Health inspection·July 31, 2025

42 CFR § 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. 22 CCR § 72311. Nursing Service- General. (a) Nursing service should 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 the admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives should be measurable and time limited. (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 each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR §72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be implemented to ensure that patient-related goals and facility objectives are achieved. On 5/22/2025, the California Department of Public Health (CDPH) received a complaint alleging the facility may have mismanaged Resident 1’s medications resulting in neglect. The complaint indicated Resident 1 was transferred to a higher level of care due to an intraparenchymal hemorrhage ([IPH] also known as intracerebral hemorrhage [ICH], a type of stroke involving bleeding within the brain tissue) and was intubated (when a breathing tube was inserted through the mouth or nose, down to the trachea [windpipe]). On 6/5/2025, the CDPH made an unannounced visit to the facility to investigate the allegation. The facility failed to provide emergency care (the provision of care for conditions that require rapid intervention to avoid death or permanent disability) to Resident 1, when the resident was found to have an altered mental status (a change in a resident's level of awareness, cognition, often indicating an underlying medical or neurological issue [any condition that affects the nervous system, including the brain, spinal cord, and nerves) and elevated blood pressure (BP) of 200/109 millimeters of mercury ([mmHg, a unit of measurement], reference range is 120/80 or lower). The facility failed to: 1. Assess Resident 1 immediately after Resident 1 had altered mental status on 5/17/2025 at 2:14 p.m. 2. Immediately provide emergency interventions by failing to send Resident 1 to the general acute care hospital (GACH) without delay for evaluation and treatment. 3. Implement the facility’s policy and procedure (P&P) titled, “Emergency Care-General,” which indicated to summon help and immediately call 911 for medical emergency assistance for new onset of unconsciousness or unresponsiveness to verbal or physical stimuli, severe low blood sugar with impaired consciousness, or any seizure activity (a sudden, abnormal surge of electrical activity in the brain that can cause temporary changes in behavior, movement, sensation, or awareness). As a result of these failures, Resident 1 did not receive the emergency care (the immediate medical attention provided to individuals experiencing serious or life-threatening health conditions) on 5/17/2025, from 2:14 p.m. to 5:47 p.m. (a total of three (3) hours and 33 minutes), when Resident 1 had a change in condition, resulting in the delay in diagnosing and treating ICH, leading to Resident 1’s intubation, being connected to the mechanical ventilator (a form of life support) and death on 5/25/2025 in GACH 2. Resident 1 was a 78-year-old female, initially admitted to the facility on 12/14/2023 and readmitted on 4/14/2025. Resident 1’s diagnoses included hypertension (high blood pressure), diabetes mellitus (DM- abnormal blood sugar level), hemiplegia (paralysis on one side of the body) affecting the right dominant side (resident’s preferred side of the body to use), and epilepsy (a neurological disorder characterized by a tendency to have recurrent, unprovoked seizures) A review of Resident 1’s Minimum Data Set (MDS - a resident assessment tool) dated 3/12/2025, indicated Resident 1 was able to understand and was understood by others. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) for activities of daily living (ADLs) such as eating, personal hygiene and upper body dressing. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) for oral hygiene, toileting hygiene, lower body dressing, and personal hygiene. The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for shower/bath and putting on/taking off footwear. The MDS indicated Resident 1 required partial/moderate assistance with rolling from lying on back, to left and right side, and in returning to lying on back on the bed. The MDS indicated Resident 1 required substantial/maximal assistance with sitting to lying and lying to sitting position on side of the bed. The MDS indicated Resident 1 was dependent on staff for chair/bed-to-chair transfer, and tub/shower transfer. A review of Resident 1’s care plan titled “The resident has altered endocrine (tissue that releases hormones) status,” initiated 4/14/2025, indicated care plan interventions to monitor Resident 1 for reports of changes to the eye (eye condition) and report to the physician as needed, resident will not experience any complications from DM status and resident will receive medications as ordered. During a review of Resident 1’s Physician’s Order Summary report dated 4/14/2025, the order summary indicated the following orders: 1. Finger stick blood sugar (FSBS, checking blood sugar level by pricking the finger and using a small drop of blood from the fingertip) as needed for hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). If FSBS is less than 60 (normal blood sugar range-70 to 99 milligrams per deciliter (mg/dL, a unit of measurement) and the resident is alert/ responsive, to give snack and recheck the blood sugar after 15 minutes, hold insulin (medicine for diabetes) and call the physician immediately, every 15 minutes, as needed. 2. Gvoke ([Glucagon] a prescription medicine used to treat very low blood sugar) prefilled syringe (PFS, a disposable syringe that comes with a pre-measured dose of insulin already loaded), 1 milligram ([mg] unit of mass measurement)/0.2 milliliter ([ml] unit of volume measurement), to inject 0.2 ml intramuscularly (injection into the muscles) as needed for hypoglycemia, if FSBS is less than (<) 60 and resident is unresponsive, call medical doctor (MD) immediately and recheck FSBS in 15 minutes. (hold insulin). 3. Monitor vital signs (physiological measurements that indicate a person's basic bodily functions, includes blood pressure, heart rate, temperature and oxygen saturation (a measure of how much oxygen is in the blood, normal range 95-100%) every shift. 4. Amlodipine Besylate (medicine for hypertension) oral tablet 10 mg., one (1) tablet by mouth one time a day, hold when systolic blood pressure (SBP- the top number in a BP reading) is <110. 5. Aspirin (for stroke prevention) 81 mg oral tablet, delayed release, daily. 6. Atorvastatin Calcium (medicine to lower cholesterol levels) 40 mg., tablet by mouth at bedtime for hyperlipidemia (high fats or lipids in the blood). 7. Lisinopril (medicine to treat high blood pressure) 20 mg., tablet by mouth, daily. Hold when SBP <110 and heart rate (HR, normal rate between 80-100 beats per minute) <60. 8. Levetiracetam oral solution (a medication primarily used to treat epilepsy) 100 mg/ml, to give 15 ml by mouth two times a day. The Physician’s Order Summary report indicated Resident 1 was discharged to GACH 1 via 911 on 5/17/2025 (no reason indicated). A review of Resident 1’s Medication Administration Record (MAR) for May 2025, indicated Resident 1 was administered Amlodipine and Lisinopril on 5/17/2025 at 9 a.m., however the MAR did not indicate a documented BP reading at the time of medication administration. The MAR indicated Resident 1 refused the levetiracetam morning dose on 5/8/2025, 5/10/2025 and 5/15/2025. A review of Resident 1’s Licensed Nurses Progress Notes dated 5/17/2025 at 2:14 p.m., indicated Resident 1 was transferred to GACH 1 via 911 (notes did not specify date and time of transfer) due to altered mental status. The Licensed Nurses Progress Notes did not have documentation regarding Resident 1’s condition, any assessment conducted, or interventions provided to Resident 1 after the change in condition was observed on 5/17/2025 at 2:14 p.m. and prior to the arrival of the paramedics on 5/17/2025 at 5:47 p.m. A review of Resident 1’s Los Angeles Fire Department (LAFD) Patient Care Report (report) dated 5/17/2025 at 5:37 p.m., indicated paramedics dispatch was notified on 5/17/2025 at 5:37 p.m. and the paramedics were on scene with Resident 1 at 5:47 p.m. The report indicated Resident 1 was unconscious (unresponsive to all stimuli). The report indicated Resident 1 was hypoglycemic. The report indicated Resident 1 had been confused for one hour in the facility (time not specified). The report indicated at 5:47 p.m. paramedics checked Resident 1’s blood sugar and it was 31. The report indicated Resident 1’s BP was 140/80 at 5:47 p.m. and 160/80 at 5:58 p.m. The report indicated an intravenous line ([IV] a thin, flexible tube inserted into a vein to administer fluids, medications or blood products directly into the bloodstream) was established and Resident 1 was given Glucagon which raised Resident 1’s blood sugar level to 164 mg/dl. The report also indicated Resident 1 was given (administered) IV of Dextrose 10 (D10- 10% [percent]of sugar in water used to provide body with extra water and calories from sugar). A review of Resident 1’s e-interact Change of Condition (COC) Evaluation dated 5/17/2025 at 6:21 p.m., completed by Licensed Vocational Nurse (LVN) 1, indicated Resident 1 had a minor shortness of breath (time not specified). The COC indicated Resident 1 did not have any oxygen in use. The COC indicated the physician was notified on 5/17/2025 at 2:23 p.m. The COC indicated, per medical order, Resident 1 was to be transferred to GACH due to altered mental status. A review of Resident 1’s GACH 1 record titled, “Emergency Department (ED) note,” dated 5/17/2025 at 6:52 p.m., indicated “Resident 1 had altered mental status one hour prior to the paramedic’s arrival at the facility.” The ED notes indicated “Resident 1 was hypoglycemic and arrived at the ED still altered”. The ED notes indicated “Resident 1 had left sided gaze deviation (a condition where a person's eyes are deviated or turned towards the left side which can be due to various neurological conditions, including stroke)”. The ED notes indicated “Resident 1’s glucose level was 248, potassium (an essential mineral and electrolyte that plays a vital role in nerve and muscle function, including the heart) level of 3 (normal range is 3.5 to 5.2 milliequivalent per liter ([mEq/L] unit of measurement)”. The GACH 1 Computerized Tomography (CT, a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) scan of the brain without contrast dated 5/17/25 at 7:15 p.m., indicated Resident 1 had a focal (localized) hematoma (a localized collection of blood outside of the blood vessels) at the left fronto (front of the head, behind the forehead) parietal (the top and back of the head, behind the frontal lobe and above the temporal (second largest lobe that sit behind the ears) and occipital lobe (the visual processing area of the brain) region, measuring 3.7 x 2.6 x 3.9 centimeters ([cm] unit measure of length) for a total ICH volume (the volume of blood collected within the brain tissue following a stroke) of 19.5 cubic centimeters ([cc). The impression indicated a focal ICH (bleeding that is localized to a specific area within the brain or its surrounding spaces) at the left posterior (back) parietal area. The ED notes indicated Resident 1 was intubated on 5/17/25 at 8:43 p.m. for airway protection during transport to GACH 2 for a higher level of care with neurosurgery (diagnosis and treatment of patients with injury or diseases/disorders of the brain, spinal cord and spinal column, and peripheral nerves within all parts of the body). The ED notes indicated Resident 1 was transferred to GACH 2 on 5/17/2025 at 10 p.m. A review of GACH 2’s History and Physical (H&P, the physician's examination of a patient) report, dated 5/17/2025 at 10:27 p.m., indicated Resident 1 was transferred from GACH 1 for the management of left parieto-occipital (the region or structures situated between the walls and occipital lobes of the brain) intracerebral hemorrhage. The H&P report indicated, “according to the nursing staff at the facility on 5/17/2025 at around 1 p.m. to 2 p.m., Resident 1 exhibited facial abnormalities, possibly twitching or asymmetry (unevenness), with left-sided gaze deviation along with movement of the resident’s arms, hands and legs.” The H&P indicated that “despite the concerning signs, Resident 1 was not immediately sent to the GACH; rather, was transferred between 4:00-5:00 p.m. (2-3 hours later).” A review of GACH 2’s CT Head or Brain without contrast dated 5/18/2025 at 1:13 a.m. indicated, “compared to the outside Head CT 5/17/2025 (from GACH 1), there was interval worsening of the left frontoparietal intraparenchymal hemorrhage with extension across midline into the right periventricular (outside the ventricle of the brain) white matter (composed of nerve fibers) and cingulate region (part of the brain)”. A review of GACH 2’s Discharge Documentation dated 5/28/2025, indicated Resident 2 was compassionately extubated (the process of withdrawing mechanical ventilation from a patient at the end of life to allow for a peaceful and comfortable death) and died on 5/25/2025 at 6:54 a.m. A review of Resident 1’s Certificate of Death indicated Resident 1 died on 5/25/2025. The Certificate of Death indicated the immediate cause of death was cardiopulmonary arrest (sudden cessation of heart function and breathing) sequentially (in succession) to cerebral edema (brain swelling), non-traumatic intracranial hemorrhage and hypertension. During a phone interview on 6/4/2025 at 3:22 p.m., with Resident 1’s Family Member (FM 1), FM 1 stated when FM 2 visited Resident 1 on 5/17/2025 around 2:30 p.m., while Resident 1 was being cleaned by Certified Nurse Assistant (CNA 1), Resident 1 was not responsive. FM 1 stated Licensed Vocational Nurse (LVN) 1 reported to FM 2 that Resident 1 had a seizure but when LVN 1 checked the BP, it was 220/138 mmHg. FM 1 stated, according to FM 2, it took the staff over one hour to send Resident 1 to GACH 1. FM 1 stated that even though Resident 1 had a stroke before, the resident had remained alert and aware of her surroundings prior to 5/17/2025. FM 1 stated Resident 1 was taken from GACH 1 to GACH 2 because GACH 1 found a bleed in her brain and GACH 2 confirmed it was a second stroke. During an interview on 6/5/2025 at 12:43 p.m. with CNA 1, CNA 1 stated on 5/17/2025 around 2:30 p.m., she went to Resident 1’s room because FM 2 was visiting Resident 1. CNA 1 stated when she entered Resident 1’s room, Resident 1 was looking blankly towards the left side. CNA 1 stated she cleaned the resident and kept calling Resident 1’s name while she was cleaning her, but Resident 1 did not answer. CNA 1 stated that prior to 5/17/2025 Resident 1 was usually awake, alert, able to make a