Health inspection·October 3, 2025

Code of Federal Regulations, Title 42, Section 483.24(a)(3) Quality of Life (a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advanced directives. Code of Federal Regulations, Title 42, Section 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, including but not limited to the following Code of Federal Regulations, Title 42, Section 483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well- being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71. (a) Sufficient staff. (3) The facility must ensure that licensed nurses have the specific competencies, and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. (4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. (d) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. California Code of Regulations, Title 22, Section 72311 Nursing Services - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 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: (9) Signs and symptoms of cardiopulmonary distress. California Code of Regulations, Title 22, Section 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 08/14/2025, the California Department of Public Health (CDPH) received a complaint alleging the facility was negligent resulting in the death of Resident 1 on 8/4/2025. On 8/15/2025, CDPH conducted an unannounced visit to investigate the complaint. Upon investigation, CDPH determined the nursing staff did not immediately initiate basic life support ([BLS] care healthcare professionals provide to anyone whose heart stops beating suddenly) by performing Cardiopulmonary Resuscitation (CPR) when Resident 1 was found unresponsive and pulseless (no detectable heartbeat). The facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 1, who was CPR certified, checked Resident 1's pulse when on 8/4/2025 at approximately 4:50 a.m. Resident 1 was found unresponsive and not breathing, called for help, activated Code Blue (a specific code used to signal a patient who is having a life-threatening medical emergency, typically a patient experiencing sudden cardiac arrest [when the heart stops beating] or respiratory arrest [when a person stops breathing]), initiated CPR and stayed with Resident 1 per the facility's policy and procedure (P&P) titled, "Emergency Procedure-Cardiopulmonary Resuscitation". 2. Ensure Licensed Vocational Nurse (LVN) 1 immediately initiated CPR when she found Resident 1 was unresponsive, without a pulse and not breathing, instead of leaving the resident's room to get her personal blood pressure (BP) machine from the medication cart, which lost critical time needed to increase Resident 1's chance of survival. 3. Ensure staff called 911 as soon as Resident 1 was found unresponsive and pulseless on 8/4/2025 at 4:50 a.m., per the facility's P&P titled, "Emergency Procedure-Cardiopulmonary Resuscitation" that indicated if the person does not respond and is not breathing or only gasping to call 911. 4. Ensure CNA 1 and LVN 1 followed the facility's P&P titled, "Emergency Cardiopulmonary Resuscitation," which indicated "to initiate CPR if sudden cardiac arrest is likely." As a result, staff delayed providing CPR to Resident 1 when CNA 1 and LVN 1 found the resident unresponsive and not breathing on 8/4/2025 at approximately 4:50 a.m. and delayed calling 911 leading to Resident 1's death. Resident 1 was pronounced dead on 8/4/2025 at 5:05 a.m. A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on 6/26/2025 with diagnoses including cervical spine fracture (broken neck), quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury [the conduit {tube} between the brain and the rest of the body]), and chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing). A review of Resident 1's History and Physical (H&P) dated 6/26/2025, indicated Resident 1 had the capacity to understand and make decisions. The H&P indicated Resident 1 was a Full Code status. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 6/30/2025, indicated Resident 1's cognition (ability to think, understand, learn, and remember) was intact and he had the ability to understand and be understood by others. The MDS indicated Resident 1 was fully dependent on staff for activities of daily living (ADLs). During a review of Resident 1's Physician's Orders for Life Sustaining Treatment ([POLST] a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end of life) dated 6/26/2025, indicated if Resident 1 had no pulse and was not breathing to attempt resuscitation/CPR. A review of Resident 1's Nurses Progress Notes dated 8/4/2025 and timed at 5:10 a.m., indicated CNA 1 notified LVN 1 that Resident 1 was unresponsive on 8/4/2025 at 4:50 a.m. The Nurses Progress Notes indicated LVN 1 went to assess Resident 1 and found him with not obtainable vital signs ([v/s]. The Nurses Progress Notes indicated LVN 1 initiated chest compression and sent CNA 1 to get LVN 2, Code Blue was initiated by LVN 2. The Nurses Progress Notes indicated LVN 2 took over the Code Blue with assistance from CNA 2 and 911 was called at 4:57 a.m. (seven minutes after CNA 1 and LVN 1 found Resident 1 unresponsive and pulseless). The Nurses Progress Notes indicated Paramedics arrived at 5:05 a.m., assessed Resident 1, who had not obtainable v/s and was not breathing. A review of Emergency Medical Service Report (EMS) dated 8/4/2025 and timed at 5:05, indicated Paramedics were called on 8/4/2025 at 4:57 a.m. and arrived at the scene on 8/4/2025 at 5:05 a.m., where they found Resident 1 deceased. The EMS Report indicated the facility staff reported Resident 1 was last seen alive on 8/4/2025 at 12 a.m. During a telephone interview on 8/15/2025 at 2:20 p.m., and a subsequent interview at 5:20 p.m., CNA 1 stated that on 8/4/2025 around 4:45 a.m., during her rounds, she walked into Resident 1's room and did not see Resident 1's chest rising, indicating the resident was not breathing. CNA 1 stated she did not check Resident 1's pulse when she found Resident 1 not breathing. CNA 1 stated she did not initiate CPR immediately and left Resident 1 unattended to get LVN 1, who was at the Nursing Station 2. CNA 1 stated she did not initiate CPR immediately because she wanted a witness and it was her first time experiencing an unresponsive resident. During an interview on 8/15/2025 at 3 p.m., LVN 2 stated on 8/4/2025 she was informed by CNA 1 that LVN 1 needed help. LVN 2 stated when she entered Resident 1's room, she saw LVN 1 on top of Resident 1's bed on her knee but she did not see LVN 1 performing chest compressions on Resident 1. LVN 2 stated Resident 1 did not have a pulse, so she initiated chest compressions and directed LVN 1 to get the crash cart (a set of trays/drawers/shelves on wheels used in hospital or skilled nursing facility for transportation and dispensing of emergency medication/equipment at site). LVN 2 stated when a resident (in general) is found without a pulse, CPR must be initiated immediately while another staff member calls 911 to increase the chance of survival and prevent brain damage. During an interview on 8/16/2025 at 7:08 a.m., LVN 1 stated on 8/4/2025, around 4:45 a.m., CNA 1 reported that Resident 1 was not responding to verbal stimuli (words or phrases designed to trigger a reaction) or tactile stimuli (physical touch). LVN 1 stated when CNA 1 and LVN 1 entered Resident 1's room, Resident 1 was in bed in an upright position with the head of the bed elevated at approximately 30-degree angle. LVN 1 stated she could not arouse Resident 1 and was not able to obtain a pulse. LVN 1 stated she then went out of Resident 1's room, down the hallway, to get her personal BP machine, returned to Resident 1's room and checked Resident 1's BP twice. LVN 1 stated both BP readings indicated "ERROR." LVN 1 stated she did not instruct CNA 1 to initiate CPR on Resident 1 while she (LVN 1) left CNA 1 alone in Resident 1's room to get a BP machine. LVN 1 stated after she could not obtain Resident 1's pulse and BP, she initiated CPR and instructed CNA 2 to call LVN 2 for help. LVN 1 stated CNA 2 came back with LVN 2, and CNA 2 continued chest compressions. LVN 1 stated she then ran to Station 3, but did not call 911, grabbed the POLST binder to check Resident 1's code status, ran to Station 2 and called 911. LVN 1 stated Paramedics arrived at 5:05 a.m., assessed Resident 1 and stated Resident 1 was deceased. LVN 1 stated she did not lower the head of the bed while performing chest compressions on Resident 1 because she stated it was an emergency, "it was four (4 a.m.) in the morning," and she did the best that she could. LVN 1 stated she should have placed Resident 1 in a flat position by lowering the head of bed while performing CPR to effectively perform chest compressions. During an interview on 8/19/2025 at 3:43 p.m., the DON stated when a resident is found unresponsive, staff should immediately check for a pulse, if the resident does not have a pulse, then immediately start chest compressions, call for help, and immediately call 911. The DON stated, if chest compressions and/or CPR was not initiated immediately after the heart stops beating, the chances of the resident's survival decrease significantly, and the risk of permanent brain damage or death increases drastically. The DON stated the resident's bed must be flat prior to initiating CPR so the person who performs chest compressions provides the appropriate compressions necessary to pump blood from the heart to the rest of the body. During a concurrent telephone interview and record review on 8/20/2025 at 8:36 a.m., with a Paramedic (PM), who was on the scene when Resident 1 was confirmed deceased, Resident 1's EMS dated 8/4/2025 and timed at 5:05 was reviewed. The EMS report indicated Paramedics were called on 8/4/2025 at 4:57 a.m. (seven minutes after Resident 1 was found unresponsive and without a pulse). The EMS report indicated the following: 1. Resident 1 was found unresponsive, he appeared to be deceased upon arrival, bilateral (both) eyes were non-reactive (the black center of the eyes [pupils] were fixed which indicates brain death). 2. Resident 1 had severe rigor (stiffening of the joints and muscles of a body) and lividity (a purplish-red skin discoloration that occurs after death due to the pooling of blood in the lower parts of the body, caused by gravity when circulation stops and is a visible sign of death) was present. 3. Resident 1 was pale and cold, had no breath sounds, his BP was unobtainable, and he had no pulse. The PM stated when they arrived, the facility staff were "attempting" CPR by pressing on Resident 1's sternum (breastbone) but not providing effective chest compressions, appearing to just go through the motions. The PM stated upon paramedic's assessment, Resident 1 looked deceased with obvious signs of death, he had no obvious chest rise, his eyes were open, his pupils were fixed, his skin was pale and cold, and he had rigor to his jaw and torso (the main part of the body that contains the chest, abdomen, pelvis, and back). The PM stated the facility staff reported Resident 1 was last seen alive by facility staff on 8/4/2025 at 12 a.m. The PM stated rigor, and lividity were signs that Resident 1 had been deceased for several hours. A review of the facility's P&P titled, "Emergency Procedure-Cardiopulmonary Resuscitation," revised 4/28/2025, the P&P indicated the facility will implement guidelines regarding CPR. The P&P indicated if an individual is found unresponsive briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR and instruct a staff member to activate the emergency response (code) and call 911. The P&P indicated all rescuers, trained or not, should provide chest compression to victims of cardiac arrest. The facility failed to: 1. Ensure CNA 1, who was CPR certified, checked Resident 1's pulse when on 8/4/2025 at approximately 4:50 a.m. Resident 1 was found unresponsive and not breathing, called for help, activated Code Blue , initiated CPR and stayed with Resident 1 per the facility's P&P titled, "Emergency Procedure-Cardiopulmonary Resuscitation". 2. Ensure LVN 1 immediately initiated CPR when she found Resident 1 was unresponsive, without a pulse and not breathing, instead of leaving the resident's room to get her personal BP machine from the medication cart, which lost critical time needed to increase Resident 1's chance of survival. 3. Ensure staff called 911 as soon as Resident 1 was found unresponsive and pulseless on 8/4/2025 at 4:50 a.m., per the facility's P&P titled, "Emergency Procedure-Cardiopulmonary Resuscitation" that indicated if the person does not respond and is not breathing or only gasping to call 911. 4. Ensure CNA 1 and LVN 1 followed the facility's P&P titled, "Emergency Cardiopulmonary Resuscitation," which indicated to initiate CPR if sudden cardiac arrest is likely. As a result, staff delayed providing CPR to Resident 1 when CNA 1 and LVN 1 found the resident unresponsive and not breathing on 8/4/2025 at approximately 4:50 a.m. and delayed calling 911 leading to Resident 1's death. Resident 1 was pronounced dead on 8/4/2025 at 5:05 a.m. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.