Health inspection·March 17, 2025

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 Page 1 of 2 555740 555740 03/17/2025 Vista Real Post Acute 1665 East Eighth Street Beaumont, CA 92223

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 . 555740 Page 2 of 2