Health inspection·September 5, 2025

The following reflects the finding of the California department of Public Health during Investigation of a facility reported incident numbers 2565738 and 2566267 A Class A citation was issued. CPR §483.24(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. § 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[.] California Code of Regulations, Title 22, Section 72311. Nursing Service- General. (a) Nursing service should include, but not be limited to, the following: (2) Implementing 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 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 7/31/2025 California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident regarding a resident's death. The facility failed to immediately initiate cardiopulmonary resuscitation (CPR - an emergency treatment that's done when someone's breathing or heartbeat has stopped) in accordance with the American Heart Association (AHA - organization dedicated to fighting heart disease and stroke) guideline for Resident 1. On 6/21/2025 at 4:08 P.M., the facility staff found Resident 1 unresponsive (when a person is not reacting to shaking, touching, sound, or verbal commands and may or may not continue breathing) in the patio, and transferred Resident 1 through another resident's room, then to Resident 1's room before starting the CPR. This deficient practice had a high probability to result in Resident 1's death in the facility on 6/21/2025 at 4:34 P.M. Los Angeles Fire Department (LAFD) paramedics (healthcare professional/s trained to provide advanced emergency medical care, often in pre-hospital settings) subsequently pronounced Resident 1 dead in the facility on 6/21/2025 at 4:34 P.M. A review of Resident 1's Admission Record, the admission record indicated the facility admitted Resident 1 on 9/28/2023 and readmitted Resident 1 on 4/19/2025 with diagnoses including chronic (on going) systolic heart failure (a specific type of heart failure that occurs in the heart's left ventricle [chamber which are responsible for pumping blood out of the heart]), generalized muscle weakness (when muscles aren't as strong as they should be), and acute embolism (a blockage of a pulmonary [lung] artery). A review of Resident 1's Physician Orders for Life -Sustaining Treatment (POLST - is a medical order that helps give people with serious illness more control over their care during a medical emergency) dated and signed by Resident 1 on 3/1/2024, indicated Resident 1 wanted the facility to attempt resuscitation (bring back to life)/CPR and provide full treatment with the primary goal of prolonging life by all medically effective means. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 6/3/2025, indicated Resident 1 was cognitive intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 required partial/moderate to substantial/maximal assistance from staff with activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) A review of Resident 1's Advance Healthcare Directive (AHCD -is a legal document that outlines a person's wishes for medical treatment, especially in situations where they can no longer make their own decisions) dated and signed by Resident 1 on 4/21/2025 indicated that Resident 1 did not have AHCD and did not want AHCD information. A review of Resident 1's Change of Condition (COC - a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) dated 6/21/2025 at 4:31 P.M., indicated Registered Nurse Supervisor (RNS) 1 documented that Resident 1 was seen unresponsive on the patio on 6/21/2025 at 4:08 P.M. A review of Resident 1's Situation Background Assessment and Recommendation (SBAR-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 6/21/2025 at 4:31 P.M., indicated that RNS 1 wrote that on 6/21/2025 at around 4:08 P.M., Resident 1 was seated in a wheelchair (WC) in the patio and was unresponsive ... Resident 1's vital (not limited to blood pressure [BP], Pulse [HR-heart rate], respirations (RR-breathing], temperature (temp-T), oxygen saturation [O2-amount of oxygen present in the blood) signs were unappreciated (not able to record). The SBAR further indicated Resident 1 ... was wheeled back to Resident 1's room ... and another nurse called 911 (telephone number used to reach emergency medical, fire, and police services) on 6/21/2025 at around 4:09 P.M. The SBAR further indicated multiple staff (unidentified) help transfer Resident 1 back to bed and that Resident 1 did not have a BP, pulse, or respirations ... During a review of Resident 1's LAFD Patient Care Report dated 6/21/2025, the LAFD Patient Care Report indicated the facility contacted LAFD on 6/21/2025 at 4:07 P.M., that Resident 1 was unconscious and had suffered a cardiac arrest (a sudden and unexpected cessation of the heart's pumping action, leading to a complete or near-complete loss of blood flow to the vital organs, including the brain). The LAFD Patient Care Report indicated that paramedics were dispatched to the facility on 6/21/2025 at 4:08 P.M., paramedics were at the scene (facility) on 6/21/2025 at 4:11 P.M., and by Resident 1 on 6/21/2025 at 4:12 P.M. The LAFD Patient Care Report indicated that on 6/21/2025 at 4:18 P.M., upon arrival, Resident 1 was found in bed in the facility, pulseless (no heart beat), was unresponsive, had apnea (cessation of breathing), was pale (pallor - refers to an abnormal loss of color in the skin or mucous membranes, often indicating reduced blood flow), and both pupils (eyes) were fixed and dilated (a condition where the pupils of the eyes are enlarged and unresponsive to changes in light or focus), and Resident 1's downtime (collapse) was unknown. The LAFD Patient Care Report indicated CPR was initiated prior to arrival, and that upon the paramedics arrival, Resident 1's initial rhythm (the sequence and regularity of the heart's electrical activity and contractions) was Pulseless Electrical Activity (PEA - is a type of cardiac arrest where the heart muscle exhibits electrical activity but is unable to contract effectively enough to produce a palpable pulse, meaning no blood is being pumped to the body). Resident 1 remained in asystole (when your heart's electrical system fails, causing your heart to stop pumping) for 20 minutes. The LAFD team pronounced Resident 1 dead in the facility on 6/21/2025 at 4:34 P.M. During a review of Resident 4's Admission Record, the admission record indicated the facility admitted Resident 4 on 5/17/2025 with diagnoses that included diabetes mellitus (DM- inappropriately elevated blood glucose levels). During a review of Resident 4's History and Physical (H&P- a term used to describe a physician's examination of a patient) dated 5/20/2025, the H&P indicated Resident 4 did not have memory loss and had the capacity to make medical decisions. During a review of Resident 4's MDS dated 5/24/2025, the MDS indicated Resident cognition was intact. During an interview on 7/31/2025, at 2:22 P.M., with Certified Nursing Assistant (CNA) 1, CNA 1 stated that a few minutes before or maybe after 4 P.M., on 6/21/2025, she (CNA 1) saw facility staff (unknown) wheeling Resident 1 in a WC. CNA 1 stated Resident 1's head was leaning on the left side and resting on the resident's left shoulder, the resident's eyes were closed, and the resident was unconscious. CNA 1 stated she was in another resident's room across from Resident 1's room providing care/changing incontinent brief. When CNA 1 was done providing care to the other resident, CNA 1 went to Resident 1's room and found Resident 1 still sitting in the WC. CNA 1 stated she then assisted the facility staff (unknown staff were already at Resident 1's bedside) to transfer Resident 1 back to bed and then the staff started performing CPR on Resident 1. CNA 1 was unable to recall how long she took to provide care to the resident before going to assist with Resident 1. During interview on 7/31/2025, at 2:50 P.M., with RNS 1, RNS 1 stated that while making rounds on 6/21/2025 at around 4 P.M., an unknown CNA told him that there was a patient that was not well on the patio. RNS 1 stated he immediately went to the patio area and saw Resident 1 and Resident 4. RNS 1 stated he saw Resident 4 asking Resident 1 if Resident 1 was okay, however, Resident 1 did not respond. RNS 1 stated that he also tapped Resident 1 on the shoulder, called the resident by name, but Resident 1 did not respond. RNS 1 stated Resident 1 was sitting in a WC, saliva was drooling (the excessive flow of saliva from the mouth) from the mouth and onto the chin. RNS 1 stated that Resident 1's vital signs were checked and none were appreciated. RNS 1 stated that he asked the facility staff around him to assist in placing Resident 1 back in bed. RNS 1 stated he and the facility staff then opened the emergency doors to another resident's room and wheeled Resident 1 through that room and then wheeled Resident 1 to Resident 1's room. RNS 1 stated that it took six to seven people (facility staff) to place Resident 1 in bed before beginning CPR. RNS 1 stated CPR should be started immediately (right away) on an unresponsive resident because the heart is not pumping, the heart needs to be pumped to help the blood flow. RNS 1 stated, "if CPR is not done immediately, there is a big chance that the patient will die." During an interview on 7/31/2025, at 3:39 P.M., Resident 4 stated that she was wheeling herself in front of Resident 1 and when she and Resident 1 got to the patio, Resident 4 noticed that Resident 1 was lagging way behind Resident 4, "and when I looked back he (Resident 4) had stopped, had his head slumped down, so I rolled my wheelchair backwards to where he was. I called his name, I rubbed his head, you know he had a bald head to stimulate him but he did not wake up, I yelled I need help here that's when all the staff came right away and took him to his room." Resident 4 stated the paramedics came right after, they did not take time they were here and that the facility staff did not start the CPR on the patio. During an interview on 8/1/2025, at 11A.M., with the medical doctor (MD), the MD stated, "We are not sure why staff moved him [Resident 1] to the room." MD stated CPR should be started immediately on an unresponsive patient. MD stated that in order for chest compressions to be adequate, residents need to have a board placed underneath them. MD stated When they find a resident unresponsive they need to get him flat as well because from what I understand I think he was he wasn't like he was leaning up against this other resident's shoulder so obviously they had to lay him flat anyways and then start CPR. MD stated that the patio floor is a flat surface and appropriate to start CPR. MD stated that when a person is pulseless, the heart is not contracting therefore blood flow and perfusion to organs are not occurring so the process of CPR is to put in place that function of the heart, you are literally pumping the chest to pump the heart, to pump the blood to try and perfuse the tissues. MD stated that the sooner CPR is started the better the outcome for the resident/person not performing CPR may lead to end organ damage, because tissue without oxygenation and perfusion can start to die. During a review of the facility Part 3: Adult Basic and Advanced Life Support 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care indicates, "1. On recognition of a cardiac arrest event, a layperson should simultaneously and promptly activate the emergency response system and initiate cardiopulmonary resuscitation (CPR)". During a review of the facility policy and procedures (P&P) titled Cardiopulmonary Resuscitation revised on 4/24/2025, indicated, "Policy: 1. The facility shall ensure that properly trained personnel (and certified in CPR for Healthcare Providers) are available immediately (24 hours per day) to provide basic life support, including cardiopulmonary resuscitation (CPR). a. The facility's procedure for administering CPR shall incorporate the guidance from the current standards established by the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility Basic Life Support (BLS) training material. 2. If an individual is found unresponsive and not breathing normally, a staff member who is certified in CPR/BLS shall initiate CPR. PURPOSE: To 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/expressed wishes. The facility failed to immediately initiate CPR in accordance with the AHA guideline for Resident 1. On 6/21/2025 at 4:08 P.M., the facility staff found Resident 1 unresponsive in the patio, and transferred Resident 1 through another resident's room, and then to Resident 1's room before starting the CPR. This deficient practice had a high probability to result in Resident 1's death in the facility on 6/21/2025 at 4:34 P.M. LAFD paramedics subsequently pronounced Resident 1 dead in the facility on 6/21/2025 at 4:34 P.M. The above 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 for Resident 1.