Health inspection·October 10, 2025

CFR§ 483.24(a)(3) Cardio-Pulmonary 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. CFR §483.10 Residents Rights (a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident’s individuality. The facility must protect and promote the rights of the resident. (f) Self-determination. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section. CFR§ 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. (c) 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. 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 8/27/2025, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) did not receive CPR when the resident was found unresponsive. Resident 1 expired on 10/5/2024. On 8/28/2025, CDPH conducted an unannounced visit at the facility to investigate the complaint allegation. During the investigation, CDPH determined Resident 1, who was a Full code (a medical term indicating a person’s consent to receive all possible life-saving measures) status, was found unresponsive on 10/5/2024 at 9:45 a.m., did not receive basic life saving measures by staff certified in cardiopulmonary resuscitation (CPR) and was pronounced dead on 10/5/2024. The facility failed to: 1. Ensure, Resident 1, who was a Full code, received basic life saving measures, including CPR per the resident’s Physician Order for Life Sustaining Treatment ([POLST] a form that contains written medical orders for healthcare professionals regarding the residents wishes for specific medical treatments that can or cannot be done during life threatening emergencies where the resident is incapacitated) dated 4/24/2024. 2. Ensure registered nurse (RN) 1 honored and followed Resident 1’s POLST dated 4/24/2024, indicating Resident 1 chose to receive life saving measures if he was found unresponsive, and performed CPR when Resident 1 was found unresponsive and without a pulse (heartbeat) on 10/5/2024 at approximately 9:45 a.m. 3. Implement the facility’s policy and procedure (P&P) titled, “Emergency Procedure-Cardiopulmonary Resuscitation,” dated 2001, which indicated, “if a resident is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: instruct a staff member to activate the emergency response system (code) and call 911.” 4. Follow the facility’s P&P titled, “POLST/ Advanced directive,” undated 2001, indicated “the purpose of the P&P was to specify the form to be used by the facility in documenting resident’s preferred intensity of care. The P&P indicated the facility will honor a resident’s completed POLST form from the hospital if there is no change to it. The facility must review the POLST with the resident / responsible party and document that this is in the resident’s medical records.” These deficient practices resulted in RN 1 not administering CPR and not calling 911 when Resident 1 was found unresponsive and pulseless on 10/5/2024. Resident 1 expired on 10/5/2024. A review of Resident 1’s Admission Record indicated Resident 1 a 73-year-old male was admitted to the facility on 4/12/2024 and readmitted on 8/24/2024 with diagnoses including chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing), chronic heart failure, and ischemic heart disease (condition where poor blood flow causes heart tissue damage or death). A review of Resident 1’s History and Physical (H&P) dated 4/13/2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1’s POLST, dated 4/24/2024, indicated Resident 1’s choices included if Resident 1 had no pulse and was not breathing Resident 1 wanted to receive life saving measures including CPR. The POLST form indicated facility staff discussed the POLST with Resident 1, who had the capacity to understand the risks and benefits of his medical decisions. The form was signed and dated by Physician (MD) 2 and Resident 1 on 4/24/2024. A review of Resident 1’s Minimum Data Set ([MDS] a resident assessment tool) dated 8/29/2024, indicated Resident 1’s cognition was moderately impaired, and he had the ability to understand and be understood by others. A review of Resident 1’s Interdisciplinary Team ([IDT] group of healthcare professionals from various disciplines who work together to develop and implement a resident's comprehensive care plan) Meeting Minutes dated 8/24/2024, indicated Resident 1 had the capacity to understand and represented himself during the meeting. The IDT Meeting Document indicated Resident 1 wished to be a Full code. A review of Resident 1’s Nurses Progress Notes, documented by Licensed Vocational Nurse (LVN) 1, dated 10/5/2024, indicated during medication pass on 10/5/2024 at 9:45 a.m., LVN 1 tried but could not obtain (detect, measure) Resident 1’s vital signs. The Nurses Progress Notes indicated LVN 1 called RN 1 to Resident 1’s bedside to assess Resident 1. A review of Resident 1’s Nurses Progress Notes dated 10/5/2024, indicated when RN 1 assessed Resident 1, RN 1 found Resident 1 unresponsive, Resident 1’s skin was warm to the touch with no obtainable vital signs (no pulse and no breathing). The Nurses Progress Notes indicated RN 1 notified MD 1 that Resident 1 had expired. A review of Resident 1’s Physician’s Discharge Summary, dated 10/5/2024, indicated Resident 1’s date of death was 10/5/2024. A review of Resident 1’s Final Autopsy Report, dated 11/12/2024, indicated Resident 1’s date of death was 10/5/2024 and the immediate cause of death was an acute myocardial infarct ([heart attack] when blood flow to the heart muscle is blocked) likely associated with COPD induced hypoxia (lack of oxygen in the body's tissues). During an interview on 8/28/2025 at 3:27 p.m., RN 1 stated LVN 1 called her to Resident 1’s bedside on 10/5/2024, around 9:45 a.m. when LVN 1 found Resident 1 unresponsive. RN 1 stated Resident 1’s skin was warm to the touch, he was not responsive, his chest did not rise and fall (indicating Resident 1 was not breathing) and did not have any detectable pulse. RN 1 stated she was CPR certified but she did not attempt CPR and instructed LVN 1 not to perform CPR nor call 911 because she thought Resident 1’s POLST indicated Do Not Resuscitate ([DNR] if a person’s heart or breathing stops, the person wishes the doctors and nurses not to restart it by doing CPR). During an interview on 8/29/2025 at 2:46 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 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 decreases and the risk of permanent brain damage or death increases. The DON stated the resident’s POLST must be honored. During a telephone interview on 8/29/2025 at 5:46 p.m., the Facility Medical Director (MD 3) stated the facility must honor the residents’ wishes as indicated in their POLST. A review of the facility’s P&P titled, “Emergency Procedure-Cardiopulmonary Resuscitation,” dated 2001, indicated if a resident is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: instruct a staff member to activate the emergency response system (code) and call 911, instruct a staff member to retrieve the automatic external defibrillator (an external defibrillator is a machine that helps restart a person’s heart if it suddenly stops or beats the wrong way), verify or instruct a staff member to verify DNR or code status of the individual, initiate the basic life support (BLS- compressions, airway, breathing) sequence of events. A review of an online article titled, "American Heart Association 2020, CPR and Emergency Cardiovascular (anything that has to do with the heart and blood vessels) Care Committee Guidelines," indicated, the adult basic life support algorithm (a process or set rules to be followed) for healthcare providers included verifying for scene safety, check for responsiveness, shout for nearby help, look for no breathing or only gasping and check pulse simultaneously (at the same time). The guidelines further indicated if there was no breathing, or only gasping, with no pulse, to immediately begin CPR and perform cycles of thirty chest compressions and two breaths. www.cpr.heart.org A review of an AHA article titled “Starting bystander CPR within 10 minutes of cardiac arrest may improve survival” dated 11/11/2024 indicated starting CPR within the first 10 minutes of someone having a heart attack may greatly improve their chances for survival. www.cpr.heart.org A review of an online article titled, “ How to Perform CPR – Adult CPR Steps” , indicated to check the scene for safety, check the person for responsiveness/breathing, if the person does not respond and is not breathing or only gasping, call 911, get equipment, or tell someone to do so, kneel beside the person, and place them on their back on a firm, flat surface. The guidelines indicated to begin chest compressions 30 at a time, give two breaths and to continue the cycle of 30 chest compression and two breaths. www.redcross.org A review of the facility’s P&P titled, “POLST/ Advanced directive,” undated 2001, indicated “the purpose of the P&P was to specify the form to be used by the facility in documenting resident’s preferred intensity of care. The P&P indicated the facility will honor a resident’s completed POLST form from the hospital if there is no change to it. The facility must review the POLST with the resident / responsible party and document that this is in the resident’s medical records.” A review of the POLST (in general) form indicated the following: 1. First follow these orders, then contact the Physician/Nurse Practitioner/Physician Assistant. 2. A copy of the signed POLST form is a legally valid physician’s order. Any section not completed implies full treatment for that section. The facility failed to: 1. Ensure, Resident 1, who was a Full code, received basic life saving measures, including CPR per the resident’s POLST dated 4/24/2024. 2. Ensure RN 1 honored and followed Resident 1’s POLST dated 4/24/2024, indicating Resident 1 chose to receive life saving measures if he was found unresponsive, and performed CPR/BLS when Resident 1 was found unresponsive and without a pulse on 10/5/2024 at approximately 9:45 a.m. 3. Implement the facility P&P titled, “Emergency Procedure-Cardiopulmonary Resuscitation,” dated 2001, which indicated, “if a resident is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: instruct a staff member to activate the emergency response system (code) and call 911.” 4. Follow the facility’s P&P titled, “POLST/ Advanced directive,” undated 2001, indicated “the purpose of the P&P was to specify the form to be used by the facility in documenting resident’s preferred intensity of care. The P&P indicated the facility will honor a resident’s completed POLST form from the hospital if there is no change to it. The facility must review the POLST with the resident / responsible party and document that this is in the resident’s medical records.” These deficient practices resulted in RN 1 not administering CPR and not calling 911 when Resident 1 was found unresponsive and pulseless on 10/5/2024. Resident 1 expired on 10/5/2024. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a substantial factor in the death of Resident 1.