femtoliters (fl). Reference range is between 7.2 fl to 11.7 fl. d. Hemoglobin A1C (HgbA1C) of 6.6 percent. Reference range is between 4.6 to 5.6 percent. e. Digoxin level of 0.4 nanograms per deciliter (Ng/dl). Reference range is between 0.8 Ng/dl to 2.0 Ng/dl. f. Triglycerides (the main type of fat in the body) of 203 milligrams ([mg] a metric unit of measurement, used for medication dosage and/or amount)/per deciliter (mg/ dl). Reference range is less than 150 mg/dl. g. Neutrophils (the most common type of white blood cell) Absolute (the actual number of diseases fighting white blood cells) of 8.3 per mcl. Reference range is between 2.0 to 8.1 per mcl. i. Lymphocytes (a white blood cell that destroys bacteria and viruses) of 8.0 per mcl. Reference range is between 14.0 to 52.0 per mcl. j. Monocytes (a white blood cell that destroys germs and eliminates infected cells in the body) of 12.0%. Reference range is between 1.0% to 11.0%. k. Monocytes Absolute of 1.3 thou/mcl. Reference range is between 0.0 thou/ul to 0.8 thou/ul. l. Sodium ([Na] an electrolyte that regulates fluid levels, transmits nerve signals in the body and contract muscles) level of 158 millimoles/liter (mmol/l). Reference range is between 136 mmol/l to 145 mmol/l. m. Chloride ([Cl] an electrolyte that maintains the fluid balance, blood pressure and acid-base balance in the body) level of 112 mmol/l. Reference range is between 98 mmol/l - 107 mmol/l. n. Electrolyte Balance (a state of the body when there is the right amount of minerals) of 15 mmol/l. Reference range is between 2 mmol/l to 12 mmol/l. o. Glucose (blood sugar [b/s]) level of 358 mg/dl. Reference range is between 85 mg/dl to 125 mg/dl. p. Blood Urea Nitrogen ([BUN] a test that reveals the function of the kidneys) of 150 mg/dl. Reference range is between 7 mg/dl to 25 mg/dl. q. Creatinine (a waste product produced by muscle breakdown, which higher levels may indicate impaired kidney function) of 3.7 mg/dl. Reference range is between 0.7 mg/dl to 1.3 mg/dl. r. Glomerular Filtration Rate ([eGFR] a measurement of how well the kidneys filter waste from the blood) of 17 ml/minute/1.73 square meters (sq/m). Reference range is more than or equal to 60 ml/minute/1.73 sq/m. s. Albumin (a protein in the blood that maintains fluid balance in the body) of 4.0 grams (g)/dl. Reference range is between 4.2 g/dl to 5.5 g/dl. t. Aspartate Amino Transferase ([AST] a test used for monitoring the liver health overtime) of 201 u/l. Reference range between 13 u/l to 39 u/l. u. Alanine Aminotransferase ([ALT] a test done to identify potential liver problems) of 228 u/l. Reference range is between 7 u/l to 52 u/l. A review of Resident 1's Clinal Record, including Nursing Notes, Laboratory Results, and Physician Progress Notes, indicated there was no documentation indicating Resident 1's physician was notified of Resident 1's Laboratory Results dated 9/9/2025. A review of Resident 1's Change of Condition (COC) Evaluation dated 9/10/2025 and timed at 9:19 a.m., indicated Resident 1 had abnormal laboratory results and Resident 1's physician ordered Resident 1 to be transferred to a GACH. A review of Resident 1's Order Summary (Physician Orders) dated 9/10/2025, indicated to transfer Resident 1 to the GACH at 12 p.m., for further evaluation due to abnormal lab results. A review of Resident 1's Transfer Form dated 9/10/2025 and timed at 9:22 a.m., indicated Resident 1 had an unplanned transfer to a GACH due to abnormal kidney function. A review of the GACH's Emergency Note dated 9/10/2025 and timed at 12:56 p.m., indicated Resident 1 was assessed with dry mucous membranes (a thin, wet, tissue layer that lines body cavities and passages that open to the outside, such as the mouth, nose, digestive tract, and respiratory tract) and was sleepy with a blood pressure ([BP] of 91/61 (with a normal range of less than 120/80 millimeters of mercury (mmHg), and a heart rate (HR) of 44 beats per minute (bpm) (with a normal range between 60 to 100 bpm. The Emergency Note indicated Resident 1 had the following abnormal laboratory results in the GACH: 1. WBC - 11.1 uL. 2. Sodium- 157 mg/dl. 3. Potassium - 5.7 mg/dl. 4. Chloride- 114 mg/dl. 5. BUN - 174 mg/dl. 6. Creatinine level - 3.42 mg/d. 7. Random blood sugar - 226 mg/dl. 8. International Normalized Ratio ([INR] a measurement used to measure how long it takes a person's blood to clot) of 1.7 INR, with a normal range between 0.8 INR to 1.2 INR. 9. AST of 202 U/L. 10. ALT of 267 U/L. 11. Total Bilirubin (a test to check for liver damage or disease) 1.9 mg/dl. Reference range is 0.2 mg/dl to 1.2 mg/dl. A review of the GACH's History and Physical (H&P) dated 9/10/2025 and timed at 4 p.m., indicated Resident 1 was restless, unable to follow commands and dehydrated. The H&P indicated Resident 1 was admitted for further medical treatment due to severe dehydration, hypernatremia, hypotension and non-traumatic acute kidney injury. The H&P indicated, Resident 1 was given an intravenous ([IV] within or through the vein) bolus (a single, concentrated dose of medication or fluid given over a short period to achieve a rapid therapeutic effect to quickly raise the substance's concentration in the blood stream to an effective level) for hydration (the process of supplying water to the body, either by drinking fluids, eating water-rich foods or by medical means to ensure it has enough fluid to function properly), and IV fluid maintenance at 150 milliliters (ml)/per hour. During a telephone interview on 9/25/2025 at 12:33 p.m., Registered Nurse Supervisor (RNS) 3 stated that on 9/9/2025 during the 3 p.m. to 11 p.m. shift, she did not recall receiving any endorsement from the outgoing (7 a.m. to 3 p.m.) nurse related to Resident 1's laboratory results. RNS 3 stated it was the responsibility of the licensed nurses to report abnormal laboratory results to Resident 1's physician during the shift that the laboratory results were reported to the facility. During an interview on 9/25/2025 at 2:03 p.m., RNS 1 stated on 9/9/2025 during the 7 a.m. to 3 p.m. shift, Resident 1's laboratory results were still pending (not available) through the end of the shift. RNS 1 stated she should have documented in Resident 1's progress notes that she followed up on Resident 1's laboratory results. RNS 1 stated when she came back to work the next day (9/10/2025) at 7 a.m., she reviewed the lab results from the previous day (9/9/2025) and found Resident 1's physician had not given any instructions related to Resident 1's abnormal laboratory results. RNS 1 stated she immediately called Resident 1's physician and received orders to transfer Resident 1 to the GACH for evaluation and treatment because of the abnormal laboratory results received on 9/9/2025. During a telephone interview on 9/25/2025 at 3 p.m., Licensed Vocational Nurse (LVN) 1 stated on 9/9/2025 during the 3 p.m. to 11 p.m. shift, she printed Resident 1's laboratory results, took photos of the results and texted the photos to Resident 1's physician. LVN 1 stated she did not call Resident 1's physician despite the abnormal laboratory results because Resident 1's physician responded with a text message 'Ok," meaning the physician acknowledged receipt of the laboratory results. LVN 1 stated she communicated the results to RNS 3 as well. LVN 1 stated it was not necessary to document the laboratory results in Resident 1's progress notes because texting Resident 1's physician was enough, and texting the results of the labs was the only documentation the licensed nurses used to relay residents' laboratory results. During an interview on 9/25/2025 at 3:25 p.m., LVN 3 stated when she came to work on 9/9/2025 at 11 p.m., she was not given a report by the outgoing shift (3 p.m. to 11 p.m.) nurse to follow up with Resident 1's physician regarding pending laboratory results and there was no endorsements noted in the communication board (a digital display often integrated with the electronic health record, that provides real-time, patient specific information for patients, families and care teams) section of the facility's electronic medical record. During a telephone interview on 9/25/2025 at 3:40 p.m., Resident 1's physician stated the facility's licensed nurses know she does not want residents' laboratory results sent to her via text message. Resident 1's physician stated during the evening on 9/9/2025 she received Resident 1's laboratory results from the facility via a text message. Resident 1's physician stated she acknowledged she received the laboratory results on 9/9/2025, by saying "OK" but stated she was not able to review the laboratory results at that time. Resident 1's physician stated the facility's licensed nurses should have called her with Resident 1's abnormal laboratory results and she would have instructed the staff to transfer Resident 1 to the GACH immediately for evaluation and treatment. Resident 1's physician stated Resident 1's care was delayed when he was transferred to the GACH on 9/10/2025, the day after abnormal laboratory results were received on 9/9/2025. Resident 1's physician stated the delay in transferring her to the GACH could have had life threatening consequences. During an interview on 9/25/2025 at 3:45 p.m., the Director of Nursing (DON) stated Resident 1's physician prefers to be called and LVN 1 should have called Resident 1's physician to notify her of Resident 1's abnormal laboratory results in a timely manner and obtain instructions for care on 9/9/2025, when the abnormal laboratory results were received to prevent a delay in care and to prevent possible complications. During an interview on 9/25/2025 at 5:01 p.m., the Administrator (ADM) stated all licensed nurses at the facility were expected to call any abnormal laboratory results to the residents' physician to ensure there was no delay in residents receiving care. A review of the facility's P/P titled, "Laboratory, Diagnostic and Radiology Services" dated 10/1/2023, indicated the primary care physician will be notified of results that fall outside of the clinical reference or expected normal ranges. The facility failed to: 1. Ensure LVN 1 relayed the results of Resident 1's abnormal laboratory (lab) tests results to the resident's physician by phone call instead of text