Other·April 1, 2026

RIVERWOOD HEALTH CARE Survey 1E4829-H1 Code of Federal Regulations, Title 42, Section 483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician Code of Federal Regulations, Title 42, Section 483.21(b) Comprehensive Care Plans (b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being Code of Federal Regulations, Title 42, Section 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Code of Federal Regulations, Title 42, Section 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning (i) 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 72301. Required Services. (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. 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. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the patient. California Code of Regulations, Title 22, Section 72313. Nursing Service-Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (1) No medication or treatment shall be administered except on the order of a person lawfully authorized to give such order. (2) Medications and treatments shall be administered as prescribed. (3) Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, shall be performed as required and the results recorded. 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. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (2) Nursing services policies and procedures which include: (D) Notification of the licensed healthcare practitioner acting within the scope of his or her professional licensure regarding sudden or marked adverse change in a patient's condition. On 02/19/2026 at 10:40 a.m., the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate two facility reported incidents regarding abuse and resident care. The facility failed to provide adequate respiratory care services, immediate ongoing clinical assessment, treatment, after identified changes in condition, as per professional standards of practice for one out of two sampled residents (Resident 1) when: 1. Licensed Vocational Nurse (LVN) 1 did not notify the Physician of Resident 1's change in condition when he had shortness of breath and low oxygen saturation level on 2/4/26. 2. LVN 1 increased Resident 1's oxygen therapy from 2 liters to 4 liters without a Physician's order. 3. LVN 1 adjusted Resident 1's oxygen liter flow and did not escalate Resident 1's care to a qualified healthcare professional, not following their scope of practice. 4. Hospital discharge orders for Resident 1's weekly Complete Blood Count (CBC -- a common, comprehensive blood test that measures white blood cells, red blood cells, platelets, hemoglobin, and hematocrit to evaluate overall health and detect disorders like anemia, infection, inflammation, and leukemia) were not transcribed into the medical record and were not followed. These failures resulted in the physician not being aware of Resident 1's change in condition, caused a delay in adequate assessment with the potential need for a higher level of care not being identified, caused a delay in adequate care and treatment and subsequently Resident 1 died within 2 hours of change in condition on 2/4/26. A review of Resident 1's "ADMISSION RECORD," indicated Resident 1 was admitted to the facility in 2026 with diagnoses including acute osteomyelitis (a serious bone infection usually caused by bacteria that spread through the bloodstream, nearby tissues, or open injuries), sepsis (a life threatening body's extreme response to an infection causing tissue damage), cellulitis and abscess of mouth (a common, potentially serious bacteria skin infection and underlying tissues, often causing rapid-spreading redness, warmth, swelling, and pain), diabetes type 2 (a chronic condition where the body resist insulin or fails to produce enough causing high blood sugar), essential hypertension (a type of high blood pressure that has no clearly identifiable cause), blindness of both eyes, depression (a mood disorder causing persistent sadness, a loss of interest in activities, and an inability to function in daily life), sleep apnea (a common serious disorder where treating repeatedly stops and starts during sleep often causing loud snoring, choking and severe daytime tiredness), morbid obesity (a chronic malfunctional disease characterized by excessive fat storage), and anxiety. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool use to guide care) dated 1/26/26, indicated Resident 1 had a score of 12 on the Brief Interview for Mental Status exam (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information with a range of scores from 0-15; a BIM score of 13-15 indicates intact cognition). Resident 1's BIMS score of 12 indicated moderate cognitive impairment (thinking and memory problems are noticeable and affect daily function). A review of Resident 1's Hospital Inpatient Discharge Instructions, indicated, "... visit date 1/20/26...Your diagnosis Facial cellulitis Sepsis without acute organ dysfunction DM type 2 ...Hypertension...SKILLED NURSING FACILITY[SNF] ADMISSION ORDERS...Oxygen Orders: Start oxygen at 2 L/min [liters per minute] for shortness of breath, chest pain, oxygen saturation less than 90% and notify physician immediately...CBC [Complete Blood Count: a blood test that measures the number, size, and characteristics of blood cells and platelets to assess overall health and detect medical conditions] and Chem 7 [a blood panel test that measures seven key chemical components to evaluate kidney function, electrolyte balance, and overall metabolic health] to be drawn weekly after SNF admission...Notify physician for Change in Condition: If patient has one or more of the following conditions, conduct full assessment and notify Physician...Abnormal lung sounds with new or increased O2[Oxygen] requirement to maintain O2 sat> [greater than] 88%...Shortness of breath while sitting still...Any abnormal labs..." Facility staff had Resident 1's Hospital Inpatient Discharge Instructions signed that Resident 1's hospital discharge orders were noted and carried out on 1/23/26. A review of Resident 1's Physician's Orders dated 1/23/26, indicated, "... Oxygen @ [at] 2 L/min via nasal canula [a thin flexible tube with two prongs inserted into the nostril allowing oxygen to flow directly into the nose] continuously every shift... " A review of Resident 1's Physician's Orders dated 1/24/26, indicated,"...CPAP [machine that delivers continuous air through the nose or mouth to keep the airways open while a person sleeps] ON at 9pm and OFF at 7 am... " Review of Resident 1's care plan initiated on 1/24/26, indicated,"...Focus...Requires IV therapy [a medical process that administers fluids, medications and nutrients directly into a person's vein] R/T [related to]: (Facial Cellulitis) ...Interventions... Observe for signs and symptoms of embolism: shortness of breath; chest pain; cough; wheezing; skin that's cool, clammy, or bluish; rapid or irregular heartbeat; weak pulse...if air embolism is suspected...notify MD and call emergency personnel (911) ..." Review of Resident 1's care plan initiated on 1/24/26, indicated,"...Focus...At risk for Cardiac Distress [a condition in which the heart suddenly and unexpectedly stops beating] R/T: Hyperlipidemia [high cholesterol level], HTN [Hypertension: high blood pressure] ...Goal...Resident will be free signs and symptoms of cardiac distress...Observe and notify MD when resident is experiencing change in level of consciousness, shortness of breath, chest pain...Follow up labs..." Review of Resident 1's care plan initiated on 1/24/26, indicated,"...Focus...Elevated Cholesterol/Lipid Level [a blood test that is used to monitor and screen a person's risk of heart disease] ...Goal...Resident will not develop complications of hypercholesterolemia/hyperlipidemia [high cholesterol levels] such as shortness of breath...Interventions...Observe for signs and symptoms of shortness of breath, chest pain secondary to heart disease...Follow up labs as ordered and report to MD..." A review of Resident 1's nurse progress note, dated 2/4/26, indicated, "... LATE ENTRY... Received resident in bed, Lying in bed comfortably, alert, and oriented x [times] 3, CPAP machine in place, oxygen in place at 2 LPM [liter per minute] via nasal canula around 07:50 AM. At same time Resident c/o [complained of] SOB [shortness of breath], checked O2 sat [oxygen saturation] 88 %. Increased Oxygen to 4 LPM via nasal canula and administered Albuterol [a medicine that relaxes airway muscles and help with breathing] 2 puffs as ordered. re check resident O2 sat at 08:15 a.m., O2 sat reading was 94 % to 95%...At 10:10 AM NP [Nurse Practitioner] make[sic] rounds and noted resident non-responsive, call the attention of writer, Code Blue [an emergency code signally a life-threatening medical situation] announce[sic] rightaway [sic] initiated CPR [Cardiopulmonary resuscitation: a critical, life-saving emergency procedure performed on people whose breathing or heart has stopped] called 911 at 10:13...10:26 AM Paramedics(911) pronounced death..." Further review of Resident 1's progress notes failed to show that physician was notified of Resident 1's change in condition sooner than 10:10am, when NP found him unresponsive. A review of Resident 1's Situation Background Assessment Recommendation (SBAR; a communication framework used in healthcare to ensure accurate, concise and timely transfer of information, especially during critical situations or patients handover) Form and Progress Notes, dated 2/4/2026, at timestamped 11:00 a.m., indicated, "... Appearance, summarize your observation and evaluation, Resident c/o sob, checked O2 sat 88 %, increased oxygen at 4 LPM and administered albuterol 2 puffs, all am medication administered as ordered, tolerating well. Recheck O2 saturation reading was 94 to 95%..." Further review of Resident 1's SBAR indicated physician was not notified of Resident 1's change in condition until 10:10 a.m. on 2/4/2026. During an interview on 2/26/26, at 3:00 p.m., LVN 1 confirmed during change of shift, on 2/4/26 at around 7:40 a.m., the Certified Nursing Assistant (CNA) on morning shift informed LVN 1 that Resident 1 was complaining of shortness of breath and had a low saturation of 88%. LVN 1 further stated she gave Resident 1 his Albuterol 2 puffs as per orders. LVN 1 added she increased his oxygen therapy from 2 LPM to 3 LPM, gradually to 4 LPM via nasal cannula, and kept it at 4 LPM. LVN 1 further stated she stayed in Resident 1's room till 8:15 a.m. to monitor Resident 1's condition. LVN 1 stated she did not get any orders from the Physician to increase Resident 1's oxygen from 2 LPM to 4 LPM, and she used her nursing judgement to titrate the oxygen. LVN 1 confirmed it was a change in Resident 1's condition when he had shortness of breath and low oxygen saturation at 88%. LVN 1 verified she did not call or notify the Physician of Resident 1's change in condition. LVN 1 stated she was passing medications and did not get the chance to do so. LVN 1 added the NP was doing rounds when she found Resident 1 unresponsive and not breathing around 10:10 a.m. LVN 1 stated the facility's policy was to notify the Physician of a change in resident's condition right away. During a concurrent interview and a record review on 2/19/26, at 2:40 p.m., with the Director of Nursing (DON), the DON stated it was not in LVNs' scope of practice to assess a resident who had a change of condition. The DON further stated an LVN was expected to notify a Registered Nurse (RN) to perform a full clinical nursing assessment when a resident had a change in condition. The DON confirmed LVN 1 did not escalate Resident 1's care to a qualified nurse who could have performed clinical assessment under their scope of practice for Resident 1, when Resident 1 had a change of condition on 2/4/26. The DON stated LVN 1 should have immediately notified the Physician about Resident 1's change in condition on 2