Other·August 7, 2017

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 the investigation of one entitiy reported incident. Entity reported incident number: CA00463984. Representing the Department: Health Facility Evaluator Nurse: 33372. The inspection was limited to the specific complaint and does not represent the findings of a full inspection of the facility. Deficiencies were issued for entity reported incident number: CA00463984. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------CLASS"_AA_" CITATION 02-2142-0013410-S Complaint Number: CA00463984 Representing the Department of Public Health: Surveyor ID #2142, HFEN 483.25(k) - TREATMENT/CARE FOR SPECIAL NEEDS The facility must ensure that residents receive proper treatment and care for the following special services: (4) Tracheostomy care The facility failed to provide proper treatment 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: RVFM11 Facility ID: CA020000083 If continuation sheet 1 of 15 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: _______________ 056327 (X3) DATE SURVEY COMPLETED 07/07/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (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 for tracheostomy care by failing to ensure staff hyperextended Resident 1's neck prior to changing a tracheostomy tube, as indicated in the facility's policy and procedure; and by failing to use an oral bag mask (BVM) to ventilate when Resident 1 experienced respiratory difficulty after the new tracheostomy tube was inserted, resulting in Resident 1's subsequent death. Review of the clinical record showed Resident 1 was admitted on 6/18/15 with diagnoses including acute and chronic respiratory failure. Resident 1 had a tracheostomy (a surgical opening through the neck into the trachea (windpipe) to allow for mechanical breathing in patients with respiratory failure and dependency on a ventilator (a breathing machine). On 10/28/15, the Director of Respiratory Therapy (DRT), Respiratory Therapist (RT) 1, RT 2, and Medical Doctor (MD) 1 performed a scheduled tracheostomy tube change ordered for Resident 1. The DRT documented vital signs for Resident 1's prior to the tracheostomy change as follows: oxygen saturation level 99% (a measurement of oxygen concentration in the blood normal: 95-100%), heart rate was 73 beats/minute (normal: 60-100), respiratory rate was 14 breaths/minute (normal: 10-20). RT 2 stated Resident 1 did not have any respiratory issues prior to the tracheostomy tube change. Review of the facility's policy and procedures, "Tracheostomy tube change," revised on 10/31/08, indicated to, "Hyperextend: (to extend beyond the normal range of motion) the resident's neck by placing a folded towel under the neck. Inflate the tracheostomy cuff (a balloon that seals off the space between the wall of the trachea and the trach tube), if physician ordered: a. Fill syringe with 10 ml of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVFM11 Facility ID: CA020000083 If continuation sheet 2 of 15 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: _______________ 056327 (X3) DATE SURVEY COMPLETED 07/07/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (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 air, and attach to cuff inflation port. b. Place stethoscope over trachea. c. Slowly inflate the cuff until no airflow is heard during inspiration. d. Slightly deflate the cuff until a minimal amount of airflow is heard." In an interview on 11/9/15 at 8:48 a.m., the DRT confirmed Resident 1 was placed in a semi-fowler's position (a position with the head of the bed elevated approximately 30 to 45 degrees) with Resident 1's neck extended. DRT stated Resident 1's stoma (an artificial opening in the neck area to allow for the tracheostomy) was patent and opened as he withdrew the old tracheostomy tube. The DRT stated he met resistance when he inserted Resident 1's new tracheostomy tube. DRT stated 15 seconds after he connected Resident 1's tracheostomy to the ventilator, Resident 1's condition changed and Resident 1's oxygen saturations decreased, Resident 1's heart rate was above 100 (60 to 100 beats per minute is normal), subcutaneous tissue emphysema was noted on the left side of Resident 1's neck, and Resident 1's lungs felt "tight". The DRT stated he deflated Resident 1's tracheostomy cuff and attempted to realign Resident 1's tracheostomy tube by backing it out, but he did not take the tracheostomy completely out. DRT stated Resident 1's oxygen saturation levels went up and down. The DRT stated he ventilated Resident 1 via Resident 1's tracheostomy tube with a bag-valve mask (BVM, a hand-held, manual, self-inflating bag used to provide ventilation) until the paramedics arrived. In an interview on 11/9/15 at 9:40 a.m., RT 1 confirmed Resident 1's facial skin color turned to "ashy color" and her oxygen saturation levels dropped and fluctuated between 58 to 80% after the tracheostomy change. In an interview on 11/18/15 at 10:45 a.m., RT 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVFM11 Facility ID: CA020000083 If continuation sheet 3 of 15 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: _______________ 056327 (X3) DATE SURVEY COMPLETED 07/07/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (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 stated moments after Resident 1's tracheostomy tube was attached to the ventilator, Resident 1 developed subcutaneous tissue emphysema (air trapped under the skin) on the left side of her neck and her skin changed to "greyish-blue, dusky". RT 2 confirmed Resident 1 had diminished breath sounds in the left lung after the tracheostomy tube change. RT 2 confirmed Resident 1's skin color remained "dusky" when Resident 1 was taken to the hospital by paramedics and stated Resident 1's tracheostomy tube could have been misplaced during the tracheostomy tube change. In a telephone interview on 11/18/15 at 11:45 a.m., RT 1 confirmed she had met resistance when she attempted to suction Resident 1 via the tracheostomy tube. RT 1 stated there were scant, blood-tinged secretions when she tried to suction the tracheostomy tube. RT 1 stated Resident 1's oxygen saturation levels were in the 80s and her heart rate was in the 120s after the DRT manipulated and repositioned Resident 1's tracheostomy. In a telephone interview on 12/31/15 at 9:00 a.m., RT 2 stated a misalignment of a tracheostomy tube would cause subcutaneous tissue emphysema in the neck and confirmed Resident 1 was ventilated with a BVM through the tracheostomy tube and not through the mouth when subcutaneous tissue emphysema was noted on the left side of Resident 1's neck. In a telephone interview on 12/31/15 at 9:20 a.m., RT 1 confirmed Resident 1 was ventilated with a BVM through the tracheostomy tube and not through the mouth. RT 1 confirmed Resident 1 was placed in a semi-fowler's position with no support under the neck. RT 1 stated Resident 1 started to develop FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVFM11 Facility ID: CA020000083 If continuation sheet 4 of 15 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: _______________ 056327 (X3) DATE SURVEY COMPLETED 07/07/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (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 subcutaneous tissue emphysema in the left neck area after her new tracheostomy tube was inserted. In a telephone interview on 12/31/15 at 11:00 a.m., an Ears, Nose and Throat Doctor (ENT) from the General Acute Care Hospital that treated Resident 1 in the Emergency Room) stated the best position to do a tracheostomy tube change was to have a patient in a supine (flat on the back facing up) position with the neck extended and a towel placed under the neck, which would allow the neck to be more exposed visibly. The ENT stated, to indicate if a tracheostomy tube was placed correctly staff could pass a suction catheter through the tracheostomy tube without resistance, and listen to both lungs for good air exchange. The ENT stated manipulating the tracheostomy tube while still in the trachea would not help and may create a false passage. The ENT stated the tracheostomy tube must be taken out and re-inserted with a smaller sized tracheostomy tube if there were any problems in ventilation. The ENT stated covering the stoma and using a BVM via mouth was a way to properly ventilate someone in an emergency if ventilating via the tracheostomy was not an option. In a telephone interview on 12/31/15 at 11:40 a.m., the DRT stated there were no emergency protocols or policy and procedures in an event like this, only to call 911. The DRT stated he did not feel comfortable to change the tracheostomy tube to a smaller size and confirmed he ventilated Resident 1 via the tracheostomy tube and not by the mouth with a BVM. Record review of "Progress notes", dated 10/28/15 by the DRT showed, "Upon insertion DRT met resistance approximately two inches FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVFM11 Facility ID: CA020000083 If continuation sheet 5 of 15 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: _______________ 056327 (X3) DATE SURVEY COMPLETED 07/07/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (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 into stoma. Clear (breath sounds) on the right (lung), diminished on the left (lung). Shortly after Resident 1's oxygen saturation levels began to drop. Resident 1 placed on 100% oxygen via BVM. Resident 1 had a change in color, absent breath sounds on the left. Heart rate in the 120s. MD 1 noticed crepitus (a clinical sign characterized by a crackling or popping sound of air in the soft tissue) around neck. Resident 1 suctioned several times, blood tinged secretions". Record review of MD 1's "Progress Note," dated 10/28/15, showed, "Resident 1's tracheostomy change got complicated with acute respiratory failure. RT 1 realigned the tracheostomy and did multiple suctions which were blood tinge for decrease oxygenation. Although her oxygen improved to the 90's initially and later fluctuated between 53-98%, also Resident 1 developed chest crepitus (crackling sound under the skin), 911 was called, started bagging (artificial respiration with a hand held air bag) and patient was transferred to acute care for tachycardia (rapid, ineffective heart beat) with decrease oxygen saturation (amount of oxygen in the blood)." Record review of the Emergency Medical Technician-Paramedic "Patient care report", dated 10/28/15, showed, "Per RT upon insertion of new (tracheostomy) tube resistance was met and blood was noted around stoma. Staff member states poor BVM compliance noted. RT states subcutaneous (tissue) emphysema noted to left chest and believes tracheostomy may be displaced. Skin temperature cool, Skin color cyanotic, left lung sounds absent, right lung sounds decreased, capillary refill (a quick test to indicate blood flow in the tissue) absent, level of consciousness unresponsive, heart rate 134, and oxygen saturations 70% with supplemental oxygen". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVFM11 Facility ID: CA020000083 If continuation sheet 6 of 15 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: _______________ 056327 (X3) DATE SURVEY COMPLETED 07/07/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (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 Record review of "Emergency Department (ED) nursing notes", dated 10/28/15 showed, "Blood coming from tracheostomy tube. Crepitus around trachea. Resident 1 is mottled (spots or patches with different colors). Record review of the "ED Physician progress notes", dated 10/28/15 at 1:40 p.m. showed, "... (Resident 1) with emergent airway issue and prolonged anoxia (absence of oxygen) with apparent severe brain injury...Unable to ventilate through trach in place with subterranean air(crepitus) felt in surrounding tissue...Time of death 1:20 (pm)." Record review of the "Coroner's Report", dated 3/31/16 showed, "Autopsy (an examination used to determine the cause of death) findings: Perforation (a hole made by piercing) of posterior wall of esophagus (throat) and trachea due to improper placement of tracheostomy tube, with tip of tracheostomy tube impacting fifth cervical vertebrum (the upper spine that form the neck). These findings are consistent with placement of the tube in the esophagus with perforation. There is also evidence of the tracheostomy tube causing perforation of the trachea and entry of the tip of the tube into the lower esophagus. Cause of Death: Acute respiratory failure, with bilateral collapsed lungs, due to improper placement of tracheostomy tube, with tracheal and esophageal perforation". The facility failed to provide proper treatment for tracheostomy care by failing to ensure staff hyperextended Resident 1's neck prior to changing a tracheostomy tube, as indicated in the facility's policy and procedure; and by failing to use an oral bag mask (BVM) to ventilate when Resident 1 experienced respiratory difficulty after the new tracheostomy FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVFM11 Facility ID: CA020000083 If continuation sheet 7 of 15 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: _______________ 056327 (X3) DATE SURVEY COMPLETED 07/07/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (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 tube was inserted, resulting in Resident 1's subsequent death. These violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of the patient.

F328 SS=G TREATMENT/CARE FOR SPECIAL NEEDS CFR(s): 483.25(k)

F328 08/06/2016 The facility must ensure that residents receive proper treatment and care for the following special services: Injections; Parenteral and enteral fluids; Colostomy, ureterostomy, or ileostomy care; Tracheostomy care; Tracheal suctioning; Respiratory care; Foot care; and Prostheses. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to provide the proper tracheostomy treatment and care for Resident 1, by not following their own policy and procedure for tracheostomy tube change and failed to provide effective resuscitation for an unsuccessful tracheostomy tube change. This failure resulted in Resident 1's subsequent death. Definitions: Tracheostomy: a surgical opening through the neck into the trachea (windpipe) to allow for mechanical breathing in patients with respiratory failure. Tracheostomy cuff: a balloon that seals off the space between the wall of the trachea and the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVFM11 Facility ID: CA020000083 If continuation sheet 8 of 15 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: _______________ 056327 (X3) DATE SURVEY COMPLETED 07/07/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (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 trach tube. Subcutaneous Tissue emphysema: air trapped under the skin. Stoma: an artificial opening in the neck area to allow for the tracheostomy. Hyperextend: to extend beyond the normal range of motion. Oxygen saturation level: "O2 sat"- a measurement of oxygen concentration in the blood. Crepitus: A clinical sign characterized by a crackling or popping sound of air in the soft tissue around the lungs in an area where it should not be. Findings: Review of the clinical record showed Resident 1 was admitted on 6/18/15 with diagnoses including acute and chronic respiratory failure. Resident 1 had a tracheostomy and was dependent on a ventilator (a breathing machine). On 10/28/15 The Director of Respiratory Therapy (DRT), Respiratory Therapist (RT) 1, RT 2, and Medical Doctor (MD) 1 performed a scheduled tracheostomy tube change ordered for Resident 1. DRT documented vital signs for Resident 1's prior to the tracheostomy change as followed: oxygen saturation level 99% (normal: 95-100%), heart rate was 73 beats/minute (normal: 60-100), respiratory rate was 14 breaths/minute (normal: 10-20). RT 2 stated Resident 1 did not have any respiratory issues prior to the tracheostomy tube change. Review of facility's policy and procedures "Tracheostomy tube change", revised on 10/31/08 indicated to, "Hyperextend the resident's neck by placing a folded towel under the neck. Inflate the tracheostomy cuff, if physician ordered: a. Fill syringe with 10 ml of air, and attach to cuff inflation port. b. Place stethoscope over trachea. c. Slowly inflate the cuff until no airflow is heard during inspiration. d. Slightly deflate the cuff until a minimal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVFM11 Facility ID: CA020000083 If continuation sheet 9 of 15 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: _______________ 056327 (X3) DATE SURVEY COMPLETED 07/07/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (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 amount of airflow is heard " . According to the "Science Journal of the American Association for Respiratory Care: When to change a tracheostomy tube," dated 8/2010 indicated, "Failure to replace the tracheostomy tube at the time of a routine change can rapidly create an emergency with loss of the airway. Figure 10 shows a suggested algorithm (a process) to help guide practitioners when this occurs." The algorithm to Figure 10 indicated the following: Failed tracheostomy tube change > Adequate oxygenation and ventilation? > No > Supplemental oxygen, oral bag-mask ventilation. Reference [ http://rc.rcjournal.com/content/55/8/1056 .full.pdf+html ] In an interview on 11/9/15 at 8:48 a.m., DRT confirmed Resident 1 was placed in a semifowler's position (a position with the head of the bed elevated approximately 30 to 45 degrees) with Resident 1's neck extended. DRT stated Resident 1's stoma was patent and opened as he withdrew the old tracheostomy tube. DRT stated he met resistance when he inserted Resident 1's new tracheostomy tube. DRT stated 15 seconds after he connected Resident 1's tracheostomy to the ventilator, Resident 1's condition changed. DRT stated Resident 1's oxygen saturations decreased, Resident 1's heart rate was above 100 (60 to 100 beats per minute is normal), subcutaneous tissue emphysema was noted on the left side of Resident 1's neck, and Resident 1's lungs felt "tight". DRT stated he deflated Resident 1's tracheostomy cuff and attempted to realign Resident 1's tracheostomy tube by backing it out, but he did not take the tracheostomy completely out. DRT stated Resident 1's oxygen saturation levels went up and down. DRT stated he ventilated Resident 1 via Resident 1's tracheostomy tube with a bagvalve mask (BVM, a hand-held, manual, selfFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVFM11 Facility ID: CA020000083 If continuation sheet 10 of 15 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: _______________ 056327 (X3) DATE SURVEY COMPLETED 07/07/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (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 inflating bag used to provide ventilation) until the paramedics arrived. In an interview on 11/9/15 at 9:40 a.m., RT 1 confirmed Resident 1's skin color on her face turned to "ashy color" and her oxygen saturation levels dropped and fluctuated between 58 to 80% after the tracheostomy change. In an interview on 11/18/15 at 10:45 a.m., RT 2 stated moments after Resident 1's tracheostomy tube was attached to the ventilator, Resident 1 developed subcutaneous tissue emphysema on the left side of her neck and her skin changed to "greyish-blue, dusky". RT 2 confirmed Resident 1 had diminished breath sounds in the left lung after the tracheostomy tube change. RT 2 confirmed Resident 1's skin color remained "dusky" when Resident 1 was taken to the hospital by paramedics. RT 2 stated Resident 1's tracheostomy tube could have been misplaced during the tracheostomy tube change. In a telephone interview on 11/18/15 at 11:45 a.m., RT 1 confirmed she had met resistance when she attempted to suction Resident 1 via the tracheostomy tube. RT 1 stated there were scant, blood-tinged secretions when she tried to suction the tracheostomy tube. RT 1 stated Resident 1's oxygen saturation levels were in the 80s and her heart rate was in the 120s after DRT manipulated and repositioned Resident 1's tracheostomy. In a telephone interview on 12/31/15 at 9:00 a.m., RT 2 stated a misalignment of a tracheostomy tube would cause subcutaneous tissue emphysema in the neck. RT 2 confirmed Resident 1 was ventilated with a BVM through the tracheostomy tube and not through the mouth when subcutaneous tissue emphysema was noted on the left side of Resident 1's neck. In a telephone interview on 12/31/15 at 9:20 a.m., RT 1 confirmed Resident 1 was ventilated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVFM11 Facility ID: CA020000083 If continuation sheet 11 of 15 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: _______________ 056327 (X3) DATE SURVEY COMPLETED 07/07/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (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 with a BVM through the tracheostomy tube and not through the mouth. RT 1 confirmed Resident 1 was placed in a semi-fowler's position with no support under the neck. RT 1 stated Resident 1 started to develop subcutaneous tissue emphysema in the left neck area after her new tracheostomy tube was inserted. In a telephone interview on 12/31/15 at 11:00 a.m., an Ears, Nose and Throat Doctor (ENT, an expert in tracheostomy from the General Acute Care Hospital that treated Resident 1 in the Emergency Room) stated the best position to do a tracheostomy tube change was to have a patient in a supine (flat on the back facing up) position with the neck extended and a towel placed under the neck, which would allow the neck to be more exposed visibly. The ENT stated to indicate if a tracheostomy tube was placed correctly staff could pass a suction catheter through the tracheostomy tube without resistance, and listen to both lungs for good air exchange. The ENT stated manipulating the tracheostomy tube while still in the trachea would not help and may create a false passage. The ENT stated the tracheostomy tube must be taken out and re-inserted with a smaller sized tracheostomy tube if there were any problems in ventilation. The ENT stated covering the stoma and using a BVM via mouth was a way to properly ventilate someone in an emergency if ventilating via the tracheostomy was not an option. In a telephone interview on 12/31/15 at 11:40 a.m., DRT stated there were no emergency protocols or policy and procedures in an event like this, only to call 911. DRT stated he did not feel comfortable to change the tracheostomy tube to a smaller size. DRT confirmed he ventilated Resident 1 via the tracheostomy tube and not by the mouth with a BVM. In an interview on 6/23/16 at 11:45 a.m., an Expert Respiratory Therapist Consultant FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVFM11 Facility ID: CA020000083 If continuation sheet 12 of 15 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: _______________ 056327 (X3) DATE SURVEY COMPLETED 07/07/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (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 (ERTC) from the Respiratory Care Board of California stated Resident 1 had the signs and symptoms (the low oxygen saturation, fast heartbeat, change in color of skin, the inability for RT 2 to suction via the tracheostomy, and the tissue emphysema) that indicated her tracheostomy was in the wrong place. Furthermore the ERTC stated the continuous resuscitation of Resident 1's tracheostomy when not in the correct place would lead to oxygen not going to the lungs and into the tissue space, which would lead to subsequent death if not corrected. The ERTC stated the facility's staff should have recognized that Resident 1's tracheostomy was not in the right place from the signs and symptoms that were present, and should have removed the tracheostomy, cover Resident 1's stoma and provided oxygen to Resident 1's mouth with a BVM. Record review of "Progress notes", dated 10/28/15 by DRT showed, "Upon insertion DRT met resistance approximately two inches into stoma. Clear (breath sounds) on the right (lung), diminished on the left (lung). Shortly after Resident 1's oxygen saturation levels began to drop. Resident 1 placed on 100% oxygen via BVM. Resident 1 had a change in color, absent breath sounds on the left. Heart rate in the 120s. MD 1 noticed crepitus (subcutaneous tissue emphysema) around neck. Resident 1 suctioned several times, blood tinged secretions". Record review of MD 1's "Progress Note" dated 10/28/15 showed, "Resident 1's tracheostomy change got complicated with acute respiratory failure, RT 1 realigned the tracheostomy and did multiple suctions which were blood tinge for decrease oxygenation. Although her oxygen improved to the 90's initially and later fluctuated between 53-98%, also Resident 1 developed chest crepitus, 911 was called, started bagging (artificial respiration with a hand held air bag) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVFM11 Facility ID: CA020000083 If continuation sheet 13 of 15 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: _______________ 056327 (X3) DATE SURVEY COMPLETED 07/07/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (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 and patient was transferred to acute care for tachycardia (rapid ineffective heart beat) with decrease oxygen saturation (amount of oxygen in the blood)." Record review of the Emergency Medical Technician-Paramedic "Patient care report", dated 10/28/15 showed, "Per RT upon insertion of new (tracheostomy) tube resistance was met and blood was noted around stoma. Staff member states poor BVM compliance noted. RT states subcutaneous (tissue) emphysema noted to left chest and believes tracheostomy may be displaced. Skin temperature cool, Skin color cyanotic, left lung sounds absent, right lung sounds decreased, capillary refill (a quick test to indicate blood flow in the tissue) absent, level of consciousness unresponsive, heart rate 134, and oxygen saturations 70% with supplemental oxygen". Record review of "Emergency Department (ED) nursing notes", dated 10/28/15 showed, "Blood coming from tracheostomy tube. Crepitus around trachea. Resident 1 is mottled (spots or patches with different colors). Record review of the "ED Physician progress notes", dated 10/28/15 at 1:40 p.m. showed, "... (Resident 1) with emergent airway issue and prolonged anoxia (absence of oxygen) with apparent severe brain injury...Unable to ventilate through trach in place with subterranean air(crepitus) felt in surrounding tissue...Time of death 1:20 (pm)." Record review of the "Coroner's Report", dated 3/31/16 showed, "Autopsy (an examination used to determine the cause of death) findings: Perforation (a hole made by piercing) of posterior wall of esophagus (throat) and trachea due to improper placement of tracheostomy tube, with tip of tracheostomy tube impacting fifth cervical vertebrum (the upper spine that form the neck). These findings are consistent with placement of the tube in the esophagus with perforation. There is also FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVFM11 Facility ID: CA020000083 If continuation sheet 14 of 15 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: _______________ 056327 (X3) DATE SURVEY COMPLETED 07/07/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WALNUT CREEK SKILLED NURSING & REHABILITATION CENTER 1224 Rossmoor Parkway Walnut Creek, CA 94595 (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 evidence of the tracheostomy tube causing perforation of the trachea and entry of the tip of the tube into the lower esophagus. Cause of Death: Acute respiratory failure, with bilateral collapsed lungs, due to improper placement of tracheostomy tube, with tracheal and esophageal perforation". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVFM11 Facility ID: CA020000083 If continuation sheet 15 of 15