Health inspection·November 26, 2025

F684 42 C.F.R. § 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: 42 C.F.R. § 483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the resident representative(s) when there is— (B) A significant change in the resident’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). 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. (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the patient. 22 CCR § 72313. Nursing Service--Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (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. 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. On 9/30/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding a resident death. The facility failed to ensure that Resident 1, who had moderately impaired cognition, bed-bound, dependent on staff for activities of daily living (ADLs – activities such as bathing, dressing, and toileting a person performs daily), and was receiving Porcine Heparin injection (a powerful anticoagulant [blood thinner] medication used to prevent and treat blood clots that increases the risk of bleeding), was provided the necessary care and services in accordance with professional standards of practice when on 9/26/2025 at 4:47 a.m., Resident 1 had a change in condition (CIC – a major decline in a resident’s status), namely bright red blood of moderate amount in the stool. The facility failed to ensure: 1. Registered Nurse (RN) 1 conducted a comprehensive assessment of Resident 1’s respiratory (relating to breathing or the organs of respiration), cardiovascular (relating to the heart and blood vessels), neurological (relating to the brain, spinal cord, and nerves), genitourinary (GU – relating to the?genital?and?urinary?organs), and behavioral (relating to or involving observable behavior) status following Resident 1’s CIC on 9/26/2025 at 4:47 a.m. RN 1 also failed to assess and document the presence or absence of bowel sounds (the noises made when food, fluids, and gases move through the intestines). 2. RN 1 followed the facility’s policy and procedure (P&P) titled, “Change of Condition (COC – when there is a sudden change in a resident’s condition): Notification of,” indicating, “… must immediately … consult with the patient’s physician … where there is: … a significant change in the patient’s physical … status; A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or A decision to transfer or discharge the patient from the Center.” 3. STAT (immediately) occult blood test and STAT complete blood count (CBC – a laboratory [lab] test that measures various components of the blood that can help diagnose and monitor conditions such as bleeding) ordered on 9/26/2025 at 8 a.m. for Resident 1 were accurately entered and carried out. On 9/26/2025 at 10 a.m., RN 2 entered an order for a routine (not STAT) occult blood test (one time), resulting in a two-hour delay from receipt of the STAT order and a five-hour and 13 minutes delay from the time of Resident 1’s CIC. RN 2 did not enter the STAT CBC order for Resident 1. 4. There was a clearly documented process for communicating Resident 1’s multiple episodes of blood in the stool to Medical Doctor (MD) 1 or Nurse Practitioner (NP) 1 following Resident 1’s initial CIC (first episode of red blood in the stool) on 9/26/2025 at 4:47 a.m. 5. Facility staff monitored and documented Resident 1’s CIC (presence of blood in the stool) beginning on 9/26/2025 at 4:47 a.m. following the initial report of blood in the stool. As a result, Resident 1 was found unresponsive with no pulse and no respirations on 9/27/2025 at 9:14 p.m. On 9/27/2025 at 9:25 p.m., paramedics arrived at the facility and found Resident 1 with rigor mortis (stiffening?of the joints and muscles of a body a few hours after death) in the jaw, arms, and legs. Resident 1’s skin was cold and pale. On 9/27/2025 at 9:28 p.m., paramedics pronounced Resident 1 deceased. A review of Resident 1’s Admission Record, undated, indicated the facility admitted Resident 1, a 92-year old female, on 7/22/2025 with diagnoses of metabolic encephalopathy (a condition in which the brain does not function properly due to an imbalance in body chemistry), altered mental status (a state of confusion, change in consciousness or unusual behavior), type 2 diabetes mellitus (DM – a chronic condition characterized by high blood sugar levels that occur when the body does not produce enough insulin [a hormone that turns food into energy and manages your blood sugar level] or does not use insulin effectively), and essential hypertension (abnormally high blood pressure with no identifiable underlying medical cause). A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 7/29/2025, indicated Resident 1 was moderately impaired in thought process (demonstrating noticeable breakdown in thinking that causes significant difficulty with daily tasks, communication, and decision-making). The MDS indicated that Resident 1 required substantial or maximal assistance (a person requires more than half of the effort from a helper to complete a task) from staff with ADLs for toileting hygiene, showering or bathing, upper body dressing, and lower body dressing. A review of Resident 1’s CIC Evaluation form, dated 9/26/2025, timed at 4:47 a.m., indicated that Resident 1 had a first episode of bright red blood in stool, described as moderate amount (exact amount not specified). The CIC Evaluation form indicated that RN 1 left voicemail and text messages to MD 1 and NP 1 on 9/26/2025 at 6 a.m., reporting the episode. On 9/26/2025 at 7:30 a.m., no response from MD 1 and NP 1 have been received, and the CIC was endorsed to the next RN Supervisor (RN 2) for follow-up. The CIC Evaluation for Resident 1 indicated an “Abdominal/GI Status Evaluation” indicating blood in stool, described as moderate in amount. The CIC Evaluation reflected that RN 1 did not perform evaluations for “Behavioral Status Evaluation,” “Respiratory Status Evaluation,” “Cardiovascular Status Evaluation,” “Genitourinary Status Evaluation,” and “Neurological Status Evaluation.” A review of Resident 1’s Situation, Background, Assessment, and Recommendation (SBAR – a communication tool that provides a consistent framework for sharing critical information, especially in healthcare) Communication Form, dated 9/26/2025, timed at 4:47 a.m., indicated that RN 1 did not assess for the presence or absence of bowel sounds. A review of Resident 1’s Care Plan, initiated on 9/26/2025, indicated Resident 1 had an “episode of blood in stool”. The Care Plan included interventions to “Assess for and report signs and symptoms of nausea/vomiting, abdominal distention, abdominal cramping, constipation, decreased bowel movements, decreased bowel sounds and abdominal pain.” A review of Resident 1’s Progress Notes, dated 9/26/2025, timed at 9:50 a.m., indicated that Resident 1 had a second episode of dark red blood in stool (estimated amount 30 cc).” A review of Resident 1’s Active Orders indicated the following: - To administer Porcine Heparin injection solution 5,000 units per milliliter (u/ml – unit of measure). Inject one ml subcutaneously (under the skin) every eight hours for deep vein thrombosis (DVT – blood clot that forms in a deep vein) prophylaxis (preventive care) with an order date of 7/23/2025. - To obtain occult blood test one time only for evaluation of blood in stool for one day with an order date of 9/26/2025 (creation time not indicated). - To obtain occult blood test STAT for blood in stool with an order date of 9/26/2025 (created on 9/26/2025 at 2:04 p.m.). - To obtain CBC STAT one time only for three days with an order date of 9/27/2025 (created on 9/27/2025 at 5:51 a.m.). A review of Resident 1’s Laboratory Result Report, dated 9/27/2025 at 11:48 a.m., indicated that Resident 1’s occult blood test result was positive. A review of Resident 1’s Progress Notes, Type: Lab Result Note, dated 9/27/2025 at 4:20 p.m., indicated a late entry (created on 9/28/2025 at 2:25 p.m., a day after Resident 1’s death) documenting that RN 4 relayed Resident 1’s positive occult blood test result to NP 1 and was waiting for orders. A review of Resident 1’s Medication Administration (Admin) Audit Report, dated 10/1/2025, indicated that heparin was administered to Resident 1 after the COC (blood in the stool), first identified on 9/26/2025 at 4:47 a.m. The medication (heparin) was administered on the following dates and times: - 9/26/2025 at 8:52 a.m. by Licensed Vocational Nurse (LVN) 3 (second episode of approximately 30 cc of blood in stool occurred on 9/26/2025 at 9:50 a.m.) - 9/26/2025 at 5:08 p.m. by LVN 6. - 9/26/2025 at 11:49 p.m. by LVN 2 (third episode of blood in stool noted on 9/27/2025 at 3 a.m.) - 9/27/2025 at 7:11 a.m. by LVN 3 (fourth episode of blood in stool noted on 9/27/2025 at 9 a.m.) - 9/27/2025 at 6:02 p.m. by LVN 4 (Resident 1 was pronounced deceased on 9/27/2025 at 9:28 p.m.) A review of Resident 1’s Certificate of Death, dated 9/30/2025, indicated Resident 1 died on 9/27/2025 at 9:28 p.m. with cardiopulmonary arrest (when the heart stops beating) as the immediate cause. The Certificate of Death indicated the list of conditions leading to cardiopulmonary arrest including ischemic coronary disease (heart damage caused by narrowed heart arteries), hypertension, and DM type 2. During an interview on 10/9/2025 at 1:06 p.m., with LVN 1, LVN 1 stated that at approximately 4:30 a.m. to 4:40 a.m. on 9/26/2025), Certified Nursing Assistant (CNA) 1 reported that Resident 1 was bleeding while being cleaned. LVN 1 stated that he (LVN 1) assessed Resident 1 and observed bright red blood spread throughout Resident 1’s diaper approximately around 10 cc of bright red blood and immediately notified RN 1. During a concurrent interview and record review on 10/3/2025 at 6:40 a.m., with RN 1, Resident 1’s COC dated 9/26/2025 (first episode of blood in the stool) was reviewed. The COC indicated that Resident 1 had signs and symptoms of blood in the stool in a moderate amount. RN 1 stated that LVN 1 notified him (RN 1) that Resident 1 had an episode of bright red blood in the stool, approximately 10 cc in volume. RN 1 stated that on 9/26/2025 at around 6 a.m. he (RN 1) notified MD 1 and NP 1 by calling them (MD 1 and NP 1) using the facility phone and also sending text messages from his (RN 1) personal phone. RN 1 stated physicians “get mad” if they (physicians) are contacted in the middle of the night and that MD 2 had previously told RN 1 (exact date not specified) that for non-emergency cases, physicians did not need to be called during nighttime hours. RN 1 stated that Resident 1 was stable and that there was no need to notify the physician at 4 a.m. because it was “too early.” RN 1 stated that it was his (RN 1) personal decision to delay notification until 6 a.m., based on his (RN 1) nursing judgment that Resident 1’s condition was not emergent. During a concurrent interview and record review on 10/3/2025 at 6:51 a.m., with RN 1, the facility P&P titled, “Change of Condition: Notification of,” with effective date of 11/28/2016 and last reviewed on 9/11/2025, Resident 1’s progress notes (from 9/26/2025 to 9/27/2025), and physician orders from 9/26/2025 to 9/27/2025 were reviewed. RN 1 stated that based on his (RN 1) nursing judgment, Resident 1’s condition was not life-threatening. RN 1 stated that the presence of a moderate amount of blood in the stool could be due to hemorrhoids (swollen veins in the anus or rectum that can cause itching, pain, and bleeding). However, RN 1 was unable to provide documented evidence indicating that he (RN 1) assessed Resident 1 for hemorrhoids and stated that he (RN 1) did not know if Resident 1 had hemorrhoids. RN 1 stated that NP 1 responded to his (RN 1) text message (sent from his personal phone) on 9/26/2025 at around 8 a.m., after his (RN 1) shift had ended, and gave verbal orders for a STAT CBC and STAT occult blood test. RN 1 stated that on 9/26/2025 at around 8 a.m., he (RN 1) called the facility, spoke to RN 2 and relayed NP 1’s orders. RN 1 further stated that he (RN 1) did not follow up with MD 1 or NP 1 after the initial notification on 9/26/2025 at 6 a.m. RN 1 stated that RN 2 did not carry out the CBC STAT order he (RN 1) had endorsed at 8 a.m. on 9/26/2025. RN 1 stated that the facility failed to carry out the CBC STAT and occult blood test STAT orders promptly as required. During a concurrent interview and record review on 10/6/2025 at 3:37 p.m., with RN 1, Resident 1’s CIC Evaluation form (presence of blood in the stool) dated 9/26/2025 and the facility’s P&P titled, “Change of Condition: Notification of” and Resident 1’s Progress Notes (from 9/26/2025 to 9/27/2025) and facility’s P&P titled “Change of Condition: Notification of:” were reviewed. RN 1 stated that the CIC form was incomplete, with no information entered regarding factors that made Resident 1’s condition better or worse. RN 1 stated that respiratory, cardiovascular, GU, behavioral, and neurological evaluations were not done. RN 1 stated that the stool sample for the occult blood test was not collected at that time of Resident 1’s COC (9/26/2025 at 4:47 a.m.) because MD 1 had not yet been notified and no orders had been received. RN 1 stated he (RN 1) contacted MD 1 on 9/26/2025 at 6 a.m., which was his personal decision, as he (RN 1) considered Resident 1 stable and did not view Resident 1’s condition as an emergency. RN 1 stated that Resident 1 was receiving heparin but stated he (RN 1) believed the