F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed for one of three residents (Resident 1) to notify the resident's
representative (RP) of a decline in the resident's health status/condition.
This failure had the potential to result in the RP not being informed in a timely manner, delaying their
opportunity to be present regarding Resident's care at the end of life.
Findings:
A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE].
A review of Resident 1's Minimum Data Set (an assessment tool), dated [DATE], indicated Resident 1 had
a Brief Interview for Mental Status (tool used to assess a resident's cognitive function) score of 2 (severe
cognitive impairment).
A review of Resident 1's Nurse's Notes, dated [DATE] at 12:50 a.m., indicated, .Resident was unresponsive
to verbal, tactile and painful stimuli .No response to sternal rub .No heart and breath sounds noted by
auscultation .No chest rise and fall noted .Skin was pale, slightly cool and clammy .No vital signs noted
.Assessed by two charge nurses .(name of facility physician) notified .Hospice nurse notified and came
.(name of hospice physician) pronounced resident dead .
A review of Resident 1's Nurse's Notes, dated [DATE], at 3:34 a.m., indicated, .May release body to family
mortuary of choice .RP made aware .
On [DATE], at 10:41 a.m. during an interview with Licensed Vocational Nurse (LVN) 2, she stated when a
hospice resident passed away in the facility, two licensed nurses conduct an assessment to determine
whether the resident had a heartbeat, was breathing, or was responsive. LVN 2 further stated after this
assessment, the facility physician and the resident's representative were to be notified immediately. LVN 2
stated hospice was contacted for further instructions and to pronounce the time of death.
LVN 2 stated on [DATE], at 12:50 a.m., Resident 1 was found unresponsive, not breathing and without a
heartbeat. LVN 2 further stated she had notified the facility physician and hospice but had not contacted
Resident 1's RP. LVN 2 stated she had waited for hospice to arrive in the facility to call Resident 1's time of
death before notifying the RP. She further stated she notified Resident 1's RP at 3:34 a.m. (approximately
2.5 hours) after Resident 1 had passed. LVN 2 stated she should have
(continued on next page)
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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
555740
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555740
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vista Real Post Acute
1665 East Eighth Street
Beaumont, CA 92223
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
contacted the RP immediately after confirming Resident 1 was no longer alive as it was important to inform
and update the RP promptly so the family could come and say goodbye.
On [DATE] at 11:15 a.m. during a concurrent interview and review of Resident 1's nurse's notes with the
Director of Nursing (DON), she stated, when a resident was on hospice and died, licensed nurses were
expected to assess the resident, and if the resident no longer had a heartbeat and was no longer breathing,
the facility physician and the resident's family or representative were to be notified immediately. The DON
further stated, hospice was contacted to officially pronounce the death. The DON stated, a resident's death
was considered a change in the resident's health status or condition.
The DON stated on [DATE], at 12:50 a.m., LVN 2 assessed Resident 1 as unresponsive, with no heartbeat
and not breathing. The DON stated, the facility physician and hospice were notified. The DON further stated
LVN 2 did not notify Resident 1's RP of the assessment immediately, and the RP was not contacted until
3:34 a.m. The DON stated, LVN 2 should have called and notified Resident 1's RP immediately to ensure
timely communication with Resident 1's family, allowing them the opportunity to see Resident 1 and say
goodbye before the remains were released to the mortuary.
A review of the facility policy and procedure titled, Death of a Resident, Documenting, dated [DATE],
indicated, .The Nurse Supervisor/Charge Nurse will inform the resident's family of the resident's death .
A review of the facility policy and procedure titled, Change in a Resident's Condition or Status, dated 2001,
indicated, .Our facility promptly notifies the resident .and the resident representative of changed in the
resident's medical/mental condition and/or status .A significant change .is a major decline .in the resident's
status .Unless otherwise instructed by the resident, a nurse will notify the resident's representative when
.there is a significant change in the resident's physical, mental .status .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555740
If continuation sheet
Page 2 of 2
