Health inspection·August 14, 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 residents’ choices, including but not limited to the following: California Code of Regulations, Title 22, Section 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. 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 7/1/2025, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to the facility to investigate a complaint regarding quality of care and treatment involving Resident 1. As a result of the investigation, the Department determined the facility failed to promptly identify signs and symptoms (S/S) of a urinary tract infection (UTI) for Resident 1 when the facility did not monitor Resident 1’s vital signs every shift according to Resident 1’s care plan for UTI, dated 1/23/2025. As a result of these failures, Resident 1 was transferred to General Acute Care Hospital (GACH) 1 from the facility, on 6/4/2025 at 10:06 pm, with urosepsis (a severe complication of an untreated urinary tract infection and can lead to organ damage, failure, and even death if not treated quickly). A review of Resident 1’s Admission Record (AR), indicated facility admitted Resident 1, a 58-year-old female, on 12/23/2024, with diagnoses that included encephalopathy, dementia, and anxiety. The AR indicated resident 1 did not have a diagnosis of UTI. A review of Resident 1’s History and Physical Examination, dated 12/20/2024, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set, dated 3/25/2025, indicated Resident 1’s cognitive skills were severely impaired, Resident 1 required partial/moderate assistance from staff for personal hygiene, and Resident 1 was incontinent (lacking voluntary control over urination and/or bowel movement). A review of Resident 1’s care plan (CP) for UTI, dated 1/23/2025, indicated Resident 1 had a UTI and was at risk for further complications from UTI. The CP interventions included monitoring Resident 1’s vital signs (VS) every shift. A review of Resident 1’s Physician’s Order, dated 6/4/2025, indicated to transfer Resident 1 to GACH 1 via 911. A review of the Public Incident Report (PIR), dated 6/4/2025, indicated the paramedics arrived at the facility and assessed Resident 1 on 6/4/2025 at 8:49 pm. The PIR indicated Resident 1 had severe shortness of breath with an oxygen saturation level of 75 percent (%), and the paramedics’ primary impression was sepsis (a life-threatening blood infection). A review of Resident 1’s Change in Condition (CIC) note, dated 6/4/2025 and timed at 9:14 pm, indicated Resident 1 had labored breathing, with a temperature of 103.3 degrees Fahrenheit, an oxygen saturation level of 66 %, and the paramedics arrived, and Resident 1 was transferred to GACH 1 via 911. A review of Resident 1’s History of Present Illness from GACH 1, dated 6/4/2025 and timed at 9:15 pm, indicated Resident 1 was admitted to GACH 1 Emergency Department from the facility in severe distress, unresponsive, with rapid shallow breathing, and Resident 1 had UTI and sepsis. A review of Resident 1’s Progress Note (PN), dated 6/5/2025 and timed at 6:50 pm, indicated Licensed Vocational Nurse (LVN) 1 followed up with Registered Nurse (RN) 1 from GACH 1 and RN 1 stated Resident 1 was admitted to GACH 1 on hospice (compassionate care for people who are near the end of life) per Resident 1’s daughter’s request. During a concurrent interview and record review, dated 7/2/2025 and timed at 4:58 pm, with the Director of Nursing (DON), the DON stated Resident 1’s VS were not monitored every shift and Resident 1’s VS were only monitored once a week. Resident 1’s clinical record was reviewed with the DON and indicated Resident 1’s VS were last checked on 5/28/2025 prior to 6/4/2025. During an interview on 7/ 17/2025 at 12:27 pm with the DON, the DON stated the care plan, dated 1/23/2025, indicated to monitor Resident 1’s VS every shift. The DON stated it was important to monitor VS to notice the S/S of decline in Resident 1 who had previously had a UTI. DON stated staff should have followed the care plan and did not. DON stated the policy for the care plans was not followed. A review of the facility's policy and procedure (P&P) titled, “Care Plans, Comprehensive Person-Centered,” dated March 2022, indicated “A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident’s physical, psychosocial and functional needs is developed and implemented for each resident”. The facility failed to promptly identify S/S of a UTI for Resident 1 when the facility did not monitor Resident 1’s vital signs every shift according to Resident 1’s care plan for UTI, dated 1/23/2025. As a result of these failures, Resident 1 was transferred to GACH 1 from the facility, on 6/4/2025 at 10:06 pm, with urosepsis. The above violations had a direct relationship to the health, safety, or security of Resident 1.