complaint·December 28, 2023

Text message indicated R1’s oxygen level was “49” and that it was “not good” and that hospice had been called. Per an interview with the administrator, the facility staff called hospice, as well as R1’s responsible party. Based on interview with administrator, facility staff did not provide any treatment other than continuing R1’s oxygen, giving a nebulizer treatment and massaging R1’s extremities. This was corroborated by a review of Facility Daily Care Notes dated 08/09/2020 for R1. Per an interview with the administrator 911 was not called because staff had contacted hospice and staff were waiting to hear back from hospice. This was refuted by a review of hospice records. Hospice death visit notes dated 08/09/2020 were reviewed. These notes revealed hospice was contacted on 08/09/2020 at 9:41am by the facility administrator. Facility administrator reported R1 had “extremely low oxygenation up to 50%...” The death visit note continues that the hospice nurse had informed the administrator about R1’s code status and that they can call 911. Note further reads, the administrator verbalized understanding. Per the death certificate dated 09/01/2020, the immediate cause of death for R1 was respiratory arrest. There is sufficient evidence to reveal 911 was not contacted, therefore, the allegation is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means the allegation is valid because the preponderance of the evidence standard has been met. An immediate civil penalty of $500 is being assessed. In accordance with H&S Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department. An exit interview was conducted where this report, the 9099D, appeal rights and the Civil Penalty assessment form and appeal rights were reviewed with Administrator Janette Rosario. *** Due to facility staff currently out of vacation and returning at different times, an extension was granted to give ample time to ensure that all staff have been retrained on resuscitative measures. The extension to submit proof of the plan of correction to the department by Friday January 12, 2024 .