Health inspection·September 24, 2025

F684 § 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. Cal. Code Regs., Tit. 22, § 72301 - Required Services (a) Skilled nursing facilities shall provide, but shall not be limited to, the following required services: physician, skilled nursing, dietary, pharmaceutical and an activity program. (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. Cal. Code Regs. Tit. 22, § 72313 - Nursing Service-Administration of Medications and Treatments (a) Medications and treatments shall be administered as follows: (1) No medication or treatment shall be administered except on the order of a person lawfully authorized to give such order. (2) Medications and treatments shall be administered as prescribed. (3) Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, shall be performed as required and the results recorded. On 8/12/2025 at 11:15 AM, the California Department of Public Health (CDPH) conducted an unannounced visit to investigate a complaint regarding quality of care and treatment. The facility failed to coordinate services related to the care and medication management of Patient 1’s cancer, including monitoring for adverse effects and toxicity associated with the administration of Belzutifan (a cancer treatment medication, known to carry risks of anemia [a condition in which the blood lacks sufficient healthy red blood cells to carry adequate oxygen to the body’s organs and tissues, leading to symptoms such as fatigue, weakness, and shortness of breath]) and hypoxemia (an abnormal condition characterized by insufficient oxygen supply to the body’s tissues). The facility failed to ensure that Patient 1’s care was coordinated in accordance with the treatment plans established by Oncologist 1, by failing to: 1. Monitor for toxicities associated with Belzutifan, including anemia and hypoxemia as indicated in Oncologist 1's Progress Notes, dated 5/30/2025 2. Ensure that the Interdisciplinary Team (IDT) addressed Patient 1’s cancer diagnosis, cancer medication management, or coordination of care with the patient’s oncologist during the IDT care conference held on 5/13/2025.   3. Notify or consult Oncologist 1 when Patient 1 experienced a change in condition (CIC) on 6/30/2025, with oxygen saturation dropping to 85%, requiring supplemental oxygen. 4. Communicate abnormal blood work results dated 6/19/2025, and 6/11/2025, to Oncologist 1 for review and appropriate follow-up. 5. Ensure that facility staff followed physician orders and scope-of-practice guidelines for the administration of supplemental oxygen for Patient 1, in accordance with the physician’s order, which required oxygen to be given only when the patient’s oxygen saturation fell below 92%. 6. Reassess the appropriateness of continuing Belzutifan after Patient 1 was hospitalized on 7/25/2025, for acute hypoxic respiratory failure (a sudden inability of the lungs to adequately oxygenate the blood, resulting in low blood oxygen levels) and readmitted to the facility on 7/26/2025, where the medication was continued without documented guidance or monitoring protocols.  These failures placed Patient 1 at risk for continued exposure to potentially harmful medication effects without appropriate clinical oversight and represent a lack of coordination and individualized care planning in accordance with professional standards and physician directives, which led to Patient 1 requiring transfer to the General Acute Care Hospital (GACH) on 7/25/25 for acute hypoxemic respiratory failure.  A review of Patient 1’s Admission Record (AR), the AR indicated the patient was originally admitted on 5/26/2017, and readmitted on 1/24/2025, with diagnoses that included left kidney cancer, pancreatic cancer, chronic obstructive pulmonary diseases (COPD, lung disease causing restricted airflow and breathing problems), and heart disease (a range of conditions that affect the heart).??The AR indicated that Family Member (FM) 1 is Patient 1’s “responsible party”.   A review of Patient 1’s History and Physical (H&P), dated 5/1/2025, indicated the patient has a diagnosis of left kidney cancer and liver cancer. The H&P indicated that the patient does not have the capacity to understand and make decisions. ? A review of Patient 1’s admission Minimum Data Set (MDS-a patient assessment tool), dated 5/8/2025, the MDS indicated that the patient did not require oxygen therapy on admission.   A review of Patient 1’s MDS, dated 7/13/2025, the MDS indicated that the patient has moderately impaired cognition (the ability to process thoughts). A review of Patient 1’s laboratory (lab) results in the facility, the lab results, dated 4/22/2025, indicated Patient 1’s hemoglobin (HgB, an iron-rich protein in the red blood cells that transports oxygen from your lungs to the rest of your body) was 12.6 (Normal hemoglobin for men ranges from 13.5 to 17.5 g/dL) and red blood cell count (RBC, [measures the number of red blood cells in your blood]) was 3.91 (normal range for males is 4.7-6.1 million cells/microliter [µL: a unit of measurement]. A review of Patient 1’s Order Summary Report (OSR) for 5/2025, dated 5/1/2025, the OSR did not include an order for supplemental oxygen. A review of Patient 1’s Oncology Clinic Notes provided by the facility, dated 5/2/2025, indicated a plan for the patient to switch medications to Belzutifan 120 mg. The notes also indicated for the patient to have a Complete Blood Count, (CBC- a common blood test that provides information about the different types of chemicals in your blood, such as salt levels, kidney function and liver function) prior to the next clinic visit.? The Notes also indicated for the patient to have a Complete Metabolic Panel, (CMP- a common blood test that provides information about the different types of cells in your blood, including red blood cells, white blood cells, and platelets) prior to the next clinic visit. A review of Patient 1’s physician order dated 5/9/2025, the order indicated that Patient 1 was to receive Belzutifan Oral Tablet 40 mg, with instructions to administer three tablets by mouth once daily for cancer, totaling 120 mg per day. However, the order did not include instructions to monitor Patient 1 for adverse effects (defined as unintended, undesirable, and potentially harmful reactions to a therapy) or for toxicities associated with Belzutifan which included hypoxemia and anemia.    A review of Patient 1’s Interdisciplinary Team (IDT) Care Conference note dated 5/13/2025, at 4:39 PM,  indicated that the attendees included representatives from the dietary, therapy, and activity departments, as well as the social worker and the MDS nurse. The IDT note did not indicate that Patient 1’s Responsible Party (FM 1) was present during the conference. Under the section titled “Evaluation/Goals,” the note indicated: “The goal is to continue receiving all services needed to thrive in long-term care.” There were no entries under the section titled “Nursing Summary” including the subsection “Problems/Needs.” The IDT notes did not indicate documented evidence that the IDT discussed Patient 1’s cancer diagnosis, cancer medication management, or coordination of patient’s care with Oncologist 1.    A review of Patient 1’s Oncology Clinic Notes provided by the facility, dated 5/30/2025, signed by Oncologist 1, the Notes indicated for the patient to “continue taking Belzutifan 120 daily”. The Notes also indicated for the patient to be monitored for toxicity, including hypoxemia, anemia, and edema. The Notes further?indicated that the patient was on drug therapy that “requires intensive monitoring for toxicity.” The Notes also added for Patient 1 to have lab tests CBC, CMP, and TSH (Thyroid Stimulating Hormone or TSH- a blood test that provides the level of a person’s TSH, a hormone secreted by the thyroid) prior to the next clinic visit around 6/27/2025. A review of Patient 1’s lab results in the facility, the lab results, dated 6/19/2025, the lab results indicated Patient 1’s HgB level was abnormally low at 7.9 (4.7 points or 37% lower from the previous lab result on 4/22/2025 when the HgB was 12.6) and RBC was low at 2.46 (1.45 points or 37% lower than the previous lab result on 4/22/2025 when the RBC was 3.91). A review of Patient 1’s progress notes, the Notes included an entry, dated 6/19/2025, timed at 2:21 PM, and signed by Registered Nurse (RN) 2, indicated the abnormal lab results dated 6/19/2025 were sent to Medical Doctor (MD) 1, the facility’s attending physician and not Oncologist 1. The Notes did not indicate if MD 1 gave orders or instructions, as a result of Patient 1’s abnormal lab results.    A review of Patient 1’s Oncology Clinic Notes provided by the facility, dated 6/27/2025,  indicated for the patient to have lab tests for CBC and CMP prior to the next Oncology Clinic Visit in 4 weeks. A review of Patient 1’s Change in Condition (CIC) notes, dated 6/30/2025, timed at 10:58 PM, indicated that the patient had an oxygen saturation of 85% while only on room air (without the patient using supplemental oxygen). The CIC indicated that Medical Doctor (MD) 1 was notified and MD 1 ordered supplemental oxygen. A review of Patient 1’s physician order with a start date of 6/30/2025, indicated an order for staff to check Patient 1’s [oxygen] saturation [every shift]. The order indicated that Patient 1 may have [oxygen] at 2 to 4 L?if [oxygen] saturation] was below 92% as needed.     A review of Patient 1’s laboratory (lab) results in the facility, the lab results, dated 7/11/2025, indicated Patient 1’s HgB levels remained abnormally low at 8.8 and RBC was low at 2.65. A review of Patient 1’s progress notes, the Notes included an entry, dated 7/11/2025, timed at 12:46 PM, and signed by RN 2, indicated the abnormal lab results dated 7/11/2025 were sent to Medical Doctor (MD) 1, the facility’s attending physician and not Oncologist 1. The Notes did not indicate if MD 1 gave orders or instructions.    A review of Patient 1’s Oncology Clinic Notes, dated 7/25/2025, signed by Oncologist 1, indicated that during the clinic visit, Patient 1 “came in hypoxic (a state of insufficient oxygen reaching tissues or a specific environment with low oxygen levels) with an oxygen saturation of 84% on room air, required 3 liters per minute (lpm) of oxygen to maintain saturation above 88%.” The Notes indicated that the clinic called 911 and the patient was taken to the emergency room (ER, a section in the hospital that specializes in providing immediate care to life-threatening medical conditions) for hypoxemia evaluation. During further review of Patient 1’s Oncology Clinic Notes, dated 7/25/2025, signed by Oncologist 1, indicated the patient’s desaturation (when a person’s oxygen saturation goes down) “might be side effect of Belzutifan”. The Notes indicated to “hold Belzutifan 120 MG daily for hypoxemia, pending further evaluation.” The Notes indicated that Patient 1 was “on drug therapy that requires intensive monitoring for toxicity.” The Notes indicated that the “decision was made to escalate level of care to emergency room.”? A review of Patient 1’s GACH 1 document provided by the facility dated 7/26/2025 indicated Patient 1 was admitted to GACH 1’s ED on 7/25/2025 at 5:20 PM. The GACH documents indicated that Patient 1 had a chief complaint of “shortness of breath” and that Patient 1 had an oxygen saturation of 85% during the patient’s appointment at the Oncology clinic. The GACH 1 document indicated under the assessment and plan, to hold Belzutifan and administer IV antibiotics. A review of Patient 1’s progress notes, a Notes entry, dated 7/26/2025, timed at 10:34 PM, signed by Registered Nurse (RN) 2, indicated Patient 1 returned to the facility from GACH 1 on 7/26/2025 at 6:34 PM with urinary tract infection (UTI, an infection of the urinary system) and respiratory infection. The Notes entry indicated the patient came back with an oxygen saturation of 95% while on room air. The Notes also indicated that Medical Doctor (MD) 1, which was Patient 1’s attending physician at the facility, was informed of Patient 1’s arrival back to the facility. The progress notes did not indicate documented evidence that the licensed nurses consulted with Oncologist 1 for guidance or monitoring protocols to ensure the appropriateness of continuing Belzutifan after Patient 1 was hospitalized on 7/25/2025, for acute hypoxic respiratory failure.     A review of Patient 1’s Medication Administration Record (MAR) for the months of 7/2025 and 8/2025, the MARs indicated that Patient 1 continued to receive Belzutifan 120 mg once a day from 7/27/2025 to 8/8/2025.    A review of Patient 1’s Order Audit Report (OAR), dated 8/14/2025, for the medication Belzutifan, the OAR indicated the medication was originally ordered on 5/9/2025. The OAR indicated the medication was discontinued on 8/8/2025, timed at 1:38 PM. A review of Patient 1’s CIC notes, dated 8/15/2025, timed at 11:19 AM, the CIC indicated that Patient 1’s oxygen needs increased and that Patient 1 requested to have continuous supplemental oxygen. The CIC indicated that MD 1 ordered Patient 1 to have continuous supplemental oxygen at 2 LPM (liters per minute, a unit of measuring the amount of oxygen delivered per minute) to maintain the oxygen saturation above 92%. During a concurrent observation and interview on 8/14/2025 at 1:37 PM inside Patient 1’s room, Patient 1 was observed sitting on the bed while wearing a nasal canula (a small plastic tube that is used to deliver supplemental oxygen to the patient) that is connected to an oxygen concentrator. The oxygen concentrator was set to deliver 3 LPM of supplemental oxygen. Patient 1 stated that he always uses his supplemental oxygen. Patient 1 added the nurses tell him to always use his supplemental oxygen because his “oxygen goes down.” During an interview on 8/14/2025 at 2:14 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated Patient 1 is always using his supplemental oxygen. CNA 1 further stated that Patient 1’s oxygen saturation “goes low” when he is not using his supplemental oxygen. During a concurrent observation and interview on 8/14/2025 at 2:22 PM while CNA 1 was being interviewed in the hallway directly in front of Patient 1’s room, Patient 1 was observed standing up inside Patient 1’s room, by the door, without wearing his nasal canula. Patient 1 stated he needs help. CNA 1 immediately went inside of the room and placed Patient 1’s nasal canula over Patient 1’s nares. CNA 1 did not check Patient 1’s oxygen saturation nor check the oxygen concentrator for the rate of oxygen delivery.??    During a concurrent observation and interview on 8/14/2025 at 2:28 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed checking Patient 1’s oxygen saturation. LVN 1 stated Patient 1’s oxygen saturation was 96%. LVN 1 stated that the patient’s supplemental oxygen was being delivered at a rate of 3 LPM. LVN 1 stated that the patient’s supplemental oxygen is ordered only as needed to keep Patient 1’s oxygen saturation above 92%. During an interview on 8/14/2025 at 2:41 PM with Registered Nurse (RN) 1 regarding the administration of supplemental oxygen, RN 1 stated only licensed nurses such as the LVN’s are able manage the patient’s supplemental oxygen. RN 1 added CNAs may not administer oxygen. During the same interview on 8/14/2025 at 2:41 PM with RN 1 regarding notifying physicians for abnormal lab results, RN 1 stated when there is an abnormal lab result, the physician that ordered the lab test must be notified. RN 1 stated an abnormal lab result can be considered a change in condition. RN 1 stated the purpose of initiating a change in condition for a patient was for the “proper management of the care of the [patients].” During a concurrent