Health inspection·September 19, 2025

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 (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. 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: 22 CCR § 72313. Nursing Service-Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. 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. (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 §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 8/1/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate an allegation of a resident death. The facility failed to provide treatment and quality of care in accordance with professional standards of practice to Resident 1, who had a diagnosis of type 2 diabetes mellitus (DM – a disease that occurs when your blood sugar [BS] is too high). On 7/19/2025 at 4 a.m., Resident 1 had a change of condition (COC – a major decline in a resident’s status), complained of nausea (a feeling of sickness in the stomach that can be accompanied by an urge to vomit), had one episode of vomiting, a documented BS of 394 (normal range is between 70 to 99) milligrams per deciliter (mg/dl – unit of measurement) obtained by Licensed Vocational Nurse 1 (LVN 1) and had a physician’s order dated 7/15/2025 instructing staff to notify Medical Doctor 1 (MD 1) if the BS is greater than 350 mg/dl. The facility failed to:   1. Follow the physician’s order, dated 7/15/2025, to notify MD 1 when Resident 1’s BS level reached at least 382 mg/dl on 7/19/2025 at 4 a.m., exceeding 350 mg/dl. indicated as the threshold for notification in the order.    2. Implement the facility’s policies and procedures (P&P) titled, “Change of Condition Notification,” last reviewed on 4/4/2025, indicating, “To ensure …? physicians are informed of changes in the resident’s condition in a timely manner”; P&P titled, “Diabetic Care,” last reviewed on 4/4/2025; and P&P titled, “Blood Glucose Monitoring,” last reviewed on 4/4/2025, which required the facility staff to notify the physician of Resident 1’s high blood sugar level.   3. Implement the P&P titled, “Obtaining Vital Signs”, last reviewed on 4/4/2025, and ensure quality of care by monitoring Resident 1’s vital signs (measurements of the body’s most basic functions) during a COC on 7/19/2025 at 4 a.m. The P&P required the facility to take vital signs when there is a change in the resident’s condition.   4. Identify Resident 1’s care needs based upon a comprehensive nursing assessment of Resident 1 that was not done during a COC on 7/19/2025 at 4 a.m.   5. Ensure that LVN 1 provided a shift endorsement (process where a licensed nurse is transferring responsibility for resident care to another licensed nurse providing a detailed summary of the resident’s condition, treatment, and ongoing needs) to the oncoming (7 a.m. to 3 p.m. shift) staff (Registered Nurse 2 [RN 2] and LVN 2) regarding Resident 1’s COC that occurred during LVN 1’s shift on 7/19/2025 at 4 a.m. consistent with quality of care and the facility’s policies and procedures titled “24-hour Communication Log” last reviewed on 4/4/2025, and “Alert Charting Documentation,” last reviewed on 4/4/2025.   As a result, Resident 1 was found unresponsive in his room on 7/19/2025 at 7:50 a.m. and was pronounced dead at the facility on 7/19/2025 at 8:05 a.m. with DM 2 identified as an underlying condition that contributed to the cause of death.   A review of Resident 1’s Admission Record indicated the facility originally admitted Resident 1, a 47-year-old male, on 12/3/2021 and readmitted on 5/27/2025 with diagnoses including type 2 DM, hypertension (high blood pressure), hyperlipidemia (a medical condition characterized by elevated levels of lipids [fats] in the bloodstream), and chronic kidney disease (a condition where the kidneys are damaged and cannot filter waste and excess water from the blood).   A review of Resident 1’s Care Plan regarding non-compliance with nursing care and interventions, initiated on 8/6/2022, indicated an intervention to notify the MD of any significant COC.   A review of Resident 1’s History and Physical (H&P – comprehensive assessment conducted by a healthcare provider that includes gathering a thorough medical history from the resident and performing a physical examination to assess their overall health and identify any potential medical concern), dated 9/13/2024, indicated Resident 1 had the capacity to understand and make decisions.    A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 6/12/2025, indicated Resident 1 had an intact thought process and required supervision from staff to complete activities of daily living (ADLs – basic, essential tasks for self-care and mobility such as eating, bathing, dressing, transferring and toileting).    A review of Resident 1’s Physician’s Orders, dated 7/15/2025, indicated to monitor Resident 1’s BS before meals and at bedtime, and to notify the MD if BS is greater than 350 mg/dl or less than 70 mg/dl.    A review of Resident 1’s Care Plan regarding type 2 DM, initiated on 7/15/2025, indicated an intervention to notify the MD if BS is greater than 350 mg/dl or less than 70 mg/dl, to monitor Resident 1’s blood sugar before meals and bedtime.  A review of Resident 1’s Medication Administration Record (MAR), dated 7/19/2025 timed at 6:30 a.m., indicated LVN 1 documented Resident 1’s blood sugar of 394 mg/dl (taken at 4 a.m.).     A review of Resident 1’s Vital Signs Record, dated 7/2025, indicated there were no vital signs taken on 7/18/2025 to 7/19/2025.   A review of Resident 1’s Progress Notes, dated 7/19/2025, timed at 8:32 a.m., indicated that on 7/19/2025 at 4 a.m. Resident 1 requested LVN 1 to check his (Resident 1) blood sugar due to complaints of nausea, and the BS result was 382 mg/dl. The Progress Notes further indicated that on 7/19/2025 at 4 a.m. Resident 1 had an episode of vomiting. The Progress Notes indicated at 7:50 a.m. LVN 2 found Resident 1 in his (Resident 1) bed in his (Resident 1) room unresponsive and LVN 2 notified RN 2 that Resident 1 was unresponsive. The Progress Notes indicated at 7:52 a.m. RN 2 initiated chest compressions, at 7:53 a.m. 911 (a phone number used to contact emergency services) was called, and at 7:56 a.m. the paramedics (persons trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) arrived and pronounced Resident 1 expired (dead) at 8:05 a.m. (7/19/2025).   A review of Resident 1’s Certificate of Death, dated 8/6/2025, indicated that Resident 1’s date of death was on 7/19/2025 at 8:05 a.m. and the immediate cause of death for Resident 1 was cardiopulmonary arrest (a life-threatening medical emergency where the heart stops effectively pumping blood and the body stops breathing), with underlying conditions contributing to the cause of death listed as respiratory failure (a life-threatening medical condition where the lungs cannot adequately exchange gases to meet the body’s needs) and type 2 DM.   During an interview on 8/4/2025 at 1:44 p.m., with RN 2, RN 2 stated that on 7/19/2025 she (RN 2) did not receive any endorsement from LVN 1 regarding Resident 1’s nausea, vomiting, and elevated BS of 382 mg/dl. RN 2 stated that three nurses (RN 1, LVN 1, and one unidentified licensed nurse) from the previous shift (11 p.m. to 7 a.m. shift) had informed her (RN 2) that everyone (referring to all residents) was fine. RN 2 further stated that on 7/19/2025 at around 7:50 a.m., LVN 2 called and notified her (LVN 2) that Resident 1 was unresponsive. RN 2 stated that upon receiving the call, RN 2 immediately responded and assessed Resident 1, noting that the resident (Resident 1) was cold to the touch. RN 2 stated she (RN 2) was unable to obtain any vital signs, at which point she (RN 2) called 911, and initiated chest compressions (using hands to push down hard and fast in a specific way on a resident’s chest in order to help blood flow through the heart in an emergency situation).   During a concurrent interview and record review on 8/5/2025 at 6:24 a.m., with LVN 1, Resident 1’s Progress Notes dated 7/19/2025, 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) dated 7/2025, and Resident 1’s Vital Signs Record dated 7/19/2025 were reviewed. LVN 1 stated that Resident 1’s last BS check was conducted on 7/19/2025 at 4 a.m., with a high result of 382 mg/dl. LVN 1 stated that on 7/19/2025 at 4 a.m., Resident 1 was nauseated and had one episode of vomiting. The MAR indicated the MD (MD 1) should be notified if Resident 1’s BS exceeded 350 mg/dl, however, he (LVN 1) did not contact MD 1 because he (LVN 1) assumed notification was only needed if the BS reading was over 400 mg/dl. He (LVN 1) did not recheck the elevated BS reading of 382 mg/dl taken at 4 a.m. on 7/19/2025 and stated he (LVN 1) should have rechecked and monitored Resident 1’s BS for any changes. There was no documented evidence of Resident 1’s vital signs or nursing assessments being completed during Resident 1’s COC as they were not done. He (LVN 1) did not notify MD 1 and stated that he (LVN 1) should have contacted MD 1 promptly to obtain orders for Resident 1’s nausea, vomiting and elevated BS (382 mg/dl). Resident 1 could have recurring episodes of nausea and vomiting and did not have any prescribed medications to manage these symptoms. If Resident 1’s condition was left unreported and unchecked, Resident 1 could have developed hyperglycemia (a condition in which blood sugar levels are abnormally high), diabetic ketoacidosis (a life-threatening complication of diabetes mellitus [DM - when the body cannot produce enough of a hormone called insulin {which regulates the amount of sugar in the blood}, or the insulin it produces is not effective]) and potentially become unresponsive.      During an interview on 8/5/2025 at 9:37 a.m., with MD 1, MD 1 stated that he (MD 1) did not recall being notified on 7/19/2025 at 4 a.m. regarding Resident 1’s COC. MD 1 further stated that, had he been notified, he (MD 1) would have ordered an insulin injection (the method of delivering insulin into the body using a needle or pen), implemented aspiration precaution (steps taken to prevent food, liquids, or vomit from accidentally entering the lungs), and initiated hydration (process of replacing water in the body) measures, depending on Resident 1’s vital signs.   During a concurrent interview and record review on 8/5/2025 at 9:56 a.m., with RN 1, Resident 1’s Progress Notes dated 7/19/2025 and Resident 1’s Physician’s Order, dated 7/15/2025, were reviewed. RN 1 stated that on 7/19/2025 at 4 a.m., Resident 1 had a BS level of 382 mg/dl, complained of nausea, and had an episode of vomiting. RN 1 stated that there was no documented evidence that Resident 1’s vital signs were taken or that an assessment was conducted when Resident 1 had a COC on 7/19/2025 at 4 a.m. LVN 1 should have checked Resident 1’s vital signs and notified MD 1 if any abnormalities (one or more key body functions like heart rate, breathing rate, blood pressure, or temperature, fall outside normal range, indicating a potential health problem that requires medical attention) were present. RN 1 further stated that LVN 1 did not recheck the elevated BS level of 382 mg/dl and that there was no ongoing monitoring of vital signs to justify that Resident 1 was not in distress (negative state). LVN 1 should have immediately notified MD 1 regarding the elevated BS result (382 mg/dl), nausea and vomiting, as these symptoms indicated a potential underlying medical issue that required further medical intervention. MD 1 might have ordered an insulin injection due to the high BS level. Resident 1’s Physician’s Order dated 7/15/2025 instructed staff to notify MD 1 if Resident 1’s BS exceeded 350 mg/dl. RN 1 stated that failure to act on these symptoms could have led to a worsening condition, and potentially death.   During an interview on 8/7/2025 at 11:05 a.m., with RN 1, RN 1 stated that Resident 1’s BS level greater than 350 mg/dl, along with nausea and vomiting constituted a COC, as these symptoms were abnormal for Resident 1. Resident 1 required a thorough assessment and appropriate medical intervention from MD 1. LVN 1 was responsible for obtaining Resident 1’s vital signs and reporting all presenting symptoms to MD 1 in order to receive appropriate medical orders to address Resident 1’s COC.   A review of the current facility-provided P&P titled, “Change of Condition Notification,” last reviewed on 4/4/2025, indicated, “To ensure …? physicians are informed of changes in the resident’s condition in a timely manner.”   A review of the current facility-provided P&P titled, “Blood Glucose (refers to the concentration of glucose [simple sugar that serves as the body’s primary source of energy] in the bloodstream) Monitoring,” last reviewed on 4/4/2025, indicated, “Notify the healthcare provider of a Blood Sugar Level … higher than 250 (mg/dl) unless otherwise indicated in the physician order.”    A review of the current facility-provided P&P titled, “Diabetic Care,” last reviewed on 4/4/2025, indicated, “In any case where the resident’s blood sugar is … greater than 350 (mg/dl), the Attending Physician must be notified: unless otherwise noted on the Physician’s order. Nursing staff will monitor the resident for signs and symptom of hypoglycemia (low BS level) or hyperglycemia, initiate intervention if necessary, and notify the Attending Physician and responsible party if the signs and symptoms are present.”   A review of the current facility-provided P&P titled, “Obtaining Vital Signs,” last reviewed on 4/4/2025, indicated, “To take clinical measurements that indicate the stated of a resident’s basic body functions…. Vitals signs will be taken: … “F. When there is a change in the resident’s condition.”