Health inspection·January 21, 2026

F580 42 CFR §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 22 CCR § 72311. Nursing Service-General (Notification of Change) (a) Nursing service shall include, but not be limited to, the following: (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 12/12/2025 at 10:50 AM, the California Department of Public Health (CDPH) conducted an unannounced visit to investigate a complaint regarding not assessing and monitoring resident’s change of condition. The facility failed to immediately inform the physician of Resident 1 who had a diagnosis of hypertension (high blood pressure) and cerebral infarct (the death of brain tissue from a sudden blockage of blood flow, depriving brain cells of oxygen and nutrients) of Resident 1’s change of condition. The facility failed to: 1. Ensure the physician was notified by licensed nurse when Resident 1 was reported by Certified Nurse Assistant (CNA) 1 that Resident 1 was “sleepier than usual” on 12/7/2025 and 12/8/2025. 2. Ensure Licensed Vocational Nurse 1 (LVN 1) notified Resident 1’s physician timely within 15 minutes from when Resident 1 had a change of condition when Resident 1 was assessed to have a blood pressure (BP) of 153/91 millimeters of mercury (mmHg – a standard unit of measuring blood pressure. Normal blood pressure for adults is generally considered less than 120/80 mm Hg) on 12/8/2025, at 8:07 AM. As a result, Resident 1’s BP was measured at 210/92 mmHg (it is considered hypertensive emergency [a severe, sudden spike in blood pressure over 180/120 mmHg that can cause damage to organs like the brain such as intracranial hemorrhage {brain bleed- this is a life-threatening neurological emergency, often called a hemorrhagic stroke, where uncontrolled high blood pressure damages arteries, leading to bleeding into the brain tissue}] because the extreme pressure overwhelms brain blood vessels, causing them to weaken, rupture, and leak blood), was assessed to be lethargic (lack of energy and decrease in consciousness), and was unable to respond verbally on 12/8/2025 at 1 PM. Resident 1 was then transferred to General Acute Care Hospital (GACH) via 911 emergency services (EMS – provides emergency medical care) on 12/8/2025 at 2 PM and was admitted to the GACH’s Emergency Department (ED). While in GACH, Resident 1 underwent Computerized Tomography scan (CT scan – imaging using x-ray [a photographic or digital image of the internal composition of a part of the body] technique to create detailed images of the body) of the head in GACH and result showed bleeding in the cerebral hemisphere (half of a brain, right or left) of 7.4 centimeters (cm- unit of measure) in craniocaudal (measuring from the head down) by 2.7 cm by 3.5 cm in the transverse dimension (a measurement or direction across). Resident 1 was intubated (breathing tube has been inserted into the windpipe to keep the airway open) in the GACH’s ED and admitted to the intensive care unit (ICU – a department in the hospital in which patients who are dangerously ill are kept under constant observation) with acute intracranial hemorrhage.  A review of Resident 1’s Admission Record, the Admission Record indicated the resident is a 75-year-old-male resident who was originally admitted at the facility on 4/18/2025 with the following, but not limited to, diagnoses of hypertension, anxiety (feeling of worry or fear, but when it is excessive, persistent, and interferes with daily life) and cerebral infraction. A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 12/1/2025, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. Resident 1 required substantial/maximal assistance (Helper lifts or holds trunk or limbs and provides more than half the effort) with sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, walking 10 feet, eating and upper body dressing. Resident 1 is dependent (Helper does all of the effort. The resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity) with oral hygiene, toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear.  A review of Resident 1’s Weights and Vitals Summary dated 12/8/2025, indicated Resident 1’s BP read 153/91 mmHg at 8:07 AM. A review of Resident 1’s Progress Notes, dated 12/8/2025, from 10:11 AM to 10:12 AM, the progress notes indicated Resident 1 refused medication and the physician was made aware. The progress notes did not specify the physician was made aware regarding Resident 1’s elevated BP of 153/91 mmHg. A review of Resident 1’s Progress Notes, dated 12/8/2025, at 1:00 PM, indicated Resident 1 was “sleepy” and refused to open his mouth. A review of Resident 1’s Weights and Vitals Summary dated 12/08/2025, at 1:00 PM, indicated Resident 1’s BP was 210/92 mmHg. 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 [is a significant, sudden shift in a person's physical, mental, behavioral, or functional state from their baseline, requiring clinical attention] among the residents), dated 12/8/2025, indicated the resident refused lunch and was sleepy. The SBAR indicated Resident 1 refused to open mouth when given medication at 1 PM, was very lethargic and was unable to respond verbally. A review of Resident 1’s Progress Notes, dated 12/8/2025, at 2:10 PM, indicated Resident 1 was transferred to the GACH at around 2 PM. A review of Resident 1’s GACH Emergency Department (ED) Hospital Admission notes, dated 12/8/2025, at 4:31 PM, indicated Resident 1 had an altered mental status, and that his blood pressure was elevated. The notes also indicated Resident 1 was very lethargic and confused. A review of Resident 1’s GACH ED Hospital Admission notes, dated 12/8/2025, at 5:16 PM, indicated a CT of the brain was done which showed bleeding in the cerebral hemisphere of 7.4 cm in craniocaudal by 2.7cm by 3.5cm. A review of Resident 1’s GACH ED Hospital Admission notes, dated 12/8/2025, at 5:20 PM, indicated Resident 1 had a diagnosis of intracranial hemorrhage and hypertensive emergency. A review of Resident 1’s GACH Discharge Summary Note, dated 12/8/2025, indicated Resident 1 arrived at the ED completely unresponsive, and underwent a CT scan which showed a large left cerebral hemisphere parenchymal (tissue of the brain) hemorrhage. Resident 1 was then intubated in the ED and admitted to the ICU. During an interview on 12/11/2025, at 4:43 PM, Certified Nursing Assistant (CNA) 1 stated Resident 1 was sleepier than usual and did not open his mouth to eat his lunch on 12/7/2025, during the 7 AM to 3 PM shift and that she reported this to Registered Nurse (RN) 1 at noon on 12/7/2025. CNA 1 also stated Resident 1 is normally active. During an interview with Resident 1’s Responsible Party (RP) on 12/12/2025, at 11:15AM, RP stated when she went to go see Resident 1 on 12/7/2025, around 5 PM to 5:30 PM at the facility, RP was unable to wake Resident 1 up and reported it to the facility staff (unable to recall who). During a phone interview on 12/12/2025, at 11:33 AM, Licensed Vocational Nurse (LVN) 3, who works the 3PM to 11PM shift, stated Resident 1 is usually active but was more sleepy than usual on 12/7/2025. LVN 3 stated she did not notify the physician about the resident being unusually sleepy, but LVN 3 endorsed it to the licensed nurse on the next shift (11PM -7AM). During an interview on 12/12/2025, at 12:05 PM, RN 1 stated, on 12/7/2025 from 7 AM to 3 PM shift, that CNA 1 stated Resident 1 was more sleepy than usual. She (RN 1) did not notify the physician. During an interview on 12/12/2025, at 12:26 PM, CNA 2 stated Resident 1 did not eat his breakfast and lunch on 12/8/2025 and was unusually sleepier. CNA 2 also stated this is not Resident 1’s normal behavior and CNA 2 did not report it to the licensed nurse. During an interview on 12/12/2025, at 1:35 PM, Resident 1’s current Care Plans dated 4/22/2025 to 12/11/2025, were reviewed. The care plan indicated a care plan with focus hypertension and chest pain was initiated on 4/22/2025. The care plan to monitor vital signs (key measurements of your body's most basic functions, including temperature, pulse (heart rate), respiratory (breathing) rate, and blood pressure) and report any abnormal findings to the physician. The Director of Nursing (DON) stated that as Resident 1 was more sleepy than the resident’s usual level of consciousness, that should have been considered a change of condition and that the physician should have been notified timely after RP reported it to the facility both on 12/7/2025, and then when Resident 1’s BP was 153/91 mmHg on 12/8/2025 around 8:07 AM. During an interview on 12/12/2025, at 2:09 PM, Nurse Practitioner (NP) stated he was neither informed of Resident 1’s change of condition of sleepiness nor of Resident 1’s elevated BP on 12/8/2025 at 8:07 AM. NP also stated Resident 1’s BP of 153/91 mmHg should have been reported. Failing to do so would delay care for Resident 1. NP stated if the BP of 153/91 mmHg was addressed to him, he would have ordered Resident 1 to be transferred to the GACH. During an interview on 12/12/2025, at 2:15 PM, with the DON, the DON stated Resident 1’s BP of 153/91 mmHg constitutes a change of condition. The DON stated that the licensed nurse should have notified the physician/NP regarding Resident 1’s elevated BP of 153/91 mmHg to obtain an order to address the elevated BP. The DON also stated Resident 1’s change of condition should have been reported in a timely manner, which according to the facility’s policy means 15 minutes. Resident 1’s change of condition was not reported timely. During an interview on 12/12/2025, at 3:15 PM, LVN 1 (who worked the 7AM-3 PM shift when the incident happened) stated Resident 1’s elevated BP pf 153/91 mmHg and sleepier than usual is considered a change of condition and the physician needs to be notified within 15 minutes. LVN 1 also stated the physician was not notified within 15 minutes from when Resident 1’s BP was assessed to be at 153/91 mmHg on 12/8/2025 at 8:07AM. She (LVN 1) should have notified Resident 1’s physician so that the facility could have provided interventions and prevented Resident 1’s BP progressing to 210/92 mmHg which may have prevented Resident 1’s hospitalization. During an interview on 12/15/2025, at 1:16 PM, the facility’s Medical Director (MD) stated if a resident’s BP is elevated, the nurse should report it to the physician timely, and that the resident should have been sent to the hospital. Resident 1 was sleepier than usual and had an elevated BP on 12/8/2025 at 8:07AM, it should have been reported to the physician timely. Such notification should not have waited until Resident’s 1BP was 210/92 mmHg in the afternoon. A review of the facility’s P&P titled “Change of Condition Notification,” revised 11/1/2017, was reviewed. The P&P indicated “an acute change of condition (ACOC) is a sudden, clinically important deviation from a patient’s (resident’s) baseline in physical” and “clinically important means a deviation that without intervention may result in complications or death.” The P&P also indicated “the facility will promptly inform the resident, consult with the resident’s attending physician… when the resident endures a significant change in their condition caused by, but not limited to… a significant in change in the resident’s physical status… a decision to transfer or discharge the resident from the facility.” The facility failed to immediately inform the physician of Resident 1 who had a diagnosis of hypertension and cerebral infarct of Resident 1’s change of condition by failing to: 1. Ensure the physician was notified by licensed nurse when Resident 1 was reported by CNA 1 that Resident 1 was “sleepier than usual” on 12/7/2025 and 12/8/2025. 2. Ensure LVN 1 notified Resident 1’s physician timely within 15 minutes from when Resident 1 had a change of condition when Resident 1 was assessed to have a BP of 153/91 mmHg on 12/8/2025 at 8:07 AM. As a result, Resident 1’s BP went up to 210/92 mmHg, was assessed to be lethargic, and was unable to respond verbally on 12/8/2025, at 1 PM. Resident 1 was then transferred to GACH via 911 EMS on 12/8/2025, at 2 PM and was admitted to the GACH’s ED. While in the GACH, Resident 1 underwent a CT scan of the head, which showed bleeding in the cerebral hemisphere of 7.4 cm in craniocaudal by 2.7 cm by 3.5 cm in the transverse dimension. Resident 1 was intubated in the GACH’s ED and admitted to the ICU with acute intracranial hemorrhage.  The above violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability for the death of Resident 1.