Other·March 19, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an ABBREVIATED survey for ENTITY REPORTED INCIDENT (ERI) No: CA00571138. Inspection was limited to the specific ERI investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyor 33434, HFEN. THE DEPARTMENT SUBSTANTIATED THE ERI ALLEGATION(S). FINDINGS WERE CITED AT F678, F711, and F842. GLOSSARY OF ABBREVIATIONS: AHA - American Heart Association DON - Director of Nursing CNA - Certified Nursing Assistant CPR - Cardiopulmonary Resuscitation EMS - Emergency Medical Service (911) LVN - Licensed Vocational Nurse P&P - policy and procedures POLST - Physician Orders for Life-Sustaining Treatment RN - Registered Nurse

F678 SS=G Cardio-Pulmonary Resuscitation (CPR) CFR(s): 483.24(a)(3)

F678 §483.24(a)(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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X7BI11 Facility ID: CA060000876 If continuation sheet 1 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555462 (X3) DATE SURVEY COMPLETED 02/15/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VILLA VALENCIA HEALTHCARE CENTER 25000 Calle De Los Caballeros Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on interview, facility document review, and facility P&P review, the facility failed to ensure the nursing staff provided basic life support to one of two sampled residents (Resident 1). The nursing staff did not follow the American Heart Association guidelines and the facility's P&P in providing basic life support prior to the arrival of emergency medical services (EMS) personnel for Resident 1. The licensed nurses failed to activate the emergency response system in a timely manner prior to the arrival of emergency medical personal. This failure resulted in Resident 1 not receiving CPR timely and continuously until the EMS personnel arrived. Findings: Review of the facility's P&P titled Emergency: Initiation of "Code Blue" dated 8/1/04, showed a licensed staff person must remain with the resident at all times, call 911 for emergency transfer to an acute care center, and continue CPR efforts until the ambulance service arrives or until spontaneous respirations, pulse, and blood pressure return. Review of the American Heart Association (AHA) Basic Life Support Sequence and Basic Life Support Healthcare Provider Adult Cardiac Arrest Algorithm dated 2015 showed, if the victim is unresponsive, shout for nearby help, and activate the emergency response system. Review of the AHA Ethical Issues-CPR and Emergency Cardiovascular Care guidelines dated 2017 showed rescuers who start basic life support (BLS) should continue resuscitation until one of the following occurs: * Restoration of effective spontaneous FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X7BI11 Facility ID: CA060000876 If continuation sheet 2 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555462 (X3) DATE SURVEY COMPLETED 02/15/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VILLA VALENCIA HEALTHCARE CENTER 25000 Calle De Los Caballeros Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE circulation, * Care is transferred to a team providing advanced life support, * The rescuer is unable to continue because of exhaustion, or * Reliable and valid criteria indicating irreversible death are met. Closed medical record review was initiated for Resident 1 on 2/6/18. Resident 1 was admitted to the facility under hospice care on 1/5/18. Hospice care was revoked by Resident 1's family on 1/9/18. Resident 1 expired on 1/12/18. Review of Resident 1's POLST dated 1/5/18, showed the box was checked for staff to attempt resuscitation/CPR when the resident has no pulse and was not breathing. Review of the History and Physical dated 1/8/18, showed the physician and Resident 1's family members had a discussion regarding the resident's plan of care including the code status. The documentation showed Resident 1's family members decided Resident 1 was to be on a full code status. This would mean the facility staff was to initiated CPR and call 911 in the event Resident 1 went into cardiac arrest. On 2/6/18 at 0950 hours, an interview was conducted with the DON concerning Resident 1. The DON stated, when she arrived to the facility on 1/12/18 at approximately 0755 hours, she saw RN 1 walking toward the nurses' station. RN 1 informed her Resident 1 had passed away. The DON asked RN 1 if CPR had been done and if 911 had been called. RN 1 stated CPR had been stopped and 911 had not been called. The DON instructed RN 1 to go back to Resident 1's room and resume CPR, and for LVN 1 to call 911. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X7BI11 Facility ID: CA060000876 If continuation sheet 3 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555462 (X3) DATE SURVEY COMPLETED 02/15/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VILLA VALENCIA HEALTHCARE CENTER 25000 Calle De Los Caballeros Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 2/6/18 at 1045 hours, an interview was conducted with LVN 1. LVN 1 stated, during her rounds on 1/12/18 at approximately 0710 hours, she observed Resident 1 and he appeared to be sleeping in bed. At approximately 0745 hours, a CNA reported they could not obtain Resident 1's vital signs. LVN 1 stated she called out for RN 1's help and they entered Resident 1's room together. Resident 1 was found without a pulse or respirations. LVN 1 stated RN 1 started CPR and LVN 1 left the room to get the crash cart (a wheeled cart with supplies and equipment used in a medical emergency). LVN 1 stated she returned to the room and assisted RN 1 with CPR. LVN 1 stated after approximately 3 to 4 rounds of CPR, LVN 1 stated she left the room to call the physician. At around 0755 hours, the DON had arrived and asked if 911 had been called. LVN 1 stated "no" as she called the physician first. LVN 1 stated the DON instructed her to call 911. LVN 1 was asked if she remembered her training in basic life support (BLS) CPR and the sequence to follow. LVN 1 stated she could not recall from her BLS training when to call 911. On 2/9/18 at 0933 hours, a telephone interview was conducted with Physician 1. Physician 1 stated he had received a telephone call from the facility's nurse on 1/12/19 approximately 0755 hours, about CPR being performed on Resident 1. He stated he asked the nurse if 911 had been called, the nurse said "no" and he instructed the nurse to call 911. On 2/9/18 at 1628 hours, a telephone interview was conducted with RN 1. RN 1 stated, on 1/12/18 at approximately 0745 hours, LVN 1 called her to come to Resident 1's room. RN 1 stated both she and LVN 1 checked Resident 1's pulse and respirations. RN 1 stated Resident 1 did not have a palpable pulse or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X7BI11 Facility ID: CA060000876 If continuation sheet 4 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555462 (X3) DATE SURVEY COMPLETED 02/15/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VILLA VALENCIA HEALTHCARE CENTER 25000 Calle De Los Caballeros Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE respirations and she initiated CPR. RN 1 stated LVN 1 left the room and returned with the crash cart. She stated they performed two person CPR (one person was at the chest performing chest compressions and the other person was giving rescue breaths) for about 10 minutes. LVN 1 then left the room to call the resident's physician while she continued to perform one person CPR (same person will do chest compression and rescue breathing). RN 1 stated she walked out of the resident's room when she was met by the DON. The DON asked RN 1 if 911 had been called. RN 1 stated she had informed the DON 911 had not been called. The DON then instructed her to resume CPR. RN 1 stated two person CPR was continued until the Paramedics arrived and took over CPR. RN 1 was asked if she remembered her training in BLS CPR and the sequence to follow. RN 1 stated to try and arouse first, then call 911, and then start CPR. RN 1 was asked if she followed the BLS sequence? RN 1 stated no; they had started CPR and 911 had not been called until the DON instructed staff to do so. Review of the Official Incident Report from the county emergency response authority dated 1/12/18, showed the emergency response system was activated on 1/12/18 at 0805 hours. This was approximately 20 minutes after the CNA reported they could not obtain Resident 1's vital signs.

F711 SS=D Physician Visits - Review Care/Notes/Order CFR(s): 483.30(b)(1)-(3)

F711 §483.30(b) Physician Visits The physician must§483.30(b)(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X7BI11 Facility ID: CA060000876 If continuation sheet 5 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555462 (X3) DATE SURVEY COMPLETED 02/15/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VILLA VALENCIA HEALTHCARE CENTER 25000 Calle De Los Caballeros Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.30(b)(2) Write, sign, and date progress notes at each visit; and §483.30(b)(3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications. This REQUIREMENT is not met as evidenced by: Based on interview, closed medical record review, and facility P&P review, the facility failed to ensure a physician visited one of two sampled residents (Resident 1) upon admit to the facility and completed a history and physical within 48 hours of admission. This placed Resident 1 at risk of not having a physician take an active role in supervising the care of the resident. Findings: Closed medical record review was initiated for Resident 1 on 2/6/18. Resident 1 was admitted to the facility under hospice care on 1/5/18. Hospice care was revoked by the family on 1/9/18. Resident 1 expired on 1/12/18. Review of a facility's P&P titled Physician Visits dated 8/1/09, showed the physician must make an actual face-to-face contact with the resident. A history and physical is required within 48 hours of admission to the facility. Review of Resident 1's closed medical record failed to identify documented evidence a physician had assessed Resident 1 and made a face-to-face visit after Resident 1 was admitted to the facility. On 2/8/18 at 0950 hours, an interview and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X7BI11 Facility ID: CA060000876 If continuation sheet 6 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555462 (X3) DATE SURVEY COMPLETED 02/15/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VILLA VALENCIA HEALTHCARE CENTER 25000 Calle De Los Caballeros Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE concurrent closed medical record review was conducted with the DON. The DON was unable to find any documentation to show Resident 1 had been seen by a physician during his stay at the facility from 1/5/18 to 1/12/18. On 2/9/18 at 0933 hours, a telephone interview was conducted with Physician 1 concerning Resident 1. Physician 1 stated he visited Resident 1 and his family on 1/5/18, but did not document the visit. Physician 1 stated since Resident 1 had been admitted under hospice care, he expected the hospice physician to follow Resident 1. Physician 1 stated it was not until 1/8/18, when the facility informed him hospice had been discontinued he was now to be Resident 1's attending physician. Physician 1 confirmed he had not document any visits in Resident 1's medical record. On 2/9/18 at 1028 hours, a telephone interview was conducted with Hospice Staff 1. Hospice Staff 1 stated she would send a copy of the history and physical completed on 1/8/18 by Physician 2. Review of the document provided by Hospice Staff 1 showed a history and physical was completed by Physician 2 on 1/8/18, three days after Resident 1 was admitted to the facility. On 2/9/18 at 1320 hours, a telephone interview was conducted with Physician 2. Physician 2 verified he made a face-to-face visit with Resident 1 on 1/8/18. Physician 2 stated on 1/8/18 he spoke with Resident 1's family members concerning hospice care and the family wanted to revoke hospice care as they wanted aggressive treatment for the resident.

F842 SS=D Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5) FORM CMS-2567(02-99) Previous Versions Obsolete

F842 Event ID: X7BI11 Facility ID: CA060000876 If continuation sheet 7 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555462 (X3) DATE SURVEY COMPLETED 02/15/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VILLA VALENCIA HEALTHCARE CENTER 25000 Calle De Los Caballeros Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X7BI11 Facility ID: CA060000876 If continuation sheet 8 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555462 (X3) DATE SURVEY COMPLETED 02/15/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VILLA VALENCIA HEALTHCARE CENTER 25000 Calle De Los Caballeros Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview, closed medical record review, and facility's P&P review, the facility failed to ensure the medical record contained the complete information of the services provided to one of two residents (Resident 1) during the initiation of a CPR. The facility licensed nursing staff did not document the care Resident 1 had received when CPR was provided on 1/12/18. This posed the risk of not addressing the appropriate care provided for Resident 1. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X7BI11 Facility ID: CA060000876 If continuation sheet 9 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555462 (X3) DATE SURVEY COMPLETED 02/15/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VILLA VALENCIA HEALTHCARE CENTER 25000 Calle De Los Caballeros Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the facility's P&P titled Emergency: Initiation of "Code Blue" dated 8/1/04, showed the following documentation in the progress notes: * When and why the "Code Blue" was initiated. * If CPR was initiated, when and how long CPR was performed. * Resident response and any complications. * Any interventions taken to correct complications. * Date, time of physician and responsible party notified. * Resident disposition. Closed medical record review was initiated for Resident 1 on 2/6/18. Resident 1 was admitted to the facility under hospice care on 1/5/18. Hospice care was revoked on 1/9/18. Resident 1 expired on 1/12/18. Review of a Health Status Note showed an entry dated 1/19/18 at 0820 hours, as a late entry by the DON for 1/12/18. The DON documented there was no documentation of the time when the CPR was initiated, when 911 was called, when the physician or family were contacted, or when paramedics arrived. On 2/6/18 at 0950 hours, an interview and closed medical record review was conducted with the DON. The DON verified her Health Status Note was the only documentation regarding the CPR performed on Resident 1 on 1/12/18. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X7BI11 Facility ID: CA060000876 If continuation sheet 10 of 10