Health inspection·June 12, 2025

The following reflects the findings of the California Department of Public Health during the investigation of complaint number: CA00959967 A Class “A” Citation was written. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations: § 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: §483.10(g)(14): Patient Rights/Exercise of Rights- Notification of Changes. (i) A facility must immediately inform the patient; consult with the Patient’s physician; and notify, consistent with his or her authority, the patient representative(s) when there is (B) A significant change in the Patient’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the patient from the facility as specified in §483.15(c)(1)(ii). 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. § 72311. Nursing Service-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 the admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating and updating the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. On 5/1/2025, the California Department of Public Health made an unannounced visit to the facility to investigate an allegation regarding the wrongful death of a Resident. Based upon observation, interview and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse (LVN) 3 notified a physician and ensure the change in condition of no urine output in the indwelling catheter was that Resident 1 did not have urine output for several hours, and urine was not collected for urinalysis (UA) as requested by the physician on 4/2/2025 from 7 a.m. to 3 p.m. 2. Ensure Resident 1's vital sign were monitored and recorded every four hours according to a physician's order dated 4/2/2025 when Resident 1 experienced a change in condition 3. Ensure Registered Nurse (RN) and or the Assistant Director of Nursing (ADON) assessed Resident 1 when Resident 1 developed difficulty in breathing, two episodes as observed by the CNA and reported to the LVN 2 on 4/2/2025 between 8 p.m. and 8.30 p.m. and again on 4/2/2025 at 9 p.m. 4. Immediately call 911 emergency services and transfer Resident 1 to a GACH when Resident 1 developed difficulty in breathing on 4/2/2025 between 8 p.m. and 8:30 p.m. and again on 4/2/2025 at 9 p.m. As a result, Resident 1 was found in respiratory distress (labored breathing) on 4/2/2025 at 10:08 p.m., the paramedics arrived at Resident 1's bedside and attempted to resuscitate (to revive a person from a state of apparent death or unconsciousness, often due to a cardiac or respiratory arrest) Resident 1. The paramedics pronounced Resident 1 dead in the facility on 4/2/2025 at 10:35 p.m. During a record review, Resident 1's admission record indicated Resident 1, a 79 year-old male, who was originally admitted to the facility on 8/29/2024 and most recently on 3/21/2025 with diagnoses including, acute respiratory failure with hypoxia (condition where the lungs are unable to deliver enough oxygen to the blood), severe sepsis with septic shock (a life-threatening blood infection), pneumonia (an infection/inflammation in the lungs) due to methicillin resistant staphylococcus aureus (MRSA - a bacteria that does not respond to antibiotics), urinary tract infection (UTI- an infection in the bladder/urinary tract), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dysarthria and anarthria (difficulty and lost ability to speak), and pleural effusion (an abnormal buildup of fluid in the space between the thin layers of the lungs and the wall of the chest cavity). During a record review, Resident 1's Admission/Re-admission Summary Note dated 3/21/2025 at 5:12 p.m., indicated Resident 1 was a Full Code (refers to a patient's status indicating they want all possible measures taken to resuscitate them if they stop breathing or their heart stops beating). During a record review, Resident 1's Care Plan (CP) on “Respiratory… At Risk for Complications …" initiated 3/21/2025, indicated the CP goal included Resident 1 will have unlabored respirations … Will not exhibit respiratory distress such as wheezing… and report abnormal findings to physician promptly. The CP interventions indicated that Resident 1 will be assessed for hypoxia (a deficiency of oxygen reaching the tissues of the body), altered level of consciousness, irritability, restlessness, and cyanosis (a bluish or purplish discoloration of the skin and mucous membranes, primarily due to a decrease in oxygen saturation in the blood). The CP interventions also included to monitor Resident 1 for shortness of breath, irregular respirations, … decreased energy, rapid breathing, … and inform physician promptly. During a record review, the facility "In-service Lesson Plan" on "Change of Condition" dated 3/26/2025, indicated the topic of In-service for nursing included: 1. Assessment of patient (resident). 2. Obtaining vital signs, reporting vital signs and change of condition (COC) to medical doctor (MD). 3. Worsening/deterioration of residents’ condition; following emergency procedures. 4. Transferring residents via paramedics. During a record review, the facility "In-service Staff Attendance" on "Change of Condition" dated 3/26/2025, indicated "Topic … Charge nurse will continue to monitor resident. If condition deteriorates and resident has no restrictions on transferring out, charge nurse/nurse sup (supervisor) will transfer patient (pt-resident) via paramedics, after transfer, charge nurse will notify MD and family/responsible party.” During a record review, Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/27/2025 indicated Resident 1's cognition (mental ability to make decisions for daily living) was not intact. The MDS indicated Resident 1 was dependent (helper does all the effort) for dressing, bathing, and toileting). The MDS indicated Resident 1 transfers (moving between surfaces) from bed to chair were not attempted due to medical condition or safety concerns. The MDS indicated Resident 1 was not on oxygen. During a record review, Resident 1's Nurse's Note dated 4/2/2025 at 11:15 a.m., indicated that on 4/2/2025 at around 9:30 a.m., the charge nurse (unidentified) noted Resident 1's BP 119/54 millimeters of mercury (mmHg- unit of measurement), PR (pulse rate-71 per minute), RR 20, O2 sat 95% on room air (RA- Normal O2 sat range is between 90%-100%), and elevated temp of 100.2 degrees F with yellow emesis (vomit). Resident 1 was provided with cold packs PRN (as necessary) Acetaminophen to reduce the fever. The Nurse's Note indicated that family (unspecified) requested to transfer Resident 1 to GACH 2, and that family was notified of MD's order to transfer Resident 1 to GACH 1. The Nurse's Note indicated MD ordered the following for Resident 1: -VS every (Q) 4 hours (Hrs.) for 72 Hrs. -Stat (now) CBC and CMP -Start Augmentin 875 mg PO BID x 10 days - UA with culture. During a record review, Resident 1's History and Physical (H&P- the attending physician assessment and plan of care) dated 4/2/2025, indicated nursing concerns about Resident 1 having increased shortness of breath today and a mild fever of 100.2 F. The H&P plan indicated to continue Augmentin every 12 hours (started today), monitor vital signs closely, obtain CBC (complete blood count-measures the numbers and types of cells in the blood), CMP (comprehensive metabolic panel-14 blood tests that provide information about the functions of the liver, kidneys, blood sugar levels, electrolyte [mineral] and fluid balance), UA with culture (a laboratory procedure used to identify microorganisms/bacteria etc) and assess the need for respiratory support. During a record review, Resident 1's Physician Order dated 4/2/2025 at 11.14 a.m., indicated to check vital signs every 4 hours x 72 hours for 3 days. During a record review, Resident 1's "Weight and Vital Summary" record effective 4/2/2025 - 4/2/2025, indicated the following: O2 sats Summary. 4/2/2025 at 9.34 a.m. - 95% (Room Air) 4/2/2025 at 1.32 p.m. - 97% (Room Air) Pulse Summary. 4/2/2025 at 9.34 a.m. - 71 beats per minute (bpm) (Regular) 4/2/2025 at 1.32 p.m. - 100 beats bpm (Regular). Respiration Summary. 4/2/2025 at 9.34 a.m. - 20 breaths per minute (/min) 4/2/2025 at 1.32 p.m. - 19 bpm Temperature Summary. 4/2/2025 at 9.34 a.m. - 97.8 degrees F (Forehead non-contact). 4/2/2025 at 9.49 a.m. - 100.2 degrees F (Forehead non-contact). 4/2/2025 at 1.32 p.m. - 98.6 degrees f (Forehead non-contact). The same Weight and Vital Summary" record indicated no vital signs were entered/recorded after 1.32 p.m. on 4/2/2025. During a record review, Resident 1's Change in Condition Evaluation form dated 4/2/2025 timed 11:21 a.m. indicated Resident 1 was noted with a fever of 100.2 F (checked on the forehead) and had color yellow emesis. The COC indicated a medical doctor (MD) was notified who ordered to monitor vital signs every 4 hours, stat (now) CBC and CMP, UA with culture and to start Augmentin twice a day. The COC Evaluation form indicated the order was carried out and the family/RP notified. The COC Evaluation form indicated that on 4/2/2025 at 9:34 a.m., Resident 1's BP was 119/54 mm/Hg, PR 71 beats per minute, RR 20 per minute, and O2 sat was 95% on RA. During a record review, Resident 1's Medication Administration Record (MAR) for the month of 4/2025, indicated effective 3/21/2025 at 6:50 p.m., Acetaminophen (Tylenol- medication for pain and raised temperature) tablet 325 mg, give 2 tablets ... every 6 hours as needed for elevated temperature (degree of temperature not indicated) and pain, and do not exceed 4 grams (G-unit of measurement) in 24 hours (hrs.). The same MAR did not indicate Resident 1 was administered Acetaminophen on 4/2/2025. During a record review, Resident 1's Change in Condition Evaluation form dated 4/2/2025 timed 10:50 p.m. LVN 2 documented that while making rounds, certified nursing assistant (CNA) asked LVN 2 to check on Resident 1. LVN 2 documented that Resident 1's O2 sat was low at 78% at room air (RA-without extra oxygen) and Resident 1 was placed on oxygen and saturation improved (the amount of oxygen administered, and saturation not indicated). LVN 2 documented that while monitoring Resident 1, the resident desaturated again (level not indicated) and that the paramedics were called. LVN 2 documented that the paramedics were unsuccessful at resuscitation attempts and that Resident 1 expired (date and time not indicated). During a record review, the Paramedic Run Sheet (a printable EMS (Emergency Medical Service) run report is a document that contains important information about a medical response or transport provided by EMS personnel) dated 4/2/2025, indicated the paramedics arrived on 4/2/2025 at 10:08 p.m. and found Resident 1 in supine (on the back) position … with a chief complaint of cardiac arrest for unknown amount of time. Staff called for a low O2 sat. Upon assessment, [Resident 1] was found to be in cardiac arrest (no heartbeat). … Resuscitation was immediately started. Initial rhythm (heart rate pattern) was asystole (no heartbeat). The Paramedic -resident remained in asystole throughout resuscitation efforts. The paramedic run sheet indicated Resident 1 received epinephrine (a stimulant medication administered during cardiac arrest to stimulate the heart and help restore the heartbeat) on 4/2/2025 at 1 mg at 10:10 p.m., 10:15 p.m., and 10:20 p.m. The paramedic run sheet indicated the time on scene to pronouncement (dead) was 27 minutes. During a record review, Resident 1's Late Entry Communication note dated 4/4/2025 at 1:30 p.m., indicated the facility conducted a conference call with Resident 1's family member (FM), MD, and the ADON. The communication note indicated that on 4/2/2025 at around 11 p.m., the nurses were completing their rounds and noted that Resident 1 had a decrease in oxygen saturation. After the RT interventions proved ineffective (duration not specified), 911 was called. 911 arrived and implemented their (911) interventions which eventually led them to call the time of death. During an interview and concurrent record review on 5/1/2025 at 12:26 p.m. with Licensed Vocational Nurse (LVN) 1. Resident 1's COC form dated 4/2/2025 and physician's order for Augmentin dated 4/2/2025 were reviewed. LVN 1 stated that while LVN 1 was rounding on 4/2/2025 at 7 a.m., LVN 1 touched Resident 1 and the resident felt warm to touch, checked Resident 1's temperature, and the resident's temperature was elevated to 100.2 Degrees F. LVN 1 stated Resident 1 vomited yellow fluid and informed MD (time not specified nor stated) who gave an order to transfer Resident 1 to GACH 1. LVN 1 stated LVN 3 then notified Resident 1's FM, and the FM requested to transfer Resident 1 to GACH 2. LVN 1 stated LVN 3 then informed the MD of the FM request. LVN 1 stated the MD cancelled the transfer to GACH altogether and decided to treat/manage the resident in the facility. LVN 1 stated "I remember her (MD) saying something like he (Resident 1) wasn't stable enough, but I am not sure for what, but I don't remember exactly" LVN 1 stated LVN 1 was not sure why the MD cancelled the transfer to GACH and was not comfortable with the decision to not transfer Resident 1 to GACH and treat the resident in the facility. LVN 1 stated that on 4/2/2025 before 3 p.m., LVN 1 rechecked Resident 1's Temp and the Temp came down (LVN 1 unable recall the exact temperature recording). LVN 1 stated, "I gave him (Resident 1) Tylenol through the g tube and placed ice packs.” LVN 1 stated LVN 3 tried to get the UA via straight catheter multiple times with no success. During a telephone interview on 5/1/2025 at 12:58 p.m., LVN 3 stated that on 4/2/2025, Resident 1 had an order for UA. LVN 3 stated Resident 1 had a urinary indwelling catheter and there was no urine output "it was dry so initially I thought it was plugged so I irrigated it, and it was not plugged, then after that I changed the indwelling catheter bag and checked for leaking and there was no leaking. It was dry and still had no output." LVN 3 stated that after about 1 (one) and half hours later LVN 3 came back and still had no output in the dwelling catheter bag and informed LVN 1. LVN 3 stated, "we need endorse to the next shift." LVN 3 stated, "I did not inform the doctor there was no urine output because I thought someone else would report that. There was no urine when I left at 3pm so it was endorsed to the next shift." During a concurre