Health inspection·July 28, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have correct and complete information on the POLST forms for one of three sampled residents (Resident 1). Acting on incomplete or erroneous information on a POLST form could contribute to a resident's death. In order for a POLST form to be valid in California it must be signed and dated by a physician, nurse practitioner, or physician's assistant, and the patient or the patient's legally recognized health care decision maker. [California Emergency Medical Services Authority, DNR, POLST and Medallion Information, https:// emsa.ca.gov/dnr_and_polst_forms/ accessed on [DATE]]. Resident 1's POLST form was not signed or dated with anyone's signature or any dates. When Resident 1 was admitted to the skilled nursing facility, her physician's orders indicated she was a full code. This meant all measures including CPR would be initiated should she stop breathing or her heart stopped beating. There were no later orders changing this full code status. Three days after admission to the skilled nursing facility, Resident 1 had difficulty breathing and was difficult to arouse. The staff administered oxygen and called 911. The RN who called 911 handed the EMS personnel who arrived at the skilled nursing facility the POLST form with Resident 1's name on it and without any signatures or dates. This RN (RN 1) told the EMS personnel Resident 1 was DNR. Resident 1 was breathing when she left the skilled nursing facility on a gurney with EMS personnel per RN 1. According to the skilled nursing facility administrator Resident 1 was not resuscitated in the ambulance and she died. Findings: The following abbreviations, definitions, and acronyms are used:911 = the phone number for the Emergency Response System in the US and Canadaantibiotics = medications used to treat bacterial or fungal infectionsBiPAP = bilevel positive airway pressure, a machine that pushes air into the lungs when breathing in and breathing out. The pressure is higher when breathing in. The patient is connected to the machine via a mask. There is no need for intubation (see below).CDPH = California Department of Public Health, the state agency that investigates reports from healthcare facilities and complaints from the public C-PAP = CPAP or continuous positive airway pressure, a machine connected to tubing and a mask that uses air pressure to keep the patient's airway open during sleep. CPR = cardiopulmonary resuscitation, an emergency procedure using chest compressions and rescue breaths to keep oxygenated blood flowing when a person stops breathing and their heart stops beating crash cart = a metal chest of drawers on wheels used to store equipment, and medications typically used to treat patients who stop breathing or whose heart stops beating.DNR = Do Not Resuscitate or do not do CPR (see above)DON = Director of NursingEMS = Emergency Medical Services (system of emergency treatment and transport which may include emergency medical technicians and paramedics who may also be firefighters).EMT = Emergency Medical Techniciangurney = a stretcher on wheelsintensive care = treatment, care, and constant monitoring of critically ill patients in a specialized unit of a hospitalintubate = a tube inserted down the throat (or nose) and into the trachea (windpipe) to keep the airway open.IV = intravenous, a Page 1 of 3 055968 055968 07/28/2025 Golden Heights Healthcare 35 Escuela Drive Daly City, CA 94015

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few needle inserted into a vein to provide medications or fluidsLN = licensed nurse refers to either a RN or LVN (see below)LVN = licensed vocational nurseMD = medical doctormg/dL = milligrams per deciliternasal cannula = nasal prongs, plastic tubing that goes inside the nostrils used to deliver supplemental oxygen non-invasive positive airway pressure = machines {C- PAP (see above) or BiPAP (see above)} that deliver oxygen under pressure via a mask. Unlike ventilators, they do not require a patient to be intubated (see above).pantoprazole = Protonix - a medication used to treat GERD or gastroesophageal reflux disease (ongoing heartburn).paramedic = an EMT (see above) with more training and skills in emergency treatmentPOLST = Physician Orders for Life-Sustaining Treatment is a portable medical order that travels with the patient that informs healthcare providers in ambulances, hospitals, nursing homes, etc. of the patient's wishes for treatment should a medical emergency occur. It typically indicates if they want CPR (see above), feeding tubes, and other forms of medical intervention. It is intended to be used for seriously ill and frail people [National POLST, https://polst.org accessed on [DATE]]RN = Registered Nurseskilled nursing facility = a healthcare facility that provides 24 hour nursing care. It may also provide physical, occupational, and speech therapy.sternal rub = a check for alertness by applying firm pressure with one's knuckles to the breastbone of a patient.vitals or vital signs = temperature, pulse, respiration, blood pressure, pain assessment A review of Resident 1's admission Record indicated she was admitted to the skilled nursing facility in March of 2025 and was discharged to a local hospital three days later. A review of Resident 1's Order Summary Report indicated FULL CODE (in boldface type), Full Treatment, No artificial means of nutrition, including feeding tubes. This order was dated [DATE]. A review of the [DATE] Progress Notes indicated LVN 1 gave Resident 1 pantoprazole at 6:30 a.m. This note indicated Resident 1 was awake and verbally responsive. A review of the [DATE] Progress Notes signed by LN 1 indicated LN 1 was making rounds around 7:25 a.m., and Resident 1 was lethargic, unable to arouse on stimulation, Vitals taken, BP (blood pressure) 94/54 (lower limits of normal 90/60); PR (pulse rate) 82 (normal range 60 to 100), RR (respiratory rate) 12 (normal range 12 to 18), (oxygen saturation) 91% (normal range 95% to 100%) (on) 4 (liters of oxygen via nasal cannula) temp(erature) 96.6 (normal range 97 to 99).Called 911 around 7:35 AM, EMTs arrived and transported resident via gurney at approximately 0755 AM. Resident is transferred to the hospital. Called (responsible party, name) @ 0800 AM. Notified MD. A review of the [DATE] Progress Notes signed by RN 1 indicated around 7:28 a.m., RN 1 was told by the charge nurse (LN 1) that Resident 1 was not responding and lethargic. RN 1's Progress Note indicated she went to Resident 1's room and found Resident 1 on her bed breathing labored, difficult to arouse, not responsive to verbal stimuli, vitals signs assessed (same as LN 1 note above) . Blood sugar: 73 mg/dl (normal fasting range 70 to 90) . warm to touch, lethargic. Called 911 @ 0738 AM, paramedics arrived around @ 0744 AM, verbal report given, paramedics assessed the patient, patient left the building around @ 0755. Called (responsible party) around @ 0758 AM regarding the transfer. A review of Resident 1's POLST form indicated it had no signatures or dates at the bottom of the form. A sticker with Resident 1's name, resident number, and health insurance name was on the top right corner of the POLST form. Check marks were placed next to Do Not Attempt Resuscitation/DNR (Allow Natural Death) and next to Selective Treatment - goal of treating medical conditions while avoiding burdensome measures. In addition to treatment described in Comfort-Focused Treatment, use medical treatment, IV antibiotics, and IV fluids as needed. Do not intubate. May use non-invasive positive airway pressure. Generally avoid intensive care. In an interview with RN 1 on [DATE] at 2:55 p.m., she stated she was sitting at the front desk when another nurse called for help. RN 1 said she ran to Resident 1's room. RN 1 stated when she arrived in Resident 1's room multiple staff members were there taking her vitals, 055968 Page 2 of 3 055968 07/28/2025 Golden Heights Healthcare 35 Escuela Drive Daly City, CA 94015

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few doing a sternal rub and they could not awaken Resident 1. RN 1 said she called for the crash cart and she called 911 herself. RN 1 said she started the paperwork. RN 1 stated she saw the POLST form with DNR and selective treatment checked. RN 1 stated she did not notice there were no signatures at the bottom of the POLST form. RN 1 said there was a sticker on the form. RN 1 stated she may have been asked by and told the 911 dispatcher Resident 1 was DNR when she called 911. RN 1 said she cannot recall if she said this as everything happened so fast. RN 1 stated when the EMS personnel arrived in the skilled nursing facility, she handed them the POLST form without dates or signatures but with check marks indicating Do Not Attempt Resuscitation/DNR (Allow Natural Death) and Selective Treatment. RN 1 said she told the EMS personnel who entered the skilled nursing facility to care for Resident 1 that Resident 1 was DNR. RN 1 said she saw Resident 1 on the gurney as she left the skilled nursing facility with EMS. RN 1 stated Resident 1 was breathing at that time. A review of the [DATE] follow up report from the skilled nursing facility Administrator indicated Resident 1 was not given CPR in the ambulance en route to the hospital and she was pronounced dead on arrival at the hospital. In an interview with the Administrator and DON on [DATE] at 4:35 p.m., the Administrator stated he obtained the information that Resident 1 was not given CPR in the ambulance and pronounced dead at the hospital from an RN Administrator at Resident 1's health insurance plan in calls over a two week period. A review of the facility's policy, Advance Directive indicated under Definitions, POLST: This document signed by an authorized health care professional, is a medical order that records residents' treatment wishes so that emergency personnel know what treatments to provide in the event of a medical emergency . Under Procedure, 4., this policy indicated, During the admission process, the POLST form (state specific) is offered, and assistance is provided in filling out these forms if the resident desires to have one. 055968 Page 3 of 3