Health inspection·April 10, 2025

Code of Federal Regulations, Title 42 F684 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, the comprehensive person-centered care plan, and the residents’ choices, including but not limited to the following: 42CFR §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. California Code of Regulations, Title 22, Section 22 CCR § 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. (b) Skilled nursing facilities caring for patients who are mentally disordered and whose needs for a special treatment program are identified shall also meet the requirements for a special treatment program service. (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. An unannounced visit was conducted by California Department of Public Health on 2/25/2025 to investigate an allegation of the facility failed to send the resident to hemodialysis (HD-a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) and provide needed care, which lead to the resident was transferred to General Acute Care Hospital (GACH). The facility failed to ensure Resident 1 received treatment and care in accordance with facility’s policies and procedures by failing to: 1. Call alternate transportation to ensure Resident 1 receive HD treatment as ordered and as scheduled on 2/12/2025. 2. Transcribe the order for Resident 1 to be monitored for fluid overload (too much fluid in the body which can raise the blood pressure [BP-the pressure of blood on the walls of the arteries as the heart pumps blood around the body] and force the heart to work harder and can also make it hard to breathe) after missing the HD treatment on 2/12/2025. 3. Administer BP medications on 2/12/2025 as ordered by the physician. This resulted in Resident 1 missing scheduled HD treatment and transfer to GACH on 2/12/2025 due to shortness of breath, chest pain, and elevated BP, which could potentially lead to prolonged hospitalization, harm, and/or death. A review of Resident 1’s Admission Record, the Admission Record indicated Resident 1, a 76-year-old-female, was initially admitted on 6/30/2021 and readmitted on 5/19/2023 with diagnoses that included but not limited to end stage renal disease (ESRD-irreversible kidney failure), dependence on HD, hypertension (HTN-high blood pressure), atrial fibrillation (Afib-a condition where the upper chambers of the heart [atria] beat irregularly and rapidly), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 1’s Minimum Data Set (MDS-a resident assessment tool), dated 12/27/2024, the MDS indicated Resident 1 had intact cognitive skills for daily decision making. The MDS also indicated Resident 1 was independent (Resident completes the activity by themselves with no assistance from a helper) with eating, required set up or clean up assistance (Helper sets up or cleans up, Resident completes activity. Helper assists only prior to or following the activity) with oral and toileting hygiene, upper body dressing and putting on/taking off footwear. The MDS further indicated Resident 1 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with shower/bathing self, lower body dressing, and personal hygiene. A review of Resident 1’s Order Summary, dated 2/3/2025, the Order Summary indicated the following: • Dialysis at Dialysis Center 1 every Monday-Wednesday-Fridays; with order date of 1/15/2025. • Transportation arrangement for wheelchair van, 7 AM pick up and chair time of 8:30 AM; with order date of 1/15/2025. During a review of Resident 1’s Order Summary, dated 2/3/2025, the Order Summary indicated: • Amlodipine Besylate (medication used alone or in combination with other medications to treat high blood pressure in adults and children 6 years and older.) oral tablet 10 milligram (mg-a unit or mass or weight in the metric system equivalent to a thousandth of a gram), give one tablet by mouth one time a day for HTN. Hold for systolic BP below 110 millimeters of mercury (mmHg- a unit of pressure measurement, most used to measure BP) or heart rate below 60 beats per min (bpm-number of times the heart beats in a one-minute period); with order date of 1/29/2025. • Losartan potassium (It's widely used to treat high blood pressure (hypertension) and heart failure. It's also used to protect your kidneys if you have both kidney disease and diabetes (diabetic kidney disease).) oral tablet 25 mg, give one tablet by mouth in the morning for HTN. Hold if systolic BP is below 110 mmhg or heart rate below 60 bpm; with order date of 1/29/2025. During a concurrent interview and review on 2/25/2025 at 1:53 PM with Licensed Vocational Nurse 1 (LVN1), the Progress Notes for Resident 1, dated 2/12/2025, was reviewed. The Progress Notes indicated at 9:04 AM, a Situation, Background, Assessment, and Recommendation (SBAR-a structured communication framework used in healthcare to facilitate clear and concise communication between healthcare professionals) was documented by LVN 1. The SBAR indicated LVN 1 notified the Physician (also known as MD-Doctor of Medicine) that Resident 1 missed HD treatment due to transportation issues and HD treatment was rescheduled for the next day. The SBAR indicated the MD ordered to monitor Resident 1 for any signs and symptoms (s/s, observable and measurable manifestations of a disease or condition that can be detected by a health professional) of fluid overload. LVN 1 stated the MD order to monitor the resident for s/s of fluid overload was not but should have been transcribed in the Order Summary (a concise overview of a patient’s medical orders, treatments, and procedures, often presented in a chronological manner to facilitate quick understanding and efficient care). Per LVN 1, she informed LVN 4, who was passing medications on 2/12/2025 during the 7 AM to 3 PM shift that Resident 1’s HD was rescheduled for next day. LVN 1 also stated unable to provide documented evidence that Resident 1 was monitored for s/s of fluid overload. LVN 1 stated it was important to document findings, so the rest of the healthcare team were aware of what was being monitored. During a concurrent interview and review of Resident 1’s Change of Condition (COC) notes on 2/25/2025 at 2 PM with LVN 1, LVN 1 stated as written on the COC notes, she called the transportation company (TC) three times. LVN 1 stated she called TC before 7:30 AM on 2/12/2025 to confirm pick up for Resident 1. LVN 1 stated according to TC, they could not find a driver. LVN 1 called the TC again at 8 AM and at 8:30 AM but was made aware that the TC company still did not have a driver. LVN 1 stated she had notified the HD Center of the transportation delay for Resident 1. LVN 1 stated the HD Center rescheduled Resident 1’s HD (after the 8:30 AM call) for the next day as they were already full on 2/12/2025. LVN 1 then notified the MD and LVN 4 who was passing medications that Resident 1 would not be going for her HD treatment. LVN 1 stated she did not call alternate transportation as this TC company was the assigned TC by Resident 1’s health insurance. LVN 1 stated that MD was notified and gave orders to monitor for fluid overload. LVN 1 stated MD was made aware that HD had been rescheduled for the next day. During a concurrent interview and record review on 2/25/2025 at 2:47 PM with LVN 2, the SBAR documented by LVN 2 on 2/12/2025 at 7:45 PM was reviewed. The SBAR indicated BP of 224/123 taken at 7:30 PM, Respiratory rate (RR-number of breaths taken per minute) of 21 taken at 7:49 PM, Pulse oximetry (non-invasive method of measuring the saturation of oxygen [O2-a colorless, odorless gas that is essential for life] in a person’s blood) of 96% taken at 6:19 AM at room air. LVN 2 stated he next saw Resident 1 around 4 PM to 5 PM on 2/12/2025 during medication pass. LVN 2 observed Resident 1 as being “off” and quiet, which was unusual of Resident 1. LVN 2 stated he made rounds around 7 PM and Resident 1 complained of SOB and chest pain. LVN 2 stated Resident 1 was short of breath, in tripod position (a posture where a person leans forward while supporting their upper body with their hands or forearms on a surface such as a table, bed, or their knees which can help with breathing by optimizing the use of the neck and upper chest muscles to get more air into the lungs). LVN 2 stated after checking Resident 1’s vital signs (measurements of the body’s most basic functions, such as breathing, heart rate, BP, and temperature), he placed Resident 1 on O2 at 2 liters per minute (LPM-flow rate of O2 delivered to a patient by cannula or mask per minute) by O2 mask (medical device that delivers oxygen covering the nose and mouth) using an oxygen concentrator (a medical device that increases the amount of O2 in the air you breathe) for comfort. LVN 2 stated he was not sure what the flow rate of O2 should be when using an O2 mask. During a concurrent interview and record review on 2/25/2025 at 3:05 PM with LVN 1, the Medication Administration Record (MAR-a report detailing the drugs administered to a patient by a healthcare professional) was reviewed. The MAR indicated amlodipine (a medication used to treat HTN and chest pain) and losartan (medication used to treat HTN and heart failure) were initialed by LVN 4 with chart code “9” (9=Other/see progress notes). LVN 1 stated the code “9” means medications were not given and see progress notes for the reason. LVN 1 stated she informed LVN 4 that Resident 1 would not be going to her HD treatment as scheduled, so Resident 1’s BP medications should have been given and not held. LVN 1 stated there was no progress notes that indicated the reason for not giving the medications. LVN 1 stated that if the BP meds were given as ordered, this could have prevented Resident’s 1’s BP to be at 224/123 at 7:30 PM. During an interview on 2/25/2025 at 3:25 PM with the Director of Nursing (DON), the DON stated Resident 1 missed the HD treatment and had subsequent change in condition later in the day, on 2/12/2025. The DON stated, MD was made aware that Resident 1 missed the scheduled HD treatment on 2/12/205 and was rescheduled the next day. The DON stated MD ordered to monitor resident for s/s of fluid overload. The DON stated it was important for residents on HD to make it to their scheduled HD treatments as it could cause fluid overload and other conditions that could result in transfer to acute hospital. During an interview on 2/26/2025 at 1:45 PM with the Admissions Coordinator (AC), AC stated he was in charge of setting up transportation for residents requiring dialysis. AC stated he arranged Resident 1’s wheelchair accessible van transportation to HD with the TC that was contracted with Resident 1’s insurance. AC stated there was a list of alternate or back up transportation in the appointment book at the Nurses’ Station. AC stated licensed staff should have called for an alternate transportation to ensure Resident 1 did not miss HD treatments and avoid negative impact on the resident’s health and wellbeing. During a concurrent interview and record review on 2/26/2025 at 3:05 PM with LVN 1, the Progress Notes documented by LVN 2 dated 2/12/2025 at 11:04 PM (late entry) was reviewed. LVN 1 stated that Resident 1 had SOB and chest pain, paramedics were called and arrived at 7:21 PM and subsequently transferred to GACH. During an interview on 2/26/2025 at 5:10 PM with Registered Nurse 1 (RN 1), RN 1 stated that BP medications should have been given on 2/12/2025 by LVN 4 as Resident 1 missed her HD appointment due to no transportation. RN 1 also stated that BP medications were held on HD days to prevent a low BP during HD. RN 1 stated Resident 1 should have received BP medications as ordered after HD was cancelled on 2/12/2025. A review of Resident 1’s GACH Emergency Room records dated 2/12/2025 at 9:07 PM, the GACH records indicated Resident 1’s chief complaints were SOB and chest pain, was quite hypertensive in the field and was given Nitroglycerin (used to treat episodes of chest pain caused by coronary artery disease [narrowing of blood vessels that supply blood to the heart]) x 3 doses. GACH records also indicated Resident 1 presented with chest pain and SOB consistent with fluid overload from missed HD, was extremely hypertensive initially, and was given intravenous (refers to a way of giving a drug or other substance through a needle or tube inserted into a vein) Lasix (medication used to treat excessive fluid accumulation caused by congestive heart failure and renal failure) for bilateral pleural effusions consistent with fluid overload. GACH records further indicated diagnoses made in the Emergency room on 2/12/2025 at 9:17 PM was acute hypoxic respiratory failure requiring bilevel positive airway pressure (BIPAP-a noninvasive ventilator that helps you breathe), acute renal failure (sudden loss of the ability of the kidneys to excrete wastes, concentrate urine, conserve electrolytes, and maintain fluid balance) and hypertensive urgency (a situation where BP is very high [180/110 mmHg or higher] requiring prompt medical attention). A review of GACH Nephrology (concerns the diagnosis and treatment of kidney diseases) Consult Notes, dated 2/12/2025, Resident 1’s acute medical issues were: 1. Acute fluid overload 2. Bilateral pleural effusions (having an abnormal buildup of fluid in the space surrounding both lungs [the pleural space]) and pulmonary edema (a condition where too much fluid builds up in the lungs, making it difficult to breathe). 3. Marked dyspnea (noticeably or severely difficult or labored breathing) due to fluid overload Nephrologist ordered a stat (from the Latin word statim, meaning “immediately”) HD to prevent Resident 1 from requiring intubation (a medical procedure where a tube is inserted through the mouth or nose into the trachea [windpipe] to help a person breathe when they cannot do so on their own) and mechanical ventilation (a medical procedure where a machine, called a ventilator, helps a person breathe by moving air into and out of their lungs when they are unable to do so on their own). A review of the Emergency Medical Services Run Sheet (a detailed document completed by Emergency Medical Services [EMS] personnel after a medical response or transport; a record of the patient’s condition, care provided, and the circumstances surrounding the call), dated 2/12/2025 at 7:20 PM, the EMS Run Sheet indicated RR of 40 breaths per minute, BP of 210/74 taken at 7:35 PM. The EMS run sheet also indicated the patient was found sitting in bed in severe distress for 10 minutes, was found wearing a non-rebreather mask (a medical device used to deliver high concentrations of O2 to patients, typically in emergency situations) that was not connected to an oxygen source. The EMS run sheet also indicated the patient was speaking in one-word sentences, gasping for air, tripoding, jugular vein distention (JVD-bulging of the major veins in the neck, a key symptom of circulatory problems and can happen with conditions that can be life-threatening), and the patient was placed on CPAP. The EMS run sheet further indicated the patient was showing signs of pulmonary edema secondary to missing the dialysis session. A review of the facility’s Policy and Procedures (P&P), titled, “Referrals to outside Services,” revised 1/22/2025, the P&P indicated its purpose was to provide residents with outside se