Health inspection·September 11, 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 California Code of Regulations, Title 22, Section 72311. Nursing Service – General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (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. (b) All attempts to notify licensed healthcare practitioners acting within the scope of his or her professional licensure shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending licensed healthcare practitioner acting within the scope of his or her professional licensure or his or her designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g). 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 7/30/2025, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to the facility to investigate a complaint regarding quality of care. The facility failed to provide necessary care and services to Resident 1 in accordance with the facility’s policy and procedure (P&P) titled, “Changes in Resident Condition," when: a. Registered Nurse (RN) 3 and Licensed Vocational Nurse (LVN) 1 did not notify Resident 1’s physician regarding Resident 1’s complaint of chest pain and not feeling well, and Resident 1’s request to be transferred to a General Acute Care Hospital (GACH) on 7/20/2025 during the 3-11 shift (3 PM to 11:30 PM). b. RN 3 and LVN 1 did not document Resident 1’s complaint of chest pain and not feeling well, and Resident 1’s request to be transferred to a GACH in Resident 1’s medical record on 7/20/2025. c. RN 1 did not notify a physician regarding Resident 1’s complaint of chest pain and Resident 1’s and Resident 1’s Representative’s (RR 1) request for Resident 1 to be transferred to a GACH on 7/21/2025 at 2 AM. d. RN 1 did not document in Resident 1’s medical record regarding Resident 1’s complaint of chest pain and Resident 1’s and RR 1’s request for Resident 1 to be transferred to a GACH on 7/21/2025 at 2 AM. As a result, Resident 1 did not receive treatment and care for Resident 1’s chest pain, cough, and shortness of breath which started on 7/20/2025 until 7/22/2025. A review of Resident 1’s Admission Record (AR) indicated the facility admitted Resident 1, a 62-year-old male, on 4/23/2025 and readmitted Resident 1 on 5/14/2025 with diagnoses including type 2 diabetes mellitus, hypertension, and hemiplegia. A review of Resident 1's History and Physical (H&P), dated 4/25/2025, indicated Resident 1 had the capacity to understand and make his own decisions. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/22/2025, indicated Resident had no impairment in cognitive skills. The MDS indicated Resident 1 required partial/moderate assistance from staff for dressing, bathing, and personal hygiene. A review of Resident 1's GACH H&P, dated 7/23/2025 and timed 10:58 AM, indicated Resident 1 was admitted to GACH 1 Emergency Department on 7/22/2025 at 12:18 PM with complaints of shortness of breath, cough, and chest pain. The H&P indicated Resident 1 was admitted to GACH 1 for aspiration pneumonia. During an interview on 7/30/2025 at 10:17 AM with RR 1, RR 1 stated Resident 1 called RR 1 on 7/21/2025 at 2 AM and informed RR 1 that Resident 1 was waiting to go to the hospital because Resident 1 had chest pain and was coughing. RR 1 stated RR 1called and spoke to the Social Services Director (SSD) on 7/21/2025 at 9:45 AM. RR 1 stated RR 1 asked the SSD when Resident 1 would be sent to the hospital. RR 1 stated the SSD informed RR 1 the SSD would speak to the Director of Nursing (DON) about Resident 1 being sent to the hospital. RR 1 stated RR 1 called again at 1:45 PM and was able to speak with the DON. RR 1stated the DON was not aware of Resident 1’s complaint of chest pain or that Resident 1 was requesting to be sent to the hospital. RR 1 stated RR 1 called later at 10:30 PM and spoke to Registered Nurse (RN) 1. RR 1 stated RN 1 informed RR 1 that RN 1 was waiting for the doctor to determine which hospital the facility would send Resident 1 to on 7/21/2025 at 2 AM. RR 1 stated RR 1 spoke to another unidentified nurse during the night of 7/21/2025 and was informed the facility would notify RR 1 when the doctor called back. RR 1 stated RR 1 called the facility early in the morning of 7/22/2025 and spoke to RN 2 about Resident 1’s complaint of chest pain and asked about the transfer to the hospital. RR 1 stated RN 2 called RR 1 back in ½ hour and informed RR 1 that Resident 1 would be transferred to the hospital at 10:30 AM on 7/22/2025. During an interview on 7/30/2025 at 10:55 AM with Resident 1, Resident 1 stated Resident 1 started to feel ill with a cough on 7/20/2025. Resident 1 stated Resident 1 informed a staff the evening of 7/20/2025 that Resident 1 had a cough. Resident 1 stated Resident 1 informed the nurse on 7/21/2025 at around 2 AM that Resident 1 was short of breath and that Resident 1’s chest hurt whenever Resident 1 took a breath. Resident 1 stated the facility staff just wanted to give Resident 1 medicine for the cough, but Resident 1 informed the facility staff Resident 1 needed to go to the hospital. Resident 1 stated Resident 1 felt upset because the facility waited over 24 hours before listening to Resident 1 and before sending Resident 1 to the hospital. Resident 1 stated Resident 1 knew something was wrong. Resident 1 stated Resident 1 knew Resident 1’s body. Resident 1 stated Resident 1 spent 7 days at GACH 1 with pneumonia in both lungs. During a concurrent interview and record review on 7/30/2025 at 12:10 PM with RN 2, Resident 1’s Change in Condition Evaluation (CIC), dated 7/22/2025 and timed 8:14 AM, was reviewed. The CIC indicated Resident 1 had, “Elevated BP (blood pressure), cough and chest tightness.” The CIC indicated Resident 1’s doctor ordered for Resident 1 to be sent to GACH 1. RN 2 stated Resident 1 had been “pushing to go to the hospital for the last two days.” During an interview on 7/30/2025 at 12:51 PM with the SSD, the SSD stated RR 1 called the SSD on 7/21/2025 during the day (time unknown) and wanted to speak to the SSD about Resident 1 being transferred to a hospital. The SSD stated RR 1 informed the SSD Resident 1 had a cough and was having pain. The SSD stated RR 1 wanted Resident 1 to be transferred to the hospital. The SSD stated the SSD directed RR 1 to talk to the nursing staff. During an interview on 7/31/2025 at 10:53 AM with LVN 1, LVN 1 stated Resident 1 complained of having back pain and requested to go to the hospital on 7/20/2025 during the evening time (exact time unknown). LVN 1 stated LVN 1 texted Resident 1’s doctor but that the doctor did not reply. LVN 1 stated LVN 1 did not try to call the doctor when the doctor did not respond to the text message. During an interview on 7/31/2025 at 2:24 PM with RN 3, RN 3 stated RN 3 was the supervisor on the 3-11 shift on 7/20/2025. RN 3 stated RN 3 was notified by LVN 1 that Resident 1 wanted to go to the hospital. RN 3 stated Resident 1 told RN 3 that Resident 1 was in pain and wanted to go to the hospital. RN 3 stated Resident 1 claimed Resident 1 “did not feel good.” RN 3 stated LVN 1 notified Resident 1’s doctor. RN 3 stated RN 3 was under the impression LVN 1 spoke to Resident 1’s doctor about Resident 1’s complaint of pain and wanting to be transferred to a hospital. RN 3 stated LVN 1 should have spoken to Resident 1’s doctor and completed a CIC in Resident 1’s medical record. During a concurrent interview and record review on 7/31/2025 at 2:38 PM with the DON, the facility’s 24-hour communication log, undated, was reviewed. The 24-hour communication log indicated RN 1 made an entry regarding Resident 1on 7/21/2025 at 4:39 PM which indicated, “Paged (Resident 1’s doctor) regarding resident (Resident 1) and (RR 1) requesting to be transferred to (GACH 1) d/t uncontrollable pain. Paged MD twice on our shift. Awaiting for response.” The DON confirmed Resident 1’s medical record did not contain documentation regarding Resident 1’s complaints of pain and requests to go to the hospital until 7/22/2025. The DON stated RN 1 should have filled out a CIC on 7/21/2025 when Resident 1 had uncontrolled pain. The DON stated the DON was not made aware of Resident 1’s complaints of pain or request to be transferred to the hospital until 7/21/2025 while the DON was driving home in the evening. The DON stated the DON instructed the facility staff to call Resident 1’s doctor. The DON stated the facility staff should have called the DON if they were unable to reach Resident 1’s doctor. The DON confirmed the facility staff did not get a hold of Resident 1’s doctor until 7/22/2205 at 8:14 AM. During a review of the P&P titled, "Changes in Resident Condition," undated, the P&P indicated, “A facility must immediately… consult with the resident's physician…when there is: …A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life - threatening conditions or clinical).” The P&P indicated, “Document in the resident's medical record: Date and time of change of condition - Who (physician/family member/responsible party) was notified regarding the condition change, information communicated, response and/or orders received, assessment of resident condition and ongoing monitoring of resident condition, care provided, document the time emergency personnel arrived and took over the care of the resident, if applicable, and update the care plan as needed.” The facility failed to provide necessary care and services to Resident 1 in accordance with the facility’s P&P titled, “Changes in Resident Condition," when: a. RN 3 and LVN 1 did not notify Resident 1’s physician regarding Resident 1’s complaint of chest pain and not feeling well, and Resident 1’s request to be transferred to a GACH on 7/20/2025 during the 3-11 shift. b. RN 3 and LVN 1 did not document Resident 1’s complaint of chest pain and not feeling well, and Resident 1’s request to be transferred to a GACH in Resident 1’s medical record on 7/20/2025. c. RN 1 did not notify a physician regarding Resident 1’s complaint of chest pain and Resident 1’s and RR 1’s request for Resident 1 to be transferred to a GACH on 7/21/2025 at 2 AM. d. RN 1 did not document in Resident 1’s medical record regarding Resident 1’s complaint of chest pain and Resident 1’s and RR 1’s request for Resident 1 to be transferred to a GACH on 7/21/2025 at 2 AM. As a result, Resident 1 did not receive treatment and care for Resident 1’s chest pain, cough, and shortness of breath which started on 7/20/2025 until 7/22/2025. The above violations have a direct or immediate relationship to the health, safety, or security of Resident 1.