Health inspection·July 11, 2025

The following reflects the finding of the California department of Public Health during Investigation of a complaint number: CA00963244. A Class AA citation was issued. 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. §483.24(a)(3): Cardiopulmonary Resuscitation (CPR). 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. Title 22, California Code of Regulations. § 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 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 of 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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (A) The admission of a patient. (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the patient. (b) All attempts to notify licensed healthcare practitioners acting within the scope of his or her professional licensure shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending licensed healthcare practitioner acting within the scope of his or her professional licensure or his or her designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g). § 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 5/21/2025, the California Department of Public Health (CDPH, the Department) made an unannounced visit to the facility to investigate a complaint allegation regarding resident’s neglect and death. As a result of the investigation, the Department determined the facility failed to: 1.Have a system in place to check and monitor blood sugar level for Resident 1 who was diabetic (A person who has high blood sugar), and on insulin (A hormone which regulates the amount of sugar in the blood). 2. Ensue the facility's Licensed Nurse contacted Resident 1's Attending Physician (AP) to obtain an order to check and monitor the blood sugar level for Resident 1 who had diabetes and on insulin. 3. Ensure the Licensed Vocational Nurse (LVN) 1 check the blood glucose level when Resident 1 was having body shakes which looked like seizures (A sudden, uncontrolled burst of electrical activity in the brain that affects awareness and muscle control) with his eyes rolling to the back of his head, became unresponsive (not reacting to or responding to a stimulus, question, or situation), had no pulse and was not breathing on 5/19/2025 at 5:30 am. . 4. Ensure the facility's Licensed Nurse followed the facility's policy and procedure (P&P) titled, "Diabetes Management" revised 1/31/2025, which indicated "monitor blood glucose levels twice a day if (Resident) on insulin" and to check blood glucose if the resident is unconscious or vital signs are absent. 5. Ensure the facility’s licensed Nurse used appropriate oxygen delivery device (Ambu bag- device known as a bag valve mask [self-inflating bag], which is used to help initiate, provide respiratory support to patients who are not breathing or need assistance) during cardiopulmonary resuscitation (CPR, It is an emergency procedure that combines chest compressions and rescue breaths to help someone whose heart has stopped beating or who is not breathing) for Resident 1. These failures resulted in Resident 1 having a seizure, hyperglycemia (occurs when the blood sugar [body's primary source of energy/food] level increases), and a high risk for diabetic ketoacidosis (DKA life-threatening complication of diabetes that occurs when the blood sugar levels are too high and untreated for a prolonged length of time) and coma. On 5/19/2025 at 5:30 am, Resident 1 became unresponsive (not reacting to or responding to stimulus, question, or situation), had no pulse and was not breathing and CPR was initiated. Licensed Vocational Nurse (LVN) 1 placed Resident 1 on a non-rebreather mask (A medical device used to deliver a high concentration of oxygen [colorless, odorless gas essential for life] to a patient in emergency situations. It was not designed or intended for use on someone who is not breathing) at 10 liters (L, unit of measurements) of oxygen. Resident 1 expired on 5/19/2025 at 5: 58 am. During a review of Resident 1's admission record, it indicated the facility admitted Resident 1, an 85-year-old male to the facility on 5/16/2025, with diagnoses that included diabetes mellitus, chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), and hypertension (HTN-high blood pressure). During a review of the Resident 1's Physician Orders 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 5/16/2025, it indicated Resident 1 was a full code. The POLST indicated to attempt resuscitation/CPR with full treatment with primary goal of prolonging life by all medical effective means. During a review of Resident 1's nurse progress note dated 5/16/2025 at 10:24 pm, it indicated, "Patient arrived at our facility (SNF- Skilled Nursing Facility) from general acute care hospital (GACH) at 8 pm. He (Resident 1) was admitted to GACH because he had previously experienced a fall and was diagnosed with embolic stroke (occurs when a blood clot or other debris travels through the bloodstream and blocks an artery in the brain, interrupting blood flow and causing brain damage) and hypoglycemia." Resident 1's GACH orders were reviewed. The orders did not include BS level monitoring even though insulin was ordered to be administered. During a review of Resident 1 ' s History and Physical (H&P- a comprehensive assessment of a patient, including a review of their medical history and a physical examination) dated 5/18/2025 indicated, Resident 1 had DM with other specified complications, with long-term use of insulin (a hormone produced by the pancreas that helps regulate blood sugar levels). During a review of Resident 1's care plan titled, "Risk for unstable blood glucose level: Hypoglycemia and Hyperglycemia) Due to DX (diagnosis) of DM," developed on 5/16/2025, the care plan included the following goals: -The resident's blood glucose level will remain stable. Early detection of the signs and symptoms of hypo/hyperglycemia. -Resident's sign and symptoms of hypo/hyper glycemia will improve with interventions. During a review of Resident 1's physician's orders dated 5/17/2025, indicated the following: - Lantus Solostar U-100 Insulin (insulin glargine- a long-acting synthetic insulin used to manage blood sugar levels in people with diabetes and can cause low blood sugar is a common side effect) pen; 100 unit/ml 3 milliliter (ml, unit of measurement); 14 units subcutaneous (under the skin in fatty tissue) Special Instructions: Inject 14 units total under the skin two (2) times daily, [Twice A Day; 9 am, 5 pm] - Glucerna 1.5 (a specialized liquid medical food designed for individuals with type 1 or type 2 diabetes) via enteral pump (a medical device used to deliver liquid nutrients and medications directly into a patient's gastrointestinal tract) at 20 cubic centimeters per hour (cc/hr.) x (for) 24 hours. May stop feeding for activities and Activities of daily living (ADL). Initiate non-Bolus (administered continually over time) continuous tube feeding with Glucerna 1.5 at 20mL/hr. and increase rate by 20 mL/hr. every 4 hours to goal rate 55 mL/hr. During a review of Resident 1's History and Physical (H&P- a comprehensive assessment of a patient, including a review of their medical history and a physical examination) dated 5/18/2025, it indicated Resident 1 had DM with other specified complications, with long-term use of insulin. During a review of a document titled “interfacility Transfer orders,” dated 4/23/2025, it indicated, “oxygen via nasal cannula as needed to maintain Sa02) oxygen saturation)> [greater]90%: specify flow rate in comments-1-6L[liters]/min[minute] to keep oxygen saturation 88-92%.” During a review of Resident 1’s SaO2 indicated the following: 05/16/2025 10:51 PM - O2 Saturation: 94 % 05/17/2025 08:12 AM – O2 Saturation: 96% 05/17/2025 11:24 PM - O2 Saturation: 97% 05/17/2025 11:26 PM - O2 Saturation: 97% 05/18/2025 08:21 AM - O2 Saturation: 93% 05/18/2025 10:14 PM - O2 Saturation: 95% 05/19/2025 12:10 AM - O2 Saturation: 94% During a review of a Situation Background Assessment and Recommendation (SBAR) dated 5/19/2025 at 3:42 am indicated, “Pt (Resident 1) was noted with congestion w/(with) phlegm. Pt required Oral suctioning, tolerated well. Head of bed keep elevated at 30-40 degrees for aspiration precautions. On continuous oxygen 2L; SPO2 @ 94%. Checked VS (vital signs) BP 161/114 HR 108 RR 18 SPO2 94% on 2L TEMP 97.9F Called On call hospitalist, (physician) N.O (new order) Ipratropium-Albuterol 3ml inhalation breathing tx (treatment) x 1 time, continue to monitor, and have MD in AM f/u w/ BP regimen for High BP. Okay to call MD back for any further changes.” During a review of Resident 1's nurse progress notes dated 5/19/2025 at 5:29 am indicated, "While walking to room (Resident 1‘s room) I (LVN 1) noticed pt (patient) having convulsions (Rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement), body shaking and his eyes were rolling to the back of his head, checked for a pulse, no pulse. Attempted to check spo2 (oxygen saturation, the percentage of hemoglobin [the protein contained in red blood cells that is responsible for delivery of oxygen to the tissues] in the blood that is carrying oxygen), unable to obtain. Called CN (Charge Nurse) from St. (Station)1 for assistance, initiated CPR (Cardiopulmonary resuscitation), LVN 1 placed pt on non-rebreather mask (a medical device used to deliver a high concentration of oxygen to a patient in emergency situations. It was not designed or intended for use on someone who is not breathing). 911 (emergency telephone number used to call for help from police, fire, or ambulance services in an emergency) was called at 0533. EMS arrived at 0540 and took over compressions. EMS (Emergency Medical Services, is the system that delivers pre-hospital emergency medical care, encompassing a range of professionals, vehicles, and resources) called time of death at 0558." During a review of the 911 (emergency telephone number used to call for help from police, fire, or ambulance services in an emergency) Runsheet dated 5/19/2025 indicated, the paramedics (healthcare professional trained to provide emergency medical care, especially in pre-hospital settings like ambulances) arrived at the facility at 5:39 am and with Resident 1 at 5:40 am. The run sheet indicated Resident 1 was in cardiac arrest (when the heart suddenly and unexpectedly stops pumping blood effectively, leading to a lack of blood flow to the brain and other vital organs), blood sugar was at 457mg/dl, and that rigor (stiffness and rigidity of the muscles that occurs after a person dies) and lividity (livor mortis, is the discoloration of a dead body caused by the pooling of blood due to gravity after the heart stops pumping) were present. Resuscitative effects were stopped, and Resident 1 was released to staff on scene. During a review of the Resident 1's facility discharge summary dated 5/19/2025 at 8:47 am, indicated the discharge diagnoses as acute hypoxemia (blood oxygen levels drop suddenly and significantly below normal) and cardiac arrest (a sudden and unexpected stoppage of the heart's ability to pump blood throughout the body). During a concurrent interview on 5/21/2025 at 12:40pm and review of Resident 1's Medication Administration Record (MAR- a report that serves as a legal record of all medications administered to a patient by a healthcare professional) dated 5/16/2025 to 5/19/2025, was reviewed. The MAR indicated the following: On 5/17/2025, Lantus 14 units was scheduled for 9 am and was documented as administered at 11:27 am. On 5/17/2025, Lantus 14 units was scheduled for 5 pm and was documented as administered at 11:25 pm. On 5/18/2025, Lantus 14 units was scheduled for 5 pm and was documented as administered at 7:17 pm. LVN 1 stated the insulin was administered on time, however, the administration was documented late on Resident 1's record. During a review of Resident 1 ' s Skilled Nursing Facility Discharge Summary dated 5/19/25 at 8:47 am indicated discharge diagnoses included acute hypoxia (A condition in which the body or a region of the body is deprived of an adequate oxygen supply at the tissue level) and cardiac arrest (sudden loss of heart function). During an interview with LVN 1 on 5/21/2025 at 12:44 pm, LVN 1 stated that on 5/19/2025 at 5:30 am, LVN 1 noted that Resident 1 was having body shakes which looked like seizures (Sudden burst of electrical activity in the brain. It can cause changes in behavior, movements, feelings and levels of consciousness) with his eyes rolling to the back of his head. LVN 1 stated that the seizure subsided after 30 seconds of LVN 1 being in the room. LVN 1 stated that Resident 1 became unresponsive, had no pulse and was not breathing and CPR was initiated. LVN 1 further stated she placed Resident 1 on a non-rebreather mask at 10 L of oxygen. LVN 1 stated that a non-rebreather mask is helpful for individuals that are still breathing, of which Resident 1 was not (not breathing). LVN 1 admitted that a non-rebreather mask could potentially obstruct the flow of oxygen if placed on a resident that is not breathing. During an interview with the Director of Nursing (DON) on 5/21/2025 at 1:23 am, the DON stated that Resident 1 was admitted to the facility with diagnoses which included diabetes. The DON stated that when a resident is found to be unresponsive and not breathing, then a positive pressure device (is a device that helps patients breathe by delivering air under pressure into the lungs) such as an Ambu bag must be used to provide oxygen to the resident when doing a CPR. During an interview with the Medical Director (MD) 1 of the facility on 5/22/2025 at 9:50 am, MD 1 st