Health inspection·September 9, 2025

A citation Regulations: Code of Federal Regulations, Title 42, Section §483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. California Code of Regulations, Title 22, Section 72311. Nursing Service--General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. On 8/6/25, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding resident care. The Department determined the facility failed to provide respiratory care (the diagnosis, treatment, and management of residents with breathing disorders) consistent with professional standards of practice for two of two sampled residents (Resident 1 and Resident 2) with a tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs) when: 1. Registered Nurses (RNs) provided care for Resident 1 and Resident 2 without documented competencies (measurable patterns of knowledge that enabled individuals to perform a skill successfully) for tracheal suctioning (a procedure that cleared mucus (a sticky substance produced by the body) and secretions (liquid substance produced by the body) from the trachea (a tube-like structure that allowed air to travel to and from the lungs) through a tracheostomy tube (a removable tube inserted in tracheostomy)), and tracheostomy care (maintaining a clean tracheostomy tube, that included cleaning the inner cannula; a removable tube that fits inside the larger outer cannula of a tracheostomy tube), and changing dressings (specialized medical dressing used to cover and protect the opening created in the neck to help manage secretions and prevent infection); 2. Tracheostomy care plans (a document that outlined a resident's health needs, goals, and the specific actions (interventions) a nurse took to achieve those goals) were not created for Resident 1 and Resident 2; and 3. RNs were not always available in the facility 24 hours a day, seven days a week from 7/28/25 through 8/7/25, to carry out Resident 1's and Resident 2's physician order for as needed tracheostomy suctioning (a respiratory task that falls within the scope of practice for trained healthcare professionals, particularly registered nurses and respiratory therapists). These deficient practices placed Resident 1 and Resident 2 at increased risk for the development of infection such as Pneumonia (when harmful germs enter the lungs, multiply, and cause illness), desaturation (a decrease in blood oxygen levels), aspiration (inhaling or drawing something into the lungs other than air), and acute respiratory distress (a serious lung condition that prevented enough oxygen from getting into the blood). This created a likelihood of serious physical harm (significant injury or damage that could have long-lasting or potentially life-threatening consequences), hospitalization, and/or death would occur, if not corrected immediately. The Immediate Jeopardy (IJ-a threat to resident health or safety which requires immediate corrective action due to the likelihood of serious injury or harm) began on 7/28/25, when the facility failed to provide competencies to nursing staff regarding tracheostomy suctioning, no care plans were in place related to tracheostomy care, and the facility did not ensure a RN was on duty for an entire 24 hour period to provide tracheostomy suctioning as needed to Resident 1 and Resident 2. The Administrator (ADM) and Director of Nursing (DON) were notified of the IJ on 8/7/25, at 5:43 PM. On August 7th, 2025, at 8:01 PM, a removal plan was provided by the facility. The State Agency verified the facility's implementation of the removal plan while onsite at the facility. On 8/7/25, at 8:35 PM, the ADM and DON were notified that the IJ immediacy was removed. No non-compliance (failure to meet federal health, safety, and quality regulation) was identified upon removal of the IJ. 1a. During a review of Resident 1's clinical document titled, "ADMISSION RECORD," the document indicated Resident 1 was admitted to the facility on 7/28/25, with a diagnosis which included respiratory failure (a serious condition that makes it difficult to breathe on your own), hypoxia (a condition where there was an inadequate supply of oxygen to the body's tissues), and the presence of a tracheostomy. A review of Resident 1's clinical document titled, "Order Summary," dated 7/29/25, ordered by the Medical Director, (Med Dir - a physician who oversees resident care), the document indicated, "...Perform suctioning via tracheostomy PRN [as needed] for audible secretions, visible mucus, increased work of breathing, or [oxygen saturation; the amount of oxygen you have circulating in your blood] < [less than] 92% [percent]. Use sterile technique [free from germs] with suction catheter [a sterile, flexible tube, used to remove secretions and other fluids from the airways of residents who cannot clear them on their own]...pre oxygenate [the administration of oxygen to a resident before a procedure]..." During a concurrent observation and interview on 8/7/25, at 9:15 AM, with Resident 1, in Resident 1's room, Resident 1 was observed to have a tracheostomy. Resident 1 stated she had asked the facility staff to please perform her tracheostomy care, stating the last time it was done was on 8/5/25, two days prior. Resident 1 stated the facility staff informed her that there was not anyone able to do her tracheostomy care. Resident 1 stated the last time she had tracheostomy care was on 8/5/25. During an interview on 8/7/25, at 12:47 PM, with Licensed Nurse (LN; a Licensed Vocational Nurse, LVN) 2, LN 2 stated she had asked Respiratory Therapist (RT) 2, on 8/5/25, if the RT staff would provide tracheostomy care for Resident 1. LN 2 stated RT 2 refused and stated she was leaving the facility and would no longer work for the facility. LN 2 stated she asked LN 4, a registered nurse on duty on 8/5/25, to provide tracheostomy care to Resident 1, but LN 4 told her that he did not know how to do tracheostomy care. LN 2 stated the RTs were only on duty on the day shift and RNs were not available when the residents with tracheostomy's were first admitted to the facility. 1b. During a review of Resident 2's clinical document titled, "ADMISSION RECORD," the document indicated Resident 2 was admitted to the facility on 7/28/25, with diagnoses which included respiratory failure with hypoxia and the presence of a tracheostomy. A review of Resident 2's clinical document titled, "Order Summary," dated 7/29/25, the document indicated, "...Perform suctioning via tracheostomy PRN for audible secretions, visible mucus, increased work of breathing, or [oxygen saturation] < 92%. Use sterile technique with suction catheter...pre oxygenate..." During an interview on 8/7/25, at 12:47 PM, with LN 2, LN 2 stated that the LVNs expressed concerns about caring for Resident 1 and Resident 2's tracheostomy needs because the facility had not provided the competencies needed to provide tracheostomy care. During an interview on 8/7/25, at 2:33 PM, with RT 1, RT 1 stated the RNs and RTs had not received any in-service (activities or training that take place while someone is employed, often to improve their skills or knowledge for their current role) training for tracheostomy care and tracheal suctioning. During a concurrent interview and record review on 8/7/25, at 2:47 PM, facility documents titled, "Tracheostomy and T-Piece Care Competency Evaluation Form," dated 7/25, and the undated "Suctioning In-Service Training," were reviewed with the Director of Nursing (DON). The DON confirmed both forms were blank (no names listed), which indicated there were no competencies completed for the RTs and LNs (both LVN's and RNs) for tracheostomy care and tracheal suctioning. The DON explained that the facility should have provided training for the RTs and LNs (both LVNs and RNs) to ensure the RTs and LNs had the competencies to provide safe tracheostomy and care and tracheal suctioning. During an interview on 8/7/25, at 2:54 PM, with RT 2, RT 2 stated she had not conducted or scheduled competencies with any of the licensed staff (additional RTs and/or RNs) to care for residents with tracheostomies (Resident 1 and Resident 2). RT 2 stated she did not work at the facility any longer. During an interview on 8/7/25, at 4:06 PM, with RT 1, RT 1 stated the RTs were not hired to do tracheostomy care and suctioning, they were hired to do incentive spirometer (a handheld medical device used to help residents breathe deeply and regularly, particularly after surgery or for those with lung conditions) and acapella (a handheld device that helped residents with respiratory conditions clear mucous; thick, slippery, and usually clear substance produced by the body to protect and lubricate various surfaces) from their lungs). RT 1 explained Resident 1 and Resident 2 were at risk for desaturation and pneumonia (infection in the lungs) when the facility did not have RNs who had the competencies to care for Resident 1 and Resident 2's tracheostomy care needs. During an interview on 8/8/25, 3:30 PM, with the Medical Director (Med Dir), the Med Dir stated the facility should have ensured they had staff that could care for, assess, and provide safe tracheostomy care and tracheal suctioning. The Med Dir stated that the facility should have ensured that staff received appropriate training and had the necessary competencies to care for residents with tracheostomies. The Med Dir further explained Resident 1 and Resident 2 were at risk of death because the staff did not have the appropriate training and competencies to manage tracheostomies. A review of the facility titled, "Competency Evaluation," dated 2024, the document indicated, "... Policy ... It is the policy of this facility to evaluate each employee to assure they meet appropriate competencies and skill for performing their job ... Competency ... a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual need to perform work roles or occupational functions successfully ..." A review of the facility policy titled, "Tracheostomy Care-Suctioning," dated 2024, the document indicated, "... Tracheal suctioning is performed by a Competent Registered Nurse and Respiratory Therapist to clear the throat and upper respiratory tract of secretions that may block the airway ..." A review of the facility policy titled, "Tracheostomy Care," dated 2024, the document indicated, "... The facility will ensure staff responsible for providing tracheostomy care including suctioning are trained and competent according to professional standards of practice..." 2. During a concurrent interview and record review on 8/7/25, at 4:55 PM, Resident 1's and Resident 2's electronic medical record was reviewed with the DON. The DON confirmed no care plans and/or baseline care plan (care plans developed during the first 48 hours of the residents stay at the facility) had been developed for Resident 1 and Resident 2 regarding tracheostomy care and tracheal suctioning. The DON explained the importance of the care plans was to direct the care of the residents. A review of a facility policy titled, "Comprehensive Care Plans," dated 2025, the document indicated, "... The comprehensive care plan will describe, at a minimum ... services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being ..." A review of the facility policy titled, "Tracheostomy Care," dated 2024, the document indicated, "... Based on the resident assessment, attending physician's orders, and professional standards of practice, the facility in collaboration with the resident/resident's representative will develop a care plan that includes appropriate interventions for respiratory care ..." 3. During a concurrent interview and record review, on 8/7/25, at 4:40 PM, the facility staffing sheets (documents that outline the number and types of staff scheduled to work at a facility on a given shift and/or day) from 7/28/25 through 8/7/25 were reviewed with the DON. The DON confirmed the following shifts (AM shift was 6:30 AM to 3 PM, PM shift was 2:30 PM to 11 PM, NOC (night) shift was 11 PM to 7 AM) and/or portions of shifts were without a RN assigned to work on the floor: 7/28/25 NOC shift, 7/29/25 NOC shift from 11 PM to 1 PM, 7/30/25 AM shift and PM shift, 7/31/25 AM shift and NOC shift, 8/1/25 AM shift and PM shift, 8/4/25 PM shift, 8/5/25 PM shift, 8/6/25 AM shift, and 8/7/25 AM shift. During a concurrent interview and record review, on 8/8/25, at 3:10 PM, the Facility Assessment (a comprehensive evaluation of a facility's ability to provide skilled nursing care, rehabilitation services, and other related health services to residents), dated 8/8/24, was reviewed with the Administrator (ADM). The ADM stated the facility had not met the facility assessment staffing plan which indicated "...Based on the facility's resident population and their needs for care and support, the facility's general approach to staffing is to ensure that it has sufficient staff members with the appropriate competencies and skill sets to meet the needs of the residents..." The ADM explained his expectations were whenever there was a resident in the facility with a tracheostomy the facility would have an RN in the building 24 hours a day to provide tracheostomy care, and that the staff would have the required competencies. The ADM also explained the risk to the residents with tracheostomies could have been a negative clinical outcome (an undesirable or unfavorable result for a patient receiving medical care). In violation of the above cited standards, the facility failed to provide competent staff to provide respiratory care consistent with professional standards of practice, 24 hours a day, for Resident 1 and Resident 2 with a tracheostomy. These violations and the immediate jeopardy, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and constitutes an A citation.