Other·April 16, 2026

The following reflects the findings of the California Department of Public Health during the investigation of: Complaint # 2663375. Survey Event ID: IDB88F-H1 State Citation AA was written. 42 CFR, §483.10(g)(14)(i)(A)(B)(C)(D) 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- (A)An accident involving the resident which results in injury and has the potential for requiring physician intervention. (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); or (D)A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). California Code of Regulations, title 22, §72523(a) 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. (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. California Code of Regulations, title 22, § 72501. Licensee--General Duties. (a) The licensee shall be responsible for compliance with licensing requirements and for the organization, management, operation and control of the licensed facility. The delegation of any authority by a licensee shall not diminish the responsibilities of such licensee. California Code of Regulations, title 22, § 72517. Staff Development. (a) Each facility shall have an ongoing educational program planned and conducted for the development and improvement of necessary skills and knowledge for all facility personnel. Each program shall include, but not be limited to: (1) Problems and needs of the aged, chronically ill, acutely ill and disabled patients. (9) Signs and symptoms of cardiopulmonary distress. (b) In addition to (a) above, all licensed nurses shall have training in cardiopulmonary resuscitation. Federal Code of Regulations, 483.70 Staff qualifications. (1) The facility must employ on a full-time, part-time or consultant basis those professionals necessary to carry out the provisions of these requirements. (2) Professional staff must be licensed, certified, or registered in accordance with applicable State laws. Cal Code Regs, title 22, section 72095. Registered Nurse. Registered Nurse means a person licensed as such by the California Board of Registered Nursing. Cal Code Regs, title 22, section 72533. Employee Personnel Records. (a) Each facility shall maintain current complete and accurate personnel records for all employees. (1) The record shall include: (A) Full name. (B) Social Security number. (C) Professional license or registration number, if applicable. (D) Employment classification. (E) Information as to past employment and qualifications. (F) Date of beginning employment. (G) Date of termination of employment. (H) Documented evidence of orientation to the facility. (I) Performance evaluations. Code of Federal Regulations § 483.45 Pharmacy services. The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in § 483.70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. Code of Federal Regulations § 51.120 Quality of care. Each resident must receive and the facility management must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Findings: On 10/29/25 at 10:00 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding a quality of care allegation for a resident (Resident 1) who had a history of heart conditions and died upon transport to the hospital after the facility failed to provide appropriate care and treatment. Based on observation, interview, and record review, the facility failed to ensure Resident 1 received timely and appropriate nursing assessments, monitoring, and interventions during an acute cardiac event (serious heart problem) while under the care of an unlicensed nurse (UN 1) who was unlicensed and was using another individual's Registered Nurse (RN) license. These failures included, but were not limited to: 1. Failure to verify and ensure that nursing staff possessed a valid, active nursing license prior to permitting them to provide resident care as required by the regulations. 2. Failure to follow physician orders and administer physician-ordered nitroglycerin to Resident 1 for reported chest pain and notify the physician of chest pain when Resident 1 had a history of cardiac events as required by the regulations and policies and procedures, resulting in a change of condition and death. 3. Failure to follow policy and procedures (P&P) for timely assessment, monitoring and physician notification when Resident 1 reported chest and abdominal pain. 4. Failure to ensure timely initiation of emergency medical services (911) for Resident 1, resulting in delayed medical intervention for life-threatening cardiac condition and subsequent death. 5. Failure to oversee pharmacy services and ensure that the appropriate medication was provided to Resident 1, including Norco for Resident 1's extreme pain, instead of the medication being diverted by UN 1. 6. Failure to have an ongoing skills assessment and competency program to ensure UN 1 was trained on skills necessary for an RN as required by the regulations. Resident 1 began experiencing chest pain and abdominal pain on 11/21/24, and UN1, an unlicensed nurse hired by the facility, failed to properly diagnose and administer medication and transfer the resident to a general acute care hospital (GACH) after the change of condition, resulting in Resident 1's death. On 3/27/26, during a telephone call to California Vital Records, the unit confirmed that Resident 1's immediate cause of death was acute ST elevation myocardial infarction inferior wall, which is a severe, life-threatening heart attack caused by prolonged blockage of a coronary artery, leading to significant heart muscle damage. Resident 1 was admitted to the facility on 11/20/24 with diagnoses that included hypertension (high blood pressure), gastric outlet obstruction (the passage between the stomach and the small intestine becomes blocked), history of stroke (when blood can't get to part of the brain), and NSTEMI (Non-ST Elevated Myocardial Infarction, a type of heart attack when blood flow to part of the heart is blocked). On 11/21/24 at approximately 3:00 p.m., Resident 1 began experiencing chest pain and abdominal pain. Unlicensed Nurse (UN) 1, who did not possess a valid and active nursing license and was using another individual's Registered Nurse (RN) license, did not administer the physician-ordered nitroglycerin (medication used to treat chest pain by relaxing and widening blood vessels, which helps more blood and oxygen reach the heart) and did not promptly activate the emergency medical services (EMS). Resident 1 was not transferred to the acute care hospital until 11:00 p.m. and died approximately two hours after the arrival in the emergency department (ED) due to a heart attack. During a record review of UN 1's record, titled, "Background Report (BR)", dated 2/6/24, the professional license verification portion reflected inconsistencies between UN 1's identity and the name listed on the nursing license. The "BR" report showed the license belonged to a different RN with a similar name. However, the first name was spelled differently, and the individual had a different middle name. During a record review of UN 1's most recent publicly available nursing license verification record, dated 11/20/25, the record indicated UN 1's Licensed Vocational Nurse (LVN) license had been revoked on 6/10/20, and UN 1's right to practice nursing was removed. During an interview on 10/29/25 at 12:42 p.m. with the Director of Nursing (DON), DON stated she was unaware that UN 1 was unlicensed during UN 1's employment at the facility until an investigation was initiated related to a drug diversion (when prescription medicine is taken or given to someone for a purpose other than what it was meant for) incident involving another resident. DON stated it was subsequently identified that the name listed on UN 1's submitted RN nursing license did not match the name on UN 1's driver's license or Social Security card, and that UN 1's LVN license had been revoked in 2020 due to drug diversion. During a review of the annual competency checklist for UN 1 [dated 2/6/25], it included a section that stated responsibilities with cardiac arrest marked, which was marked as "P" or Previous experience. No previous experience was identified in the document or in any other document provided by the facility. There was no documentation of previous experience. During a record review of Resident 1's record titled, "Physician History and Physical" (H&P), dated on 11/21/24, documented by Medical Doctor (MD) 1, the "H&P" indicated "Resident 1 had a ventral hernial repair (fixing a hole or weak spot in the abdominal wall) on 11/14 ...Afterward, Resident 1's recovery was complicated by a NSTEMI... Cardiology (branch of medicine that deals with the heart) was consulted and recommended medical management...had episode of chest pain 11/17..." indicating Resident 1 had a history of heart attack. During a record review of Resident 1's record titled, "Change in Condition Evaluation" (CCE) record with effective date on 11/21/24 at 11:05 p.m., the "CCE" indicated, "resident noted to have pain unrelieved by pain medication and complaining of abdominal and upper chest area pain, resident noted with increase respiration..." The "CCE" record also showed Resident 1 had "uncontrolled pain" that started on 11/21/24, with no specific time documented other than "afternoon". The "CCE" record further indicated that Resident 1 had occasional moaning and groaning, facial grimacing, rigid, fists clenched, and knees pulled up during the assessment. During a record review of Resident 1's "Medication Administration Report" (MAR), dated from 11/1/24 through 11/30/24, the "MAR" indicated the physician order for "Nitroglycerin Sublingual (placed under the tongue) Tablet 0.4 milligrams (mg)...Give 0.4 mg sublingually every 5 minutes as needed for chest pain...May repeat x2 (twice) every 5 minutes. Call 911 if the pain persists longer than 5 minutes after the first dose...Continue to take the 2nd and 3rd dose if pain persists." was not given at any time on 11/21/24, despite Resident 1's complaints of chest pain. The physician's order did not include any blood pressure (bp) parameters restricting administration of nitroglycerin. During a record review of Resident 1's, "SNF/NF (Skilled Nursing Facility/Nursing Facility) to Hospital Transfer Form", dated 11/21/24, the "SNF/NF to Hospital Transfer Form" indicated Resident 1 was transferred to the hospital on 11/21/24 at 11:00 p.m. During a record review of Resident 1's EMS record, titled, "Resident Care Report" (PCR), dated 11/21/24, the "PCR" showed EMS assumed Resident 1's care at 10:53 p.m. The "PCR" indicated, "Complaints: (Chief) chest pain as of 9 hours ago". The record also indicated, "RP (Responsible Party) stated that starting at 1500 (3:00 p.m.) hours pt. (resident) began to complain of abdominal pain that radiated up to her chest. pt. was in obvious discomfort and stated the pain was sharp...pt. had previous MI (myocardial infarction or heart attack) on Saturday...pt recent surgery for hernia repair..." The "PCR" also indicated that the EMS administered the nitroglycerin 0.4 mg sublingually to Resident 1 at 11:23 p.m. During record review of Resident 1's "Progress Notes", dated 11/21/24, the "Progress Notes" did not show any documentation of nursing assessment, monitoring, and interventions in response to Resident 1's complaints of chest and abdominal pain that began approximately at 3:00 p.m. During a record review of Resident 1's record from the hospital, titled, "ED Provider Note", dated 11/22/24, the "ED Provider Note" indicated Resident 1 had an acute ST elevation MI (a severe heart attack from complete blockage of a coronary artery), inferior wall (lower portion of the heart) and cardiac arrest (heart suddenly stops beating). The "ED Provider Note" further indicated, "Pt (resident) was having chest pain and upper abdominal pain earlier today...Pt was having agonal (gasping, irregular, or labored breath) respirations on arrival and not too responsive...Pt lost her pulses and CPR (cardiopulmonary resuscitation) started..." The "ED Provider Note" further indicated Resident 1 was pronounced deceased at 1:39 a.m. on 11/22/24. During an interview and record review on 11/12/25 at 1:10 p.m. with the Assistant Director of Nursing (ADON) 1, Resident 1's medical records including "Progress Notes" and "MAR", dated 11/21/24, were reviewed. ADON 1 stated on 11/21/24, Resident 1 received PRN (as needed) pain medications, including two tablets of acetaminophen (over-the-counter pain reliever) 500 mg for moderate pain at 4:08 p.m. and one tablet of Norco 5-325 mg (controlled substance used for severe pain) PRN for pain at 8:05 p.m.; however, ADON 1 stated there was no documented evidence of a comprehensive pain assessment, including location and type of pain, nor documentation of any nursing interventions implemented beyond administration of pain medication. ADON 1 stated she was unable to determine whether the pain medication was administered in response to chest or abdominal pain due to lack of documentation. ADON 1 further stated accurate pain assessment and nursing interventions were essential, as pain was considered as the fifth vital sign (basic measurement that shows how well the body is working), and failure to perform such placed Resident 1 at risk for worsening conditions. During a follow up interview and record review on 11/12/25 at 1:47 p.m. with ADON 1, Resident 1's "MAR", "CCE" and "SNF/NF to Hospital Transfer Form" dated 11/21/24 were reviewed. ADON 1 stated on 11/21/24, Resident 1 was transferred to ED after exhibiting symptoms consistent of a heart attack, including chest pain, abdominal pain, and increased respirations. ADON 1 stated there was no documentation indicating UN 1 initiated the timely administration of nitroglycerin in response to Resident 1's unresolved chest pain, despite the physician's order indicated nitroglycerin should have been given as an intervention prior to calling 911 if chest pain was unrelieved. ADON 1 stated in the event of a heart attack, failure to administer nitroglycerin in a timely manner could place an individual at risk for death. During an interview and record review on 11/12/24 at 3:11 p.m. with Nurse Supervisor (NS) 1, "SNF/NF to Hospital Transfer Form", dated 11/21/25, was reviewed. NS 1 stated she documented "SNF/NF to Hospital Transfer Form" because she was the nursing supervisor during Resident 1's transfer to ED. NS 1 stated she also documented that the physician was notified through the hospital's advice line on 11/21/24 at 10:00 p.m. based on the information UN 1 gave her. NS 1 stated there was no documentation made by UN 1 regarding the call with the hospital advice line. NS 1 stated if UN 1 had contacted the advice line, UN 1 should have documented the information such as the nurse UN 1 spoke with, any new orders or instructions regarding Resid