Health inspection·December 4, 2025

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure they obtained a credible Physicians Orders for LifeSustaining Treatment ([POLST] a portable medical order form for seriously ill or frail individuals that translates that provides specific instructions for medical professionals when a person can't speak for themselves) for one of three sampled residents (Resident 1) By failing to: 1. Obtain the POLST from Resident 1, who was capable of signing her own consent instead of allowing Resident 1's Family Member (FM 1), who was designated as Resident 1's emergency contact (a person designated by the resident to be notified first in the event of a medical or general emergency), and who only interpreted for Resident 1, to sign Resident 1's POLST, which indicated ([DNR] a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation (CPR) if breathing stops or the heart stops beating). 2. Prevent confusion by not determining before an emergency situation occurred with Resident 1 what her code status (a physician ordered directive outlining whether or not they should receive full life-saving interventions like CPR if their heat or breathing stops) outlining weather was, instead of inquiring with FM 2 who was at Resident 1's bedside and then phoning FM 1 to ask what they wanted to do. These deficient practices resulted in the inability of the facility to determine Resident 1's code status during Resident 1's medical emergency and a delay in life sustaining procedures ([CPR] an emergent life sustaining procedure performed when the heart stops breathing). When the paramedics arrived to the facility they performed CPR on Resident 1. Resident 1 expired at the facility. Findings: During a review of Resident 1's admission Record (Face Sheet) the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing), generalized muscle weakness and an anxiety disorder (a mental health condition where a person experiences constant worrying). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated [DATE], the MDS indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding ability) was moderately impaired. During a review of Resident 1's POLST dated [DATE], the POLST which was signed by FM 1 on [DATE], indicated DNR and to provide comfort-focused treatment (relieve pain and suffering with medication). During an interview on [DATE] at 11:54 a.m., FM 1 stated sometime after 3p.m., on [DATE] she received a telephone call from a nurse (unknown), the nurse stated Resident 1 does not look good and she wanted to know if she (FM 1) wanted Resident 1 to have CPR. FM 1 stated she told the nurse that she (FM 1) was not Resident 1's Responsible Party (RP) and only translated for Resident 1. FM 1 stated she changed her mind and told the nurse on the telephone, yes you can do CPR. During an interview on [DATE] at 12:15 p.m., FM 2 stated he arrived at the facility at 1:30 p.m., to visit Resident 1. FM 2 stated Resident 1 was agitated, moving around and she told him she wanted to go to a General Acute Care Hospital (GACH). FM 2 stated he told a nurse Page 1 of 2 055918 055918 12/04/2025 Villa Del Sol Post Acute 16910 Woodruff Ave. Bellflower, CA 90706

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (unknown) his mom did not feel well, and she did not look good. FM 2 stated a nurse (unknown) came to Resident 1's room, assessed her and she left the room. Later the nurse told him the paramedics (transportation) would arrive in 45 minutes. FM 2 stated around 3:45 p.m., Resident 1 looked worse, so he went to the door to call for assistance from a nurse. FM 2 stated Certified Nurse Assistant (CNA)1, who was in the room with him and Resident 1 stated I think you should sit next to Resident 1 because she was not breathing. FM 2 stated he looked at Resident 1 she was pale, and her mouth was open. FM 2 stated LVN 1 arrived in the room and asked him if it was ok to give Resident 1 CPR. FM 2 stated he told LVN 1 you have to call FM 1 because he doesn't make the decisions. During an interview on [DATE] at 12:30 p.m., LVN 1 stated he saw that Resident 1 did not look well, he checked Resident 1's pulse and it was weak. LVN 1 stated he checked Resident 1's POLST, which indicated DNR. LVN 1 stated, FM 2 was in the room with Resident 1, so he asked FM 2, what do you want us to do, LVN 1 stated FM 2 said call FM 1. LVN 1 stated he usually called the family to report a change of condition (COC) because the family might change their mind regarding resident's code status. LVN 1 acknowledged and stated what he did could cause confusion and go against the Resident 1's right to have their wishes met, per the POLST. During an interview on [DATE] at 1 p.m., Registered Nurse (RN) 1, stated, when a resident stops breathing, she (RN 1) always calls the family to let them know the resident's condition because sometimes the family changes their mind about the resident's code status. During an interview on [DATE] at 3:10 p.m., LVN 2 stated CPR was not started on Resident 1 until after FM 1 was called. LVN 2 stated this was not a good practice because life saving measures could be delayed and it went against Resident 1's wishes. During an interview on [DATE] at 1:57 p.m., the Director of Nursing (DON), stated calling the family during an emergency to see if they wanted to change the DNR status was not the correct practice. The DON stated calling FM 1 and doctors cause a delay in starting CPR. During a review of the facility' Policy and Procedure (P/P), titled Resident's Rights, dated 2022, the P/P indicated he resident has the right to a dignified existence, self-determination. The P/P indicated the resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. During a review of the facility's Policy and Procedure (P&P) titled, Physician Orders for Life Sustaining Treatment (POLST) dated [DATE] the P&P indicated completing a POLST form is voluntary. California law requires that a POLST form be followed by health care providers and provides immunity to those who comply in good faith. In the hospital setting, a patient will be assessed by the physician, or a nurse practitioner (NP) or a physician assistant (PA) acting under the supervision of the physician, who will issue appropriate orders that are consistent with the patient's preference. 055918 Page 2 of 2