Health inspection·October 29, 2025

The following reflects the findings of the California Department of Public Health during the investigation of: Complaint # 2553450 Survey Event ID: 1D1183-H1 State Citation B was written. § 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. (c) Skilled nursing facilities providing intermediate care services shall do so in a distinct part separately approved by the Department and shall be in conformity with the licensing regulations for the type of service provided in that distinct part. The facility license shall indicate approval of the distinct part by the Department. (d) Written arrangements shall be made for obtaining all necessary diagnostic and therapeutic services prescribed by the attending physician, podiatrist, dentist, or clinical psychologist subject to the scope of licensure and the policies of the facility. If the service cannot be brought into the facility, the facility shall assist the patient in arranging for transportation to and from the service location. (e) Arrangements shall be made for an advisory dentist to participate at least annually in the staff development program for all patient care personnel and to approve oral hygiene policies and practices for the care of patients. (f) The facility shall ensure that all orders written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. (g) The facility shall make arrangements for a physician or physicians to be available to furnish emergency medical care if the attending physician, or designee, is unavailable. The telephone numbers of those physicians shall be posted in a conspicuous place in the facility. On 7/17/2025 at 9:45 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding an allegation. Resident 1 was admitted to the facility in December 2023 with multiple medical diagnoses which included multiple fractures, cerebral infarction (stroke) and chronic pain syndrome. Resident 1 had been on long-term use of narcotics for chronic pain. In April of 2025 Resident 1 was admitted into hospice care (end-of-life comfort care). Progression through hospice care eventually leads to an inability to swallow. In April 2025 Resident 1 lost her ability to swallow narcotic pills. The facility had no plans in place to address narcotic withdrawal symptoms. This resulted in Resident 1 becoming agitated, in "Severe discomfort" and screaming at the end-of-life. During a review of Resident 1's clinical document titled "MDS 3.0 Nursing Home Quarterly (NQ) Version 1.19.1" (Resident Assessment) dated 3/26/2025, the MDS indicated, Resident 1 was alert, could repeat the number of words presented to her and could identify the year and month. During a review of Resident 1's clinical document titled "Order Summary Report" dated 4/1/2025, the document indicated, staff were to administer Baclofen (muscle relaxant) 3 times per day, Lyrica (medication for nerve pain) 3 times per day and oxycodone 10 milligrams 4 times a day (narcotic) for pain management for Resident 1. During a review of Resident 1's clinical document titled "Medication Administration Record (MAR)", dated March 2025, the MAR indicated Resident 1 had received the medications Baclofen, Lyrica and Oxycodone every day in March and into April of 2025. Further review of the MAR showed the start date for the oxycodone was 1/2/2024. During a review of Resident 1's MAR dated April 2025, the MAR indicated Resident 1 was able to take the Baclofen and Lyrica the morning of 4/12/2025 but refused subsequent dosages. Further review of the MAR showed the last dose of oxycodone was administered on 4/11/2025 at 5 p.m. During a review of Resident 1's clinical document titled "Progress Notes *NEW*", the progress notes indicated, on 4/12/2025 at 2:33 a.m., Resident 1 was "Resting comfortably but arousable. No complaints of pain or discomfort." Review of the note dated 4/12/2025 at 11:07 p.m. showed Resident 1 "Appeared to be (having) multiple (episodes of) confusions and episodes of screaming during shift." Resident 1 had "Refused most of the medications, Morphine and Ativan given..." (30 hours and 7 minutes since the last administered dose of oxycodone) (Morphine: pain medication) (Ativan: anti-anxiety medication) During a review of Resident 1's clinical document titled "Pulse Summary" indicated at 9:22 p.m. on 4/12/2025, Resident 1's pulse was elevated at 98. Her baseline range for April 2025 showed a pulse in the 60's and 70's. (normal range is 60-100) Review of the document "O2 Sats Summary" showed Resident 1's oxygen saturation at 9:22 p.m. on 4/12/2025 was 52% (amount of oxygen in the blood: normal range 95-100%) During further review of Resident 1" s progress notes showed the following: 4/13/2025 at 10:43 a.m. - "Resident is having frequent episodes of restlessness, agitation and screaming. Resident is clearly in severe discomfort despite administering morphine and Ativan..." 4/13/2025 at 1:50 p.m. - "Resident is still in severe discomfort and distress." 4/13/2025 at 9:55 p.m. - "Resident is in declining condition. Resident appears to be (having) episodes of confusion and screaming." There was nothing in the clinical record which showed the doctor had been notified regarding the screaming and abrupt discontinuation of the oxycodone. During a record review of the document "Hospice Admission Plan of Care" dated 4/7/2025 indicated no plan had been put into place to address stopping the oxycodone and potential for withdrawal. During an interview on 7/16/2025 at 4:44 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN1 confirmed, on 4/12/2025 Resident 1 had refused most of her medications and was agitated. LVN 1 stated she had not notified the doctor regarding the screaming and abrupt stoppage of the oxycodone but stated she should have because "Something was wrong" with the medication. During an interview on 7/25/2025 at 2:06 p.m., with Director of Nursing (DON), DON confirmed there was nothing in the clinical record which showed the doctor had been notified regarding the abrupt stopping of the oxycodone and continued screaming. The DON also stated, "Stopping Oxycodone suddenly can cause withdrawal symptoms" and there had been no back-up plan or updated plan of care in place when Resident 1 could no longer swallow the oxycodone. During an interview on 7/28/2025 at 1:57 p.m., with DON, DON stated Resident 1 had not received the oxycodone on 4/12/2025 because she was getting lethargic and "Could not swallow it." The DON stated signs of withdrawal included being "Anxious, can't relax, irritable, restless, mood changes." During a review of Resident 1's clinical document titled "Progress Notes *NEW*" dated 4/14/2025 timestamped at 7:40 a.m., the progress note indicated Resident 1 was "Sleeping with daughter and hospice nurse at bedside, occasional moaning noted, routine morphine given and Lorazepam (anti-anxiety medication)) with good result." (41 hours and 46 minutes since she was last described as "Resting comfortably" on 4/12/2025 at 2:33 a.m.) Record review of Resident 1's clinical document titled "Progress Notes *NEW* dated 4/14/2025 showed Resident 1 passed away on 4/14/25 at 1:40 p.m. During an interview on 8/11/2025 at 11:05 a.m., with facility's consulting pharmacist (CP), CP stated "You never want to stop oxycodone because of withdrawal." The CP stated best practice is to use something like alcohol withdrawal and typically there is a protocol that is used. The CP stated one option would have been for staff to slowly decrease the dosage of the oxycodone and consulted with a pain management group "Especially as she developed swallowing issues." In violation of the above cited standards, the facility failed to ensure Resident 1 was pain-free and comfortable while in hospice. Staff did not ensure a plan had been put into place to address withdrawal symptoms in anticipation of Resident 1's eventual inability to swallow narcotic medication. This failure resulted in Resident 1 screaming with agitation for several hours. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.