Health inspection·October 8, 2025

F580 Code of Federal Regulations, Title 42, Section 483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the Patient; consult with the Patient’s physician; and notify, consistent with his or her authority, the Patient representative(s) when there is— (B) A significant change in the Patient’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). 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. (C) An unusual occurrence, as provided in Section 72541, involving 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 8/19/2025, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to the facility for the facility’s annual recertification survey. The facility failed to notify Resident 11’s physician of Resident 11’s complaint of burning when urinating on 8/19/2025. As a result, Resident 11 continued to feel burning pain when urinating on 8/20/2025, negatively affecting the resident’s health and wellbeing. A review of Resident 11's Admission Record (AR) indicated the facility admitted Resident 11, a 58-year-old female, on 12/19/2014 and readmitted on 7/6/2023 with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus, and bipolar disorder. A review of Resident 11’s History and Physical (H&P) dated 6/7/2025 indicated Resident 11 had the capacity to understand and make medical decisions. A review of Resident 11's Minimum Data Set (MDS) dated 8/5/2025 indicated Resident 11 had no impairment in cognitive skills. The MDS indicated Resident 11 was dependent on staff for bathing, dressing, and toileting hygiene. A review of Resident 11’s care plan titled, “Risk for Impaired Urinary Elimination,” dated 7/29/2025 indicated facility staff were to notify Resident 11’s healthcare provider (physician/MD) immediately if Resident 11 had any voiding (urinating) abnormalities. During an interview on 8/19/2025 at 1:35 PM with Resident 11, Resident 11 stated Resident 11 had been recently treated for a urinary tract infection (UTI). Resident 11 stated Resident 11 currently had another UTI because Resident 11 felt a burning pain when Resident 11 urinated. Resident 11 stated Resident 11 told multiple nurses (unidentified) about Resident 11’s burning pain with urination, but the unidentified nurses told Resident 11 that Resident 11 was “fine.” During an interview on 8/19/2025 at 2:00 PM with Licensed Vocational Nurse 1 (LVN 9), the surveyor informed LVN 9 that Resident 11 complained of feeling burning pain when Resident 11 urinated. LVN 9 stated LVN 9 would go and evaluate Resident 11. During an interview on 8/20/2025 at 10:06 AM with Resident 11, Resident 11 stated Resident 11 still felt burning pain when Resident 11 urinated. Resident 11 stated Resident 11 had complained to multiple staff (unidentified) about the pain on 8/19/2025 but no one did anything about Resident 11’s complaint. During an interview on 8/20/2025 at 10:09 AM with LVN 9, LVN 9 confirmed Resident 11 had complained to LVN 9 that Resident 11 experienced burning pain when Resident 11 urinated on 8/19/2025. LVN 9 stated LVN 9 did not notify Resident 11’s doctor of Resident’s complaint of burning when urinating. LVN 9 stated LVN 9 notified Registered Nurse (RN) 4 about Resident 11’s complaint of burning when urinating. During an interview on 8/20/2025 at 10:15 PM with RN 4, RN 4 stated burning when urinating is a symptom of a UTI. RN 4 stated if a resident (in general) complained of burning when urinating, the licensed staff should call the resident’s physician. RN 4 stated RN 4 did not notify Resident 11’s physician of Resident 11’s complaint of feeling burning pain when urinating. During a concurrent interview and record review on 8/21/2025 at 9:06 AM with RN 1, Resident 1’s lab report (LR) titled, “Urinalysis”, collected 8/20/2025 was reviewed. The LR indicated Resident 11’s urine showed a large amount of Leukocyte esterase and positive for nitrite. RN 1 stated Resident 11’s LR indicated Resident 11 had a UTI. A review of the facility's Policy and Procedure (P&P) titled, “Change in a Resident’s Condition or Status” revised 11/2015 indicated “The facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).” The P&P indicated, “The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been…A significant change in the resident's physical/emotional/mental condition…A need to alter the resident's medical treatment significantly.” The facility failed to notify Resident 11’s physician of Resident 11’s complaint of burning when urinating on 8/19/2025. As a result, Resident 11 continued to feel burning pain when urinating on 8/20/2025, negatively affecting the resident’s health and wellbeing. The above violations have a direct or immediate relationship to the health, safety, or security of Resident 11.