Health inspection·January 30, 2026

483.25(d) ACCIDENTS The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible: and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. Title 22 California Code of Regulations: 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 November 19, 2025, an unannounced visit was conducted at the facility to investigate a facility reported incident where Patient 1 was unsafely reconnected to the ventilator (a machine that supports or controls a person's breathing when they cannot breathe adequately on their own) following a shower. On November 18, 2025, Respiratory Therapist (RT 1) disconnected Patient 1 from the ventilator and attached Patient 1 to Ambu bag (a device used to provide positive pressure ventilation to patients who are not breathing or have difficulty breathing) for a shower. Upon returning from the shower, RT 1 disconnected Ambu bag and reconnected Patient 1 back to the ventilator but failed to resume the ventilator from "standby mode" (device is not active to save power) leaving it inactive from 10:35 AM to 1:39 PM (3 hours and 4 minutes). The facility failed to ensure the staff followed its policy and procedure (P&P) for manual ventilation (technique to provide assisted breathing by a staff) of patient during the shower. This failure resulted in an avoidable interruption in Patient 1's respiratory support triggering a code blue response (an emergency code indicating a patient needs immediate medical attention), which had the potential to cause further brain damage from lack of oxygen, and potentially death. Patient 1 was subsequently transferred to Intensive Care Unit (ICU) for close observation and treatment. Findings: A review of Patient's 1's face sheet (contain demographic and medical information), indicated Patient 1 was admitted to the facility on June 9, 2025, with diagnoses including sepsis (a life threating medical emergency that happens when the body's extreme response to an infection causes widespread inflammation and tissue damage) and respiratory failure (a condition where the lungs does not have enough oxygen in the blood). A review of Patient 1's "Physician Notes," dated June 11, 2025, indicated, Patient 1 is ventilator-dependent, via a tracheostomy (a surgical procedure to create an opening in the neck into the windpipe, called trachea, to establish a direct airway for breathing), with anoxic brain injury (occurs when the brain is completely deprived of oxygen, leading to brain damage), encephalopathy (any disorder that affects the brain function or structure) and chronic respiratory failure (a long term condition where the lungs cannot supply enough oxygen to the blood or remove enough carbon dioxide). A review of Patient 1's "Nursing Progress Note," dated November 18, 2025, indicated, "approximately around 1:40 PM Respiratory Therapist (RT 1) came to charge nurse [RN 1] and says that patient [Patient 1] unresponsive". A review of Patient 1's document titled, "CODE BLUE RECORD," dated November 18, 2025, indicated that CPR (cardiopulmonary resuscitation-an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) initiated at 1:45 PM. During a concurrent interview, and record review on November 19, 2025, at 4:50 PM, with the Director of Cardiopulmonary Services (DCPS), the facility's policy and procedure (P&P), titled, "Manual ventilation [technique to provide assisted breathing by a staff] of Patient During Shower Procedure in NCU [Neurological Care Unit-area for patient with brain condition]," dated July 2025, was reviewed. The P&P stated "...7.0 The RCP (Respiratory Care Practitioner or RT) is responsible for powering on the ventilator, confirming proper ventilator function and reconnecting the patient..." The DCSP stated, looking at the incident, it appeared that RT 1 reconnected Patient 1 to the ventilator following shower; however, RT 1 did not resume ventilation from "standby mode". During an interview on November 20, 2025, at 1:30 PM, with Registered Nurse (RN 1), RN 1, stated on November 18, 2025, she oversaw 28 patients in the unit, including 15 who were on ventilators. The last time she checked Patient 1 was at approximately 12:00 PM. RN 1 further stated at the time Patient 1 had returned from shower room, she does not recall checking the ventilator or its setting. At approximately 1:45 PM, RT 1 came and told her that Patient 1 was unresponsive, so RN 1 went to Patient 1's room and code blue was initiated. During an interview on November 20, 2025, at 1:45 PM, with Certified Nursing Assistant (CNA 1), CNA 1 stated that she took Patient 1 to shower room with CNA 2 and RT 1 on November 18, 2025, at 10:30 AM. CNA 1 saw RT 1 disconnect Patient 1 from the ventilator and attached Patient 1 to Ambu bag. Upon returning from the shower, RT 1 disconnected Ambu bag and reconnected Patient 1 back to the ventilator. CNA 1 further stated she did not see the ventilator being turned on. During an interview on November 20, 2025, at 2:00 PM, with RT 1, RT 1 stated that on November 18, 2025, he assisted with Patient 1's shower. RT 1 reported shower took approximately 30 minutes, from 10:30 AM to 11:00 AM. RT 1 stated, he disconnected Patient 1 from the ventilator and connected to Ambu bag to 10 liters per minute (L/min) of oxygen cylinder for transfer to shower gurney (hospital stretcher or transport bed). Upon returning from the shower, RT 1 stated he reconnected Patient 1 to the ventilator, resumed ventilation from "standby mode", and performed dressing change on tracheostomy. RT 1 further stated during routine rounds at 1:35 PM, RT 1 found Patient 1 was lying in bed, pale, eyes closed, unresponsive, no pulse or respirations, and the ventilator was on "standby mode." RT 1 notified charge nurse and code blue started immediately. During an interview on November 20, 2025, at 2:25 PM, with CNA 2, CNA 2 stated that she was working with CNA 1 on November 18, 2025, and helped with showering Patient 1, which took 30 minutes to complete the task. CNA 2 further stated that RT 1 connected Patient 1 back to the ventilator and changed tracheostomy dressing, but CNA 2 does not remember looking at the ventilator. During a concurrent interview and record review on November 20, 2025, at 2:25 PM, with Bio Med Technician (BMT), the facility's document titled, "[Brand name] Ventilator [Serial number], Export timestamp: 2025-11-19_09-57-00," dated from November 18, 2025, at 8:04 AM through November 18, 2025, 1:55 PM, was reviewed. The document indicated that the ventilator was on standby mode. BMT verified and confirmed that the ventilator was on "Standby" mode from 10:35 AM to 1:39 PM (3 hours and 4 minutes). A follow-up concurrent interview and record review on November 20, 2025, at 2:35 PM, with BMT, the facility's document titled, "OEM [Original Equipment Manufacturer] -Scheduled Preventative Maintenance", dated November 11, 2025, was reviewed. The document indicated that the scheduled preventative maintenance for "[Brand name] Ventilator [Serial number]," was conducted on November 5, 2025. BMT stated that there was nothing wrong with the ventilator. A review of Patient 1's "Nursing Progress Note," dated November 18, 2025, indicated, Patient 1 was transferred after the emergency response to ICU on November 18, 2025, at 2:18 PM, for close observation and treatment. During an observation of Patient 1 in ICU, on November 20, 2025, at 2:45 PM, Patient 1 was observed lying in bed attached to ventilator, with FiO2 (the percentage of oxygen a person inhales with each breath with the maximum of 100 percent) set at 30 percent. During a concurrent interview and record review on November 20, 2025, at 3:10 PM, with the DCPS, the facility's document titled, "[Brand name] Ventilator [Serial number], Export timestamp: 2025-11-19_09-57-00," dated from November 18, 2025, at 8:04 AM, through November 18, 2025, 1:55 PM, was reviewed. The document indicated that the ventilator was on "standby mode". The DCPS confirmed RT 1 did not resume ventilation from standby mode. As a result, Patient 1 experienced respiratory arrest (a person has stopped breathing or is breathing so weakly that is not sustainable for life), which led to initiation of code blue and transferred to ICU for closed observation and treatment. In violation of the above cited standards, the facility failed to ensure the staff followed its policy and procedure (P&P) for manual ventilation of patient during shower. This failure resulted in an avoidable interruption in Patient 1's respiratory support triggering a code blue response, which had the potential to cause further brain damage from lack of oxygen, and lead up to death. Patient 1 was subsequently transferred to Intensive Care Unit (ICU) for close observation and treatment. These violations, 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.