Health inspection·October 30, 2025

REGULATION VIOLATION(S) F0678 42 CFR: § 483.24(a)(3) Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. (a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: (3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives. § 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[.] 22 CCR: § 72311(a)(2) Nursing Service- General (a) Nursing service should include, but not be limited to, the following: (2) Implementing each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR: §72523(a) Patient Care Policies and Procedures (a)Written patient care policies and procedures shall be implemented to ensure that patient-related goals and facility objectives are achieved. On 2/10/25, the California Department of Public Health (Department) received a complaint indicating resident neglect and death. On 2/13/25, CDPH conducted an unannounced visit at the facility to investigate the allegations. Based on its investigation, the Department determines that the facility failed to: 1. Identify and act on a need to provide emergency care and life support consistent with standard practices, the physician's orders, and the resident's directives. 2. Implement facility policies and procedures concerning emergency care, life support, and compliance with residents' advance directives As a result, the facility staff failed to recognize a cardiorespiratory arrest (a life-threatening medical emergency that occurs when the heart and lungs stop functioning properly) in Resident 1, which resulted in a delay in performing CPR (or cardiopulmonary resuscitation, a procedure to keep the blood pumping when the heart stops or when it beats too ineffectively to circulate blood to the brain and other vital organs) on Resident 1, who was a full-code (a medical directive indicating that a patient wishes to receive all possible life-saving measures in the event of a medical emergency) after he was found unresponsive. This failure was a substantial factor contributing to Resident 1's death. Findings: Resident 1 was a 77-year-old male admitted to the facility on 11/6/24. Resident 1's diagnoses at admission included acute and chronic respiratory failure (a condition where the body is not getting enough oxygen due to a failure of the lungs to properly exchange gases, which can occur suddenly or over time). Resident 1's "Physician Orders for Life-Sustaining Treatment (POLST)," dated 11/13/24, indicated a check mark next to the "Attempt Resuscitation/CPR" order. During an interview on 2/13/25 at 9 a.m., Complainant 5 stated he arrived at the facility on 2/6/25 in his capacity as a 911 emergency responder, approximately five to seven minutes after receiving a call about an unresponsive patient who was having difficulty breathing. Complainant 5 stated he found Resident 1 on a non-rebreather mask (a mask that delivers high concentrations of oxygen), diaphoretic (covered with sweat), exhibiting agonal breathing (an abnormal gasping and labored breathing pattern), and was pulseless. Complainant 5 stated two facility staff were present in Resident 1's room, but neither staff member was performing CPR on Resident 1. Complainant 5 stated he immediately started chest compressions on Resident 1. Complainant 5 stated he continued to perform CPR on Resident 1 until his time of death, about 20-25 minutes later. Complainant 5 stated an AED (automated external defibrillator, or a portable medical device that can analyze the heart's rhythm and, if necessary, deliver an electrical shock, or defibrillation, to help the heart re-establish an effective rhythm) was available at Resident 1's bedside, but the machine was not on, nor were the pads applied on Resident 1's chest. Complainant 5 stated he was later told by the staff that Resident 1 had been unresponsive and had oxygen saturation levels (a measure of how much oxygen is in your blood) in the 60's or 70's approximately 40 minutes before Complainant 5's arrival (normal range for oxygen saturation is 95% to 100%). Complainant 5 stated he could not understand why CPR was not started on Resident 1 before his arrival, or why the AED machine was not turned on and the pads applied to Resident 1 before his arrival. A review of Resident 1's "Progress Notes," dated, "2/7/25," indicated, "... At around 1650 (4:50 p.m.) respiratory nurse was doing her rounds and noticed this resident was not wearing his NC (nasal cannula [a device with two prongs that deliver oxygen directly into the nostrils]). The nurse put resident back on his O2 (oxygen) via NC, states when she was with the pt (patient) he woke up but didn't say anything. At around 1655 (4:55 p.m.) this writer went to give resident his evening medications. Resident was asleep and unable to wake up. This LN (Licensed Nurse) did a sternum rub (to determine if a person is conscious and responsive) and resident would wake up and fall straight back to sleep. This LN then took resident V/S (vital signs) again ... BP (blood pressure) 150/74, 97.5 F, 22 RPM (respirations per minute), 75 SPO2 (oxygen saturation), BG (blood glucose [blood sugar level]) 156 on 2L (2 liters of oxygen) via NC. Immediately this LN called the respiratory nurse, put his bed into high fowlers [positioned with the head elevated between 60-90 degrees], increase his 02 (oxygen) to 4L, and gave this resident his nebulizer tx [a treatment involving a device that delivers medications directly into the lungs], Resident's 02 was not increasing so this writer called 911. Respiratory nurse and Nurse Supervisor 2 was with the resident monitoring (sic). Upon completion of nebulizer tx resident's 02 was unchanged. The respiratory nurse then put a nonrebreather mask on resident and increased the 02 to 15L. Resident's 02 then went up to 97%. At around 1730 (5:30 p.m.) at the same (sic) this resident stopped breathing, and the paramedics arrived on scene. CPR was initiated by paramedics ... 30 minutes of CPR was conducted. Time of death was called at 1753 (5:53 p.m.) ..." During an interview on 2/13/25 at 1:31 p.m., Licensed Staff A stated she was called by staff, possibly a CNA, into Resident 1's room on 2/6/25 because his oxygen level was low. Licensed Staff A was unable to recall the time or Resident 1's oxygen level. Licensed Staff A stated she replaced Resident 1's nasal cannula with a non-rebreather mask. Licensed Staff A stated Resident 1 was diaphoretic and would briefly open his eyes as she performed sternal rubs. Licensed Staff A stated she did not recall what time she told Licensed Staff C to call 911, as she and another staff stayed at Resident 1's bedside. Licensed Staff A stated she continued to monitor Resident 1's breathing and performing sternal rubs. Licensed Staff A stated Resident 1 stopped breathing "very suddenly," and as she was about to get the crash cart from outside the room, she almost ran straight into the paramedics. Licensed Staff A stated she never had a chance to start CPR. During an interview on 2/13/25 1:40 p.m., Licensed Staff B stated she recalled Resident 1's death and added she was in the room "very briefly." Licensed Staff B stated Resident 1 was nonresponsive to sternal rubs. Licensed Staff B demonstrated "gasping" motions when asked to describe how Resident 1's breathing was. Licensed Staff B stated she was checking Resident 1's carotid pulse (the rhythmic pulse of the carotid arteries located on either side of the neck) while she was at the bedside, and stated Resident 1 never lost a pulse. Licensed Staff B stated there was an AED at the bedside, but it was not used. Licensed Staff B stated she had never used an AED outside of training. Licensed Staff B stated AED pads were placed on patients when CPR was started, and the AED was used when a patient became pulseless. During an interview on 2/13/25 at 1:58 p.m., Licensed Staff C stated she was about to give Resident 1 his medications the evening of 2/6/25, when he would not wake up. Licensed Staff C stated Resident 1 would briefly open his eyes as she did sternal rubs but would fall back to sleep after. Licensed Staff C stated Resident 1's vital sign (temperature, blood pressure, heart rate and respiratory rate) were normal except for his low oxygen saturation. Licensed Staff C stated she started the nebulizer treatment and called for Licensed Staff A for further assistance. Licensed Staff C stated after a few minutes of the nebulizer treatment; she called 911. Licensed Staff C stated she brought the AED to Resident 1's room per 911's instructions. Licensed Staff C stated the AED was for Licensed Staff A and B to use, as they were at Resident 1's bedside. Licensed Staff C stated CPR was not started on Resident 1 as he never lost his pulse, nor had his breathing stopped. During an interview on 2/13/25 at 3:10 p.m., the Director of Nursing (DON) stated CPR was performed when someone was unresponsive, not breathing or had lost their pulse. The DON stated she expected staff to follow the paramedics' instructions during emergency situations. A review of the facility policy titled, "Emergency Crash Cart and Automated External Defibrillators (AEDs)," dated "2023," indicated, "...The facility will ensure that at least one AED, if available, is for use in the case of cardiac emergencies... Clinical staff will be educated on the location and use of the emergency crash cart and AED..." A review of a national standard by the American Heart Association titled, "Treatment of Cardiac Arrest," dated "2025," indicated, "Cardiac arrest can strike without warning ... The signs are: Sudden loss of responsiveness - The person doesn't respond, even if you tap them hard on the shoulders or ask loudly if they're OK. The person doesn't move, speak, blink or otherwise react. No normal breathing - The person isn't breathing or is only gasping for air ... If you think the person may be suffering cardiac arrest and you're a trained lay rescuer: Ensure scene safety. Check for response. Shout for help. Tell someone nearby to call 911 or your emergency response number. Ask that person or another bystander to bring you an AED, if there's one on hand. Tell them to hurry - time is critical. If you're alone with an adult who has signs of cardiac arrest, call 911 and get an AED (if one is available). Check for no breathing or only gasping. If the person isn't breathing or is only gasping, begin CPR with compressions. Administer high-quality CPR. Push down at least two inches in the center of the chest at a rate of 100 to 120 pushes a minute. Allow the chest to come back up to its normal position after each push. Use an AED. As soon as it arrives, turn it on and follow the prompts. Continue CPR. Administer it until the person starts to breathe or move, or until someone with more advanced training, such as an EMS team member, takes over ..." A review of the document titled, "CPR Facts and Statistics" by, "The American Red Cross Training Services," published "October 2, 2024," indicated, "Out-of-Hospital Cardiac Arrest Facts: Survival chances decrease by 10% for every minute that immediate CPR and use of an AED is delayed. Immediate CPR can triple the chance of survival ..." Based on its investigation, the Department determines that the facility failed to: 1. Identify and act on a need to provide emergency care and life support consistent with standard practices, the physician's orders, and the resident's directives. 2. Implement facility policies and procedures concerning emergency care, life support, and compliance with residents' advance directives As a result, the facility staff failed to recognize a cardiorespiratory arrest (a life-threatening medical emergency that occurs when the heart and lungs stop functioning properly) in Resident 1, which resulted in a delay in performing CPR (or cardiopulmonary resuscitation, a procedure to keep the blood pumping when the heart stops or when it beats too ineffectively to circulate blood to the brain and other vital organs) on Resident 1, who was a full-code (a medical directive indicating that a patient wishes to receive all possible life-saving measures in the event of a medical emergency) after he was found unresponsive. This violation of the regulation presented an imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result and was a substantial factor contributing to Resident 1's death.