Health inspection·July 3, 2025

F684 Code of Federal Regulations, Title 42, Section 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: California Code of Regulations, Title 22, Section 72301. Required Services. (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. California Code of Regulations, Title 22, Section 72309. Nursing Service. Nursing service means a service staffed, organized and equipped to provide skilled nursing care to patients on a continuous basis. California Code of Regulations, Title 22, Section 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. (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 shall 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 of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 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. 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. California Code of Regulations, Title 22, Section 72545. Admission Records. (a) For each patient a facility shall complete an admission record which shall include the following: (10) Admission diagnoses, known allergies and final diagnoses. An unannounced visit was conducted by California Department of Public Health on 5/20/2025 at 8:20 AM to investigate a complaint regarding an allegation that the facility failed to follow a physician’s order to not start Plavix (medication to prevent blood clots) for Resident 1 until 4/30/2025. The facility started giving Plavix to Resident 1 on 4/22/2025 and continued to administer the medication until Resident was found unresponsive on 4/26/2025 and transferred to General Acute Care Hospital (GACH), where Resident 1 was found with multiple brain bleedings and brain dead. Resident 1 passed away on 4/27/2025. The facility failed to provide treatment and services in accordance with professional standards of practice (guidelines and expectations that define competent and ethical conduct within specific profession) for Resident 1 who had a diagnosis of other sequalae of cerebral infarction (the long-term conditions and complications that result from brain tissue damage due to reduced blood supply), other interval disc (a cushion of cartilage found between the vertebrae [bones] of the spine) lumbar region (the lower back region of the spinal column or backbone), other spondylosis (general wear and tear) with radiculopathy - lumbar region (pinched nerve in the spine) and status post (S/P) lumbar decompression and fusion (a surgical procedure that fuses the vertebrae together to stabilize the spine) posterior (further back position) on 4/14/2025 from GACH by failing to: 1. Ensure Registered Nurse (RN) 1 reviewed and verified with the facility’s attending physician (Physician 1) Resident 1’s GACH records dated 4/21/2025 and relayed the complete and accurate discharge order from GACH’s neurosurgeon (Physician 2) of Resident 1’s Plavix 75 milligram (mg) to start on 4/30/2025 (9 days from the day of admission). 2. Ensure the facility provided continuity of care to Resident 1’s S/P lumbar decompression and fusion posterior when licensed nurses started administering Plavix 75 mg on 4/22/2025 to 4/25/2025 (for 4 days) rather than starting it on 4/30/2025 in accordance with Physician 2’s order. 3. Ensure Resident 1 was assessed and monitored for signs and symptoms of bleeding/ hematoma (pool of mostly clotted blood that forms in an organ, tissue, or body space)/ hemorrhage (bleeding from a damaged blood vessel) specifically for Resident 1’s S/P lumbar decompression and fusion posterior, and Plavix use from 4/22/2025 to 4/25/2025. As a result, Resident 1 had a change of condition (COC) on 4/26/2025 at 1:05 PM, as evidenced when Resident 1 was found unresponsive to external stimuli (external changes or events that trigger a response in the nervous system, it can be anything from sight and sounds to smells, tastes, and physical sensations like pain or touch). Resident 1 was transferred to GACH via 911 emergency services (EMS) on 4/26/2025 at 1:30 PM and was admitted to the Emergency Department (ED). Resident 1 underwent a Computerized Tomography scan (CT scan – an imaging technique to create detailed images of the body) of the head in the GACH and results showed an acute (sudden) right subdural (between the membrane that surrounds the brain and spinal cord] of the brain and spinal cord) hematoma measuring 14 millimeters (mm) in width. The CT scan result also showed there was an adjacent right temporal intraparenchymal (bleeding within the brain tissue) hematoma measuring 3.7 x 2.8 x 4.2 centimeters (cm). In addition the CT scan result showed there was subfalcine herniation (brain tissue is displaced under the vertical fold that separates the two halves of the brain), uncal herniation (occurs when rising intracranial pressure causes portions of the brain to move from one intracranial compartment to another) and subacute hemorrhage in the left parietal lobe (left side of the brain) measuring 2.7 cm x 2.7 cm. Resident 1 was also intubated (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their airway/windpipe so that air can get through. The tube can connect to a machine that delivers air or oxygen) and Resident 1 died in the GACH on 4/27/2025 at 12:17 PM. According to Resident 1’s Death Certificate, Resident 1’s immediate cause of death was nontraumatic intracranial hemorrhage (bleeding within the brain tissue that is not the result of head trauma or surgery- can be caused by blood clotting problems. It's a serious condition that can lead to stroke and potentially be fatal). A review of Resident 1’s Admission Record, indicated that Resident 1, a 83-year-old-female, was admitted to the facility on 4/21/2025 with diagnoses that included intervertebral disc displacement (breakdown of one or more disc that separates the bones) in lumbar region (lower back), spondylosis with radiculopathy and hypertension (high blood pressure). A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 4/26/2025, indicated Resident 1was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with eating and oral hygiene but was dependent (helper does all of the effort.) with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing and putting on/taking off footwear. A review of Resident 1’s GACH records dated from 4/8/2025 to 4/21/2025, indicated Resident 1’s CT of the brain without contrast (without the use of a special dye) was done on 4/8/2025, showed no bleed or large infarct (an area of brain tissue death) in the brain. The GACH records also indicated Resident 1 was diagnosed at GACH with other sequalae of cerebral infarction, other interval disc lumbar region, other spondylosis with radiculopathy - lumbar region and S/P lumbar decompression and fusion posterior on 4/14/2025 in GACH. A review of Resident 1’s facsimile (fax) GACH Discharge Medication List, dated 4/21/2025, indicated Plavix 75 mg Tab (did not indicate start date). A review of Resident 1’s GACH pended (awaiting completion) discharge orders, dated 4/21/2025, indicated Plavix 75mg Tablet Daily will start on 4/30/2025. A review of Resident 1’s GACH discharge medication list, dated 4/21/2025, indicated to start Plavix 75mg tablet on 4/30/2025. A review of Resident 1’s Physician Orders at the facility, dated 4/21/2025, indicated Plavix Oral Tablet 75 mg. Give one tablet by mouth one time a day for cardiovascular accident (CVA) prophylaxis (PPX, preventive treatment). A review of the facility’s Pharmacy Records for Resident 1, dated 4/21/2025, indicated Plavix tab 75mg was delivered to the facility. A review of the Facility’s Pharmacy Receipt dated 4/22/2025, indicated Resident 1’s medication of Plavix Tab 75 mg delivered with 14 tablets. A review of Resident 1’s Care Plan with focus “Antiplatelet (medications that prevent blood clots) use related to Clopidogrel Bisulfate (same as Plavix),” revised 4/22/2025, indicated resident will be free from signs/symptoms of abnormal bleeding. A review of Resident 1’s Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) from the facility, dated April 2025, indicated Plavix was given once daily to Resident 1 from 4/22/25 to 4/25/2025. A review of Resident 1’s SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 4/26/2025 at 1:05 PM, indicated Resident 1 was unresponsive to external stimuli and was sent to the GACH via 911 (time not indicated). A review of Resident 1’s ED to GACH Admission Record, dated 4/26/2025, indicated Resident 1 underwent a CT scan of the head and was found to have an acute right subdural hematoma measuring 14 mm in width. The record indicated there was also an adjacent right temporal intraparenchymal hematoma measuring 3.7 x 2.8 x 4.2 cm and these resulted in significant leftward shift (natural centerline of the brain is pushed to the left) with 2 cm leftward shift, subfalcine and uncal herniation. The CT scan result also showed subacute hemorrhage in the left parietal lobe (Left side of the brain) measuring 2.7 cm x 2.7 cm. A review of Resident 1’s GACH discharge summary, dated 4/27/2025 at 12:35 PM, indicated Resident 1 had a worsening of mental status requiring intubation and found intracranial hemorrhage with poor neurological prognosis (a low likelihood of recovery) and progression to brain death. Resident 1 was pronounced dead on 4/27/2025 at 12:17 PM. During an interview on 5/20/2025 at 12 PM, RN 2 stated when a resident is admitted from the hospital to the nursing facility, the hospital discharge medication list should be clarified with the attending physician to obtain orders to continue the orders or not. RN 2 stated, the GACH discharge paper works that came with Resident 1 when the resident was admitted on 4/1/2025 should have been thoroughly reviewed by the admitting licensed nurse to ensure they can obtain the complete and/ or accurate order from Physician 2 for Resident 1’s Plavix. During an interview on 5/20/2025 at 1:43 PM, the Medical Records Personnel (MRP) stated an admission audit would be done the next day for residents admitting or re-admitting to the facility. MRP also stated during the audit, the hospital discharge papers and orders from the admitting nurse would be reviewed to ensure they match. During an interview on 5/20/2025 at 2 PM, Physician 1 stated if the Nursing Facility notified Physician 1 of the Plavix being held until 4/30/2025 by Physician 2, Physician 1 would have ordered to hold Plavix until 4/30/2025. Physician 1 stated GACH discharge orders needed to be followed for continuity of care and to avoid worsening of the resident’s condition. During a concurrent record review and interview on 5/20/25 at 2:20 PM of Resident 1’s admitting medication orders and GACH discharge medication list with the Director of Nursing (DON), dated 4/21/2025, the DON stated during admission, when a nurse admits a resident, the medical records department would then do an audit of the resident’s medical record to ensure the discharge orders from the hospital match the physician orders. The DON also stated Resident 1’s admitting orders to give the resident’s Plavix with start date of 4/22/2025 did not match Resident 1’s GACH discharge medication list/ orders to start the Plavix on 4/30/2025. The DON further stated it is important to follow the discharge orders from the hospital for accurate care of the resident and that nurses should have clarified the GACH discharge orders with the resident’s physician upon admission. During an interview on 5/20/2025 at 4:21 PM, RN 1 stated Resident 1’s admitting medication orders and Resident 1’s GACH discharge medication list did not match but should have matched to ensure continuity of care and that the Plavix was given to Resident 1 on 4/30/2025 and not on 4/22/2025. RN 1 also stated she used the medication list that was faxed by the GACH nurses to the facility (no start dates) and not the GACH discharge medication list (with start dates) that was given to Resident 1. RN 1 also stated, there was no documented evidence in Resident 1’s medical records that the facility assessed, monitored and documented Resident 1 for specific signs and symptoms of bleeding/hematoma/hemorrhage specifically for Resident 1’s S/P lumbar decompression and fusion posterior, and Plavix use from 4/22/2025 to 4/25/2025. During an interview on 5/21/2025 at 12 PM, Physician 2 stated he would generally wait 2 weeks after surgery before ordering to give an anticoagulant to patients. Physician 2 also stated if the nurses start a medication when they should not have, “then that is wrong.” Physician 2 stated, sometimes the healthcare provider gives dangerous medications to the residents, and it can cause an adverse effect. During an interview on 5/21/2025 at 12:25 PM, Physician 3 (GACH’s doctor) stated Resident 1 had surgery prior to being admitted to the skilled nursing facility on 4/21/2025. Physician 3 stated Resident 1 received Plavix from the facility earlier than it should have been given. Physician 3 stated, this placed Resident 1 at risk for bleeding and/or brain bleeding. Physician 3 stated Plavix increased the risk of bleeding. During an interview on 5/21/2025 at 2:57 PM, Pharmacist 1 stated there was no documentation indicating Resident 1 had post spinal surgery. Pharmacist 1 also stated if the facility informed the pharmacy that Resident 1 was status post spinal surgery, administering the Clopidogrel Bisulfate (same as Plavix) medication would have been questioned. During an interview on 5/21/2025 at 4 PM, MR stated while auditing Resident 1’s admission record, she reviewed the hospital faxed medication list (no start dates) and not the hospital discharge medication list (with start dates) that was given to Resident 1. MR also stated she should have reviewed the hospital discharge medication list when auditing the admission record but rather reviewed the