Health inspection·May 30, 2025

F770 42 CFR §483.50(a) Laboratory Services. §483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. (i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter. 22 CCR § 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. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (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. 22 CCR § 72315. Nursing Service-Patient Care. (i) Measures shall be implemented to prevent and reduce incontinence for each patient and shall include: (1) Written assessment by a licensed nurse to determine the patient's ability to participate in a bowel and/or bladder management program. This is to be initiated within two weeks after admission of an incontinent patient. (2) An individualized plan, in addition to the patient care plan, for each patient in a bowel and/or bladder management program. (3) A weekly written evaluation in the progress notes by a licensed nurse of the patient's performance in the bowel and/or bladder management program. (j) Fluid intake and output shall be recorded for each patient as follows: (1) If ordered by the physician. (2) For each patient with an indwelling catheter: (A) Intake and output records shall be evaluated at least weekly and each evaluation shall be included in the licensed nurses' progress notes. (B) After 30 days the patient shall be reevaluated by the licensed nurse to determine further need for the recording of intake and output. 22 CCR § 72301. Required Services. (d) Written arrangements shall be made for obtaining all necessary diagnostic and therapeutic services prescribed by the attending physician, podiatrist, dentist, or clinical psychologist subject to the scope of licensure and the policies of the facility. If the service cannot be brought into the facility, the facility shall assist the patient in arranging for transportation to and from the service location. (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. 22 CCR § 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. An unannounced visit was conducted by the California Department of Public Health (CDPH) on 4/15/2025 at 8:30 AM to investigate a complaint regarding allegations of quality of care including facility staffing issue, infection control practice, and resident being left wet for extended periods of time. The facility failed to provide the appropriate care and services for Resident 1 who was admitted with Indwelling catheter (a tube that helps drain urine from the bladder [organ inside the body that stores urine] then your urine goes from your bladder and through a drainage tube [indwelling catheter tube] into a drainage collection bag) in accordance with the facility's policy and procedure title, "Care of Catheter" by failing to: 1. Monitor and document Resident 1 for signs and symptoms of urinary tract infection (UTI, an infection in the bladder/urinary tract) such as pain, burning, blood-tinged urine (presence of blood in the urine) in accordance with Resident 1's Care Plan for Indwelling Catheter and bilateral (both sides) nephrostomy tubes (small catheter placed through the skin of the lower back into the kidney to drain urine directly form the kidney into a bag outside the body). 2. Ensure Resident 1's laboratory test for Complete Blood Count (CBC, a common blood test that measures the number and types of cells in the blood) was done on 4/6/2025 in accordance with the physician's order placed on 4/3/2025. Resident 1's CBC test was done on 4/15/2025 (9 days from 4/6/2025). These deficient practices had resulted in the delay of obtaining Resident 1's CBC result and Resident 1 had critical laboratory results on 4/15/2025 which resulted in Resident 1 was transferred to the General Acute Care Hospital (GACH) 2 and getting blood transfusion (a medical procedure where donated blood or blood components are given to a patient through a narrow tube placed within a vein) one (1) unit of Red Blood Cells (RBC- a type of blood cell that is made in the bone marrow [soft spongy tissue that is in the center of the bone] and found in the blood and carries Hgb) on 4/15/2025 and another 1 unit of RBC on 4/16/2025. A review of Resident 1's Admission Record, the Admission Record indicated Resident 1, a 75-year-old-male, was originally admitted to the facility on 3/31/2025 with diagnoses which included bladder cancer (a type of cancer that develops in the bladder [the organ that stores urine]), acute kidney failure (a sudden and temporary loss of kidney function, where the kidneys can no longer effectively filter waste and excess fluid from the blood) and anemia (a condition where the body does not have enough healthy red blood cells leading to a reduced ability to carry oxygen throughout the body. This can result in various symptoms like fatigue, weakness and shortness of breath). A review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 4/4/2025, the MDS indicated Resident 1 had intact cognitive skills (ability to think, understand, and reason) for daily decision making. The MDS indicated Resident 1 needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/ shower transfer and walk 10 feet. The MDS indicated Resident 1 came in with indwelling catheter (including nephrostomy tubes [small catheter placed through the skin of the lower back into the kidney]). A review of Resident 1's Laboratory (Lab) Results in General Acute Care Hospital 1 (GACH 1- where Resident 1 was admitted from on 3/31/25) dated 3/31/2025. Laboratory Results indicated: 1. Hemoglobin (Hgb- a protein found in red blood cells that carries oxygen from the lungs to the body's tissues and organs) level was 8.7 grams per deciliter (g/dL, unit of measurement. Normal Hgb level is 11.0-18.8 g/dL). 2. RBC level was 3.03 million cells per microliter (mcL- unit of measurement. Normal RBC level is 3.9-5.5 mcL). A review of Resident 1's Physician's Order dated from 3/31/2025 to 4/15/2025, indicated: 1. On 4/1/2025, may flush (process of introducing a sterile solution such as NS into the catheter to clear blockages or debris such as mucous plugs or blood clots to avoid the urine to back up into the kidney) Indwelling catheter with 10 cubic centimeters (cc- unit of measurement) of normal saline (NS- a sterile solution containing 0.9% of sodium chloride in water used to flush catheters and irrigate wounds) as needed for clogged Sediments. 2. On 4/3/2025, Resident 1 is for laboratory test for CBC, Comprehensive Metabolic Panel (CMP, test provides information about your metabolism, how your body uses food and energy, and the balance of certain chemicals in your body), Vitamin B-12 (cobalamin, plays an essential role in red blood cell formation) Ferritin ( measures the level of this protein in the blood), Iron Panel (blood tests that look at how much iron is in your blood and other cells) to be done on 4/6/2025. A review of Resident 1's Care Plan (CP) for Indwelling Catheter and bilateral (both sides) nephrostomy tubes dated 4/1/2025, the CP Interventions indicated: a. Check tubing for kinks each shift. b. Monitor and document intake and output as per facility policy. c. Monitor for signs and symptoms (s/s) of discomfort on urination and frequency. d. Monitor/document for pain/discomfort due to catheter. e. Monitor/record/report to MD (doctor) for signs and symptoms (s/s) of UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, and altered mental status. During an observation on 4/15/2025 at 10:16 AM inside Resident 1's room, Resident 1 was awake and laying on his bed. Resident 1 had a dark red colored urine output in the resident's Indwelling catheter tubing and there were 800 milliliters (mL- unit of measurement) of dark red colored urine output in Resident 1's Indwelling catheter drainage bag. During a concurrent observation and interview on 4/15/2025 at 10:18 AM with Treatment Nurse 2 (TN 2) inside Resident 1's room, Resident 1 was observed having dark red colored output in the resident's Indwelling catheter tubing and dark red colored output in his Indwelling catheter drainage bag. TN 2 stated Resident 1 was newly admitted to the facility, and the Indwelling catheter output has been bloody since the resident was admitted at the facility. During a concurrent observation and interview on 4/15/2025 at 10:36 AM with TN 1 inside Resident 1's room, Resident 1 had a nephrostomy drainage bag connected on the resident's left lower back with a reddish colored urine output. Resident 1's nephrostomy drainage bag connected on the resident's right lower back has an amber (shade of dark yellow, typically indicated dehydration) colored urine output. TN 1 observed Resident 1's Indwelling catheter tubing and drainage bag with dark red colored output. During an interview on 4/15/2025 at 11:28 AM with Licensed Vocational Nurse (LVN 2), LVN 2 stated, Resident 1 was admitted with bloody urine. LVN 2 stated if a resident had a bloody urine, the facility staff should have called the doctor and ask order for laboratory test and placed the resident on monitoring if blood form the urine is getting worse or improving. LVN 2 also stated, if Resident 1's urine was bloody for two weeks, Resident 1 will have anemia because the blood is coming out of the urine. During a concurrent interview and record review on 4/15/2025 at 11:39 AM with Assistant Director of Nursing 1 (ADON 1), Physician's order dated 4/3/2025 was reviewed. The Physician's order indicated CBC, CMP, Vit B12, Ferritin, Iron Panel to be completed (done) on 4/6/2025. ADON 1 stated the order indicated to complete the CBC, CMP, Vit B12, Ferritin, Iron Panel but there was no laboratory result for 4/6/2025 in Resident 1's laboratory results records and no documented evidence the laboratory tests were done on 4/6/2025. During an interview on 4/15/2025 at 11:48 AM, with Assistant Director of Nursing (ADON), ADON stated if Resident 1 had a bloody urine for two weeks, this place Resident 1's Hgb level to potentially decrease which can result to Resident 1 feeling weak and for the resident to experience discomfort. During a concurrent interview and record revied on 4/15/2025 at 11:51 AM with LVN 3, the facility's Laboratory Logbook dated 4/3/2025 to 4/14/2025 was reviewed. Laboratory Logbook did not indicate documented evidence that Resident Test Request Form for CBC, CMP, Iron Panel, Vit B12 and Ferritin was done and/ or completed on 4/6/2025. LVN 3 stated, there was no Test Request Form dated 4/6/2025 meaning it was not done on 4/6/2025. During a concurrent interview and record review on 4/15/2025 at 11:52 AM with ADON 1, Resident 1' Nurses' Progress Notes (NPN) dated 4/3/2025 to 4/14/2025 were reviewed. Resident 1's Nurses Progress Notes did not indicate Resident 1 refused the laboratory test or the blood was drawn (laboratory test was done) on 4/6/2025. ADON 1 stated, Resident 1's NPN has no documentation if the blood draw was refused by the resident, and it did not have documented evidence Resident 1's laboratory test for was done on 4/3/2025 to 4/14/2025. During a concurrent interview and record review on 4/15/2025 at 11:53 AM with ADON 1, Laboratory Logbook dated 4/6/2025 was reviewed. Laboratory Record Logbook did not indicate Test Request Form for Resident 1 on 4/6/2025 for Resident 1's CBC, CMP, Iron Panel, Vit B12 and Ferritin. ADON 1 stated there was no documented evidence that the test ordered for Resident 1 was done on 4/6/2025. During an interview on 4/15/2025 at 11:56 AM with LVN 3, LVN 3 stated, if we do not have the Test Request Form it means it was not done on that date (4/6/2025). During a concurrent interview and record review on 4/15/2025 at 12:01 PM with Assistant Director of Nursing 1 (ADON 1), Resident 1's Laboratory Results Report (done in the facility) dated 4/15/2025 were reviewed. Laboratory Results indicated: 1. Hgb level was 6.8 g/dL. 2. RBC level was 2.35 mcL. ADON 1 stated, Resident 1's CBC test was done on 4/15/2025 (9 days from 4/6/2025). ADON stated the laboratory test of Resident 1 was delayed, and it was not done according to the doctor's order placed on 4/3/2025 to do the CBC test on 4/6/2025. ADON stated, Resident 1's laboratory result for Hgb and RBC done on 4/15/2025 were critically low and the facility staff must call the doctor to obtain orders and possible transfer Resident 1 to GACH 2. During a concurrent observation and interview on 4/15/2025 at 12:21 PM with Resident 1 inside Resident 1's room, Resident 1 was laying on his bed and was fully covered with multiple blankets up to the resident's neck. Resident 1 stated, "I always feel cold and weak." A review of Resident 1's physician's order information on 4/15/2025 at 12:25 PM, Physician's order indicated transfer Resident 1 to GACH 2's ER (emergency room- a specialized hospital area that provides immediate medical care for urgent or life-threatening conditions) for critical laboratory results. During a concurrent interview and record review on 4/15/2025 at 2:37 PM with LVN 2, Resident 1's NPN dated from 4/1/2025 to 4/15/2025 were reviewed. The NPN did not indicate documented evidence regarding observation of Resident 1's urine output on the bilateral nephrostomy bags and Indwelling catheter drainage bag from 4/1/2025 to 4/15/2025. LVN 2 stated, there was no documentation in the NPN regarding the observations/ assessment of Resident 1's urine output in the Indwelling catheter drainage bag from 4/1/2025 to 4/15/2025. LVN 2 stated licensed staff should have monitored and documented the color of Resident 1's urine output in the Indwelling catheter bag to monitor if the blood in the ur