Health inspection·June 6, 2025

42 CFR §483.24 Quality of Life (a)Based on the comprehensive assessment of a resident and consistent with the resident’s needs and choices, the facility must provide the necessary care and services to ensure that a resident’s abilities in activities of daily living do not diminish unless circumstances of the individual’s clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: (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 advance directives. 22 CCR § 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 of all facility personnel. Each program shall include, but not limited to: (9)Signs and symptoms of cardiopulmonary distress (b)In addition to (a)above, all licensed nurses shall have training in cardiopulmonary resuscitation. 22 CCR § 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 4/21/2025, the California Department of Public Health (CDPH) received a complaint indicating Resident 1 was pulseless, not breathing upon arrival of the Los Angeles Fire Department (LAFD), the facility was not able to provide proper documented vital signs of the resident and the Registered Nurse (RN 1) was not in the room guiding other staff members on the proper basic life support (BLS-medical care for residents experiencing cardiac arrest [when the heart stops beating]). On 4/22/2025, the CDPH conducted an unannounced visit at the facility to investigate the allegations. The facility failed to: 1. Implement its Policy and Procedure (P&P) titled, “Emergency Procedure-Cardiopulmonary Resuscitation” (CPR- an emergency procedure to restart a person’s heart and breathing after one or both suddenly stop) which indicated staff trained to initiate CPR, BLS and defibrillation (Automated External Defibrillation [AED]- an electrical current to help your heart return to a normal heart beat in someone experiencing cardiac arrest or severe arrhythmias [improper beating of the heart]), would immediately check the resident’s vital signs including breathing and pulse, activate the code blue (emergency code that alerts staff that a resident is experiencing a life-threatening medical emergency such as a cardiac arrest) and start CPR, for Resident 1 who had a full code status (when medical personnel performs life-saving measures in a medical emergency), was observed unresponsive and not breathing in bed. 2. Ensure RN 2 and Licensed Vocational Nurse (LVN) 1 who initiated CPR on Resident 1 used the AED. 3. Train RN 1 on how to use the AED. These deficient practices contributed to Resident 1’s death and placed 86 residents who had full code statuses at risk of not receiving timely life saving measures. Resident 1 was a 50-year-old male, who was originally admitted on 4/9/2022 and readmitted on 10/30/2024. Resident 1’s diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) with ketoacidosis (a life-threatening complication of DM in which acids build up in the blood) and hyperglycemia (a condition where the level of sugar in the blood is too high), hypertension (HTN-high blood pressure) and schizophrenia (a mental illness that is characterized by disturbances in thought). A review of Resident 1’s Physician’s Order for life sustaining treatment (POLST- a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) dated 4/15/2022, indicated Resident 1 was Full Code (when medical personnel performs life-saving measures in a medical emergency). The POLST indicated to attempt resuscitation/CPR with full treatment with primary goal of prolonging life by all medical elective means. A review of Residents 1’s Minimum Data Set (MDS – a resident assessment tool) dated 2/11/2025, indicated Resident 1 had the ability to make self-understood and to understand others. The MDS indicated Resident 1 required partial/moderate assistance (staff lifts, holds, or supports trunk or limbs but provides less than half the effort) for activities of daily living such as toileting hygiene, showering/bathing and lower body dressing. A review of Resident 1’s LAFD Patient Care Record dated 4/18/2025 at 4:16 p.m., indicated paramedics (EMS-Emergency Medical Services) were dispatched to the facility on 4/18/2025 at 4:18 p.m., for Resident 1 who was in cardiac arrest and EMS arrived on scene at the facility on 4/18/2025 at 4:25 p.m. The Record indicated Resident 1 was found not breathing, without a pulse and facility staff performed chest compressions (vital part of CPR performed when someone’s heart stops beating) without using AED for Resident 1 prior to EMS arrival. The Record indicated Resident 1’s blood sugar level was “high” at 500 milligrams per liter (mg/dl- unit of measurement [reference target range 80-180 mg/dl]). The Record indicated Resident 1 was pronounced dead on 4/18/2025 at 4:47 p.m. A review of Resident 1’s progress notes dated 4/18/2025 at 4:47 p.m. indicated on 4/18/2025 at 4:10 p.m., CNA 1 went to Resident 1’s room, observed Resident 1 was not breathing, and CNA 1 notified RN 1 and RN 2 (at the nurse’s station). The Progress Notes indicated RN 2 initiated CPR on Resident 1, and the paramedics arrived at the facility around 4:17 p.m. During an interview on 4/22/2025 at 10:03 a.m. EMS staff (EMS 1), stated, when the EMS team responded to the facility’s emergency call for Resident 1 who suffered cardiac arrest, RN 1 could not provide the last set of vital signs and blood sugar level taken during the code blue for the resident and staff did use the AED. During a telephone interview on 4/22/2025 at 2:46 p.m., RN 1 stated CNA 1 came to the nurse’s station and told him (RN 1) that Resident 1 was not breathing. RN 1 stated he sent RN 2 and LVN 1 who were also at the nurse’s station, to go and assess Resident 1. RN 1 stated he (RN 1) activated the code blue system, called 911 and waited for EMS to arrive to lead them to Resident 1’s room. RN 1 stated, when he arrived at Resident 1’s room with the EMS team, CNA 1 was performing chest compressions and RN 2 was assisting with the Ambu bag. RN 1 stated, he did not see facility staff (RN 2, LVN 1 and CNA 1) using the AED for Resident 1. RN 1 stated he did not know how to use the AED, and he had not been trained on how to use an AED during CPR. During an interview on 4/22/2025 at 3:35 p.m., RN 2 stated, on 4/18/2025 at around 4:00 p.m., while he was at the nurse’s station, CNA 1 came and said Resident 1 was not breathing, RN 2 stated he (RN 2) went to Resident 1’s room with LVN 1, and he (RN 2) assessed the resident. RN 2 stated, Resident 1 had no pulse and was not breathing, so he (RN 2) started chest compressions (part of CPR performed when someone’s heart stops beating) on Resident 1, while another staff (LVN 1) was assisting with the Ambu bag (a hand-held device used to provide ventilation [moving air into and out of the lungs] to someone who are struggling to breathe or have stopped breathing). RN 2 stated the paramedics arrived at around 4:17 pm and pronounced Resident 1 dead at around 4:47 pm. RN 1 stated the facility staff did not remember to use the AED on Resident 1 during CPR. During an interview on 4/22/2025at 4:40 p.m., CNA 1 stated he was on his way to Resident 1’s room, when Resident 1’s roommate came out of the room and told him (CNA 1) to look at Resident 1 because the resident was not “looking good.” CNA 1 stated he observed Resident 1 not breathing. CNA 1 stated he left Resident 1 in bed, did not activate code blue and went to the nurse’s station (nursing station 1) to inform the RN supervisor (RN 1). CNA 1 stated he returned to resident 1’s room and assisted other staff perform CPR on Resident 1. CNA 1 stated staff did not use the AED on Resident 1 during the code blue. During a concurrent interview and record review on 4/23/2025 at 10:03 a.m. with the Director of Nursing (DON), Resident 1’s Weights and Vitals Summary was reviewed. The DON stated staff were required to assess residents during a code blue including the complete vital signs as well as the blood sugar, especially if the resident was diabetic (someone who has DM). The DON stated the last documented pulse, BP and respiration for Resident 1 were on 4/18/2025 at 9:58 a.m., 4/18/2025 at 9:59 a.m. and 4/18/2025 at 1:30 p.m. sequentially. The DON stated the last blood sugar check was done on 4/17/2025 at 9:51 p.m. During a subsequent interview on 4/24/2025 at 10:00 a.m., the DON stated any staff who found a resident in bed unconscious or not breathing should not leave the resident unattended, should immediately call for help from the resident’s room, initiate code blue and start CPR. The DON also stated staff in the facility were not trained in the use of an AED and did not use it when staff performed CPR on Resident 1 on 4/18/2025. A review of the facility’s P&P titled, “Emergency Procedures-Cardiopulmonary Resuscitation” dated 2021 indicated Personnel have completed training on the initiation of CPR and BLS, including defibrillation, for victims of cardiac arrest. The P&P indicated all clerical staff members should obtain and maintain certification in BLS/CPR that adheres to the American Heart Association guidelines. The P&P indicated adult BLS Sequence for Healthcare Providers included to: 1. Ensure scene safety 2. Check for response 3. Shout for nearby help/activate the resuscitation team (Code Blue) a. The provider can activate the resuscitation team at this time or after checking for breathing a pulse. 4. Check for no breathing or only gasping and check pulse (ideally simultaneously) 5. Immediately begin CPR 6. When the second rescuer arrives, provide 2-rescuer CPR The facility failed to: 1. Implement its P&P titled, “Emergency Procedure-Cardiopulmonary Resuscitation” which indicated staff trained to initiate CPR, BLS and defibrillation, would immediately check the resident’s vital signs including breathing and pulse, activate the code blue and start CPR, for Resident 1 who had a full code status, was observed unresponsive and not breathing in bed. 2. Ensure RN 2 and LVN 1 who initiated CPR on Resident 1 used the AED. 3. Train RN 1 on how to use the AED. These deficient practices contributed to Resident 1’s death and placed 86 residents who had full code statuses at risk of not receiving timely life saving measures. These 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.