Health inspection·February 13, 2026

F580 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the Patient representative(s) when there is: (B) A significant change in the resident’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);

F777 §483.50(b)(2) The facility must- (i) Provide or obtain radiology and other diagnostic services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws. (ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders.

F695 §483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a Patient who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the Patients’ goals and preferences, and 483.65 of the subparts. On 1/3/2024 at 8:30 AM, an unannounced visit was made to conduct an investigation related to resident’s death. The California Department of Public Health (CDPH) conducted a closed record review regarding the quality of life and quality of care and death of Resident 1. During the investigation the department determined that the facility failed to provide the necessary respiratory care and interventions in accordance with the resident’s respiratory care needs, care plan, facility policy and professional standards of practice, the physician’s order and facility’s policy and procedure for Resident 1 who was diagnosed of respiratory failure (a condition where the lungs cannot supply enough oxygen or remove carbon dioxide from the blood) with hypoxia (a life-threatening condition where the lungs fail to deliver enough oxygen to the blood, leading to dangerously low oxygen levels in the body), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty breathing), emphysema (a lung disease where the air sacs [alveoli] in the lungs are damaged, making breathing difficult) and recurrent pneumonia (a severe infection/inflammation in the lungs) by failing to: 1. Administer respiratory medications consistently as ordered for Resident 1 for COPD, chest congestion and shortness of breath. The Medication Administration Record (MAR) indicated the following missed respiratory treatments: -Acetylcysteine Inhalation Solution 20% (a medication used to thin mucus in the lungs) 25 (twenty-five) scheduled times between September 2025 to November 2025. -Budenoside Inhalation Suspension (a medication inhaled to reduce swelling in the airways) 31 (thirty-one) scheduled times between September 2025 to November 2025. -Ipratropium-albuterol Inhalation Solution (a medication used in a nebulizer that combines two drugs to relax and open the airways) 60 (sixty) scheduled times between September 2025 to November 2025. 2. Monitor Resident 1 for respiratory distress (life-threatening condition that causes severe difficulty breathing. It occurs when the lungs become inflamed and damaged, making it difficult for oxygen to reach the bloodstream) and change in respiratory condition, in accordance with the resident’s care plan for COPD and emphysema when Nurse Practitioner (NP) 1 identified Resident 1 on 12/20/2025 as having cough, congestion, abnormal lung sounds and respiratory distress with oxygen saturation of 93% at 3 liter of oxygen and Registered Nurse (RN) 5 received abnormal laboratory (lab) and chest Xray (CXR - (a type of imaging that uses electromagnetic radiation to view internal structures of the body) results on 12/21/2025. 3. Revise and implement Resident 1’s care plan to assess or monitor Resident 1’s respiratory status that included assessment of lung sounds and monitoring Resident 1’s worsening cough and congestion to initiate nursing interventions, after receiving Resident 1’s abnormal laboratory (lab) and chest X-ray (CXR) results on 12/21/2025. 4. Notify Medical Doctor (MD) 1 of Resident 1’s elevated white blood cell (WBC - a blood cell that helps attack infection or injury in the body) count and abnormal chest x-ray results indicating mild patchy opacity (an area that appears white or dense on an x-ray) in the left lower lung which represented a potential indicator of lung infection. As a result of these deficient practices Resident 1 had the potential to result to medical and respiratory complications which included severe respiratory distress/failure, collapsed lungs, septicemia that may lead to hospitalization and/or death. Furthermore, these deficient practices delayed necessary medical evaluation and treatment of Resident 1’s respiratory condition from 12/20/2025 to 12/23/2025. On 12/23/2025, Resident 1 was found unresponsive and pulseless at 3:05 PM. Cardiopulmonary Resuscitation (CPR) was performed, and Resident 1 was later pronounced dead on 12/23/2025 at 3:48 PM by Emergency Medical Services (EMS). During a review of Resident 1’s Admission Record, the record indicated Resident 1 was admitted to the facility on 9/12/2023 with diagnoses including COPD, emphysema, respiratory failure with hypoxia, recurrent pneumonia and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). During a review of Residents 1’s Minimum Data Sheet (MDS- a resident assessment tool) dated 10/6/2025, the MDS indicated Resident 1 had significantly impaired cognition (the ability to process thoughts) and was dependent on staff for all cares such as eating, bathing, and rolling left and right in bed. During a review of Resident 1’s Medication Administration Record (MAR) for the months of September 2025, October 2025, and November 2025, the MAR indicated the following orders: 1. Acetylcysteine Inhalation Solution 20% three mL (milliliter- a unit measure of volume) inhale orally two times a day for COPD, start date 9/30/2025. 2. Budenoside Inhalation Suspension 0.25 milligram (mg- a unit of measurement)/2 mL, inhale two mL orally every morning and at bedtime for COPD, start date 3/3/2025. 3. Ipratropium-Albuterol Inhalation Solution 0.5-2.5 mg (3 mg)/3 mL, inhale three mL orally four times a day for congestion/breathing treatment, start date 6/16/2025. During a continued review of resident 1’s MAR for the months of September 2025, October 2025, and November 2025 indicated no documented evidence that Acetylcysteine Inhalation Solution was administered to Resident 1 on the following days and times: 9/30/2025 at 6 PM, 10/1/2025 at 6 PM, 10/2/2025 at 6 PM, 10/3/2025 at 6 PM, 10/4/2025 at 6 PM, 10/5/2025 at 6 PM, 10/6/2025 at 6 PM, 10/7/2025 at 9AM and 6 PM, 10/8/2025 at 6 PM, 10/9/2025 at 6 PM, 10/11/2025 at 6 PM,10/12/2025 at 6 PM, 10/17/2025 at 6 PM, 10/18/2025 at 6 PM, 10/20/2025 at 6 PM, 10/23/2025 at 6 PM, 10/24/2025 at 6 PM, 10/25/2025 at 6 PM, 10/28/2025 at 9AM and 6 PM, 10/31/2025 at 6 PM, 11/1/2025 at 6 PM, 11/15/2025 at 6 PM, and 11/22/2025 at 9 AM. The MAR indicated for September 2025, October 2025, and November 2025 indicated a total of 25 undocumented administrations for Acetylcysteine between September 2025 and November 2025. During a continued review of Resident 1’s MAR for the months of September 2025 to November 2025 indicated no documented evidence that Budenoside Inhalation Suspension was administered to Resident 1 on the following days and times: 9/5/2025 at 9 PM, 9/30/2025 at 9 PM, 10/1/2025 at 9 PM, 10/2/2025 at 9 PM, 10/3/2025 at 9 PM, 10/4/2025 at 9 PM, 10/5/2025 at 9 PM, 10/6/20258 at 9 PM, 10/7/2025 at 9AM and 9 PM, 10/8/2025 at 9 PM, 10/9/2025 at 9 PM, 10/11/2025 at 9 PM, 10/12/2025 at 9 PM, 10/15/2025 at 9 PM, 10/17/2025 at 9 PM, 10/18/2025 at 9 PM, 10/20/2025 at 9 PM, 10/22/2025 at 9 PM, 10/23/2025 at 9 PM, 10/24/2025 at 9 PM, 10/25/2025 at 9 PM, 10/28/2025 at 9AM and 9 PM, 10/31/2025 at 9 PM, 11/1/2025 at 9 PM, 11/6/2025 at 9 PM, 11/13/2025 at 9 PM, 11/14/2025 at 9 PM, 11/15/2025 at 9 PM, and 11/22/2025 at 9 AM . The MAR indicated for September 2025 to November 2025 indicated a total of 31 undocumented administrations for Budenoside between September 2025 and November 2025. During a continued review of Resident 1’s MAR for the months of September 2025 to November 2025 indicated no documented evidence that Ipratropium-Albuterol Inhalation Solution was administered to Resident 1 on the following days and times: 9/5/2025 at 5 PM and 9 PM, 9/30/2025 at 5 PM and 9 PM, 10/1/2025 at 5 PM and 9 PM, 10/2/2025 at 5 PM and 9 PM, 10/3/2025 at 5 PM and 9 PM, 10/4/2025 at 5 PM and 9 PM, 10/5/2025 at 5 PM and 9 PM, 10/6/2025 at 5 PM and 9 PM; 10/7/2025 at 9 AM, 12 PM, 5 PM and 9 PM; 10/8/2025 at 5 PM and 9 PM; 10/9/2025 at 5 PM and 9 PM, 10/11/2025 at 5 PM and 9 PM, 10/12/2025 at 5 PM and 9 PM, 10/15/2025 at 9PM, 10/17/2025 at 5 PM and 9 PM, 10/18/2025 at 5 PM and 9 PM, 10/20/2025 at 5 PM and 9 PM, 10/22/2025 at 9 PM, 10/23/2025 at 5 PM and 9 PM, 10/24/2025 at 5 PM and 9 PM; 10/25/2025 at 12 PM, 5 PM, and 9 PM; 10/28/2025 at 9 AM, 12 PM, 5 PM, and 9 PM; 10/31/2025 at 5 PM and 9 PM, 11/1/2025 at 5 PM and 9 PM, 11/6/2025 at 9 PM, 11/13/2025 at 9 PM, 11/14/2025 at 9 PM, 11/15/2025 at 5 PM and 9 PM, 11/19/2025 at 12 PM, 11/22/2025 at 9 AM and 12 PM, and 11/30/2025 at 12 PM. The MAR indicated for September 2025 to November 2025 indicated a total of 60 undocumented administrations for Resident 1’s Ipratropium-Albuterol between September and November 2025. During a review of Resident 1’s physician Progress Notes (PN) dated 9/29/2025, authored by Nurse Practitioner (NP) 1, the PN indicated Resident 1 had diminished breath sounds, was receiving three liters of oxygen, no respiratory distress, and with a nonproductive (no mucus or phlegm) cough at the time of the exam. The PN further indicted Resident 1 had rales (crackling sounds in the lungs caused by air moving through fluid) and rhonchi (low, snoring-like lung sounds caused by air moving through mucus in larger airways) noted on respiratory exam with the “Plan is to continue regular breathing treatments as scheduled…” During another review of Resident 1’s PN dated 10/11/2025, authored by Licensed Vocational Nurse (LVN) 8, the PN indicated, “shortness of breath noted. Nurse observed shortness of breath (upon exertion). Right lung clear. Left lung clear. Oxygen via nasal cannula (a small plastic tube, which fits into the person’s nostrils for providing supplemental oxygen).” During a review of Resident 1’s physician PN dated 11/8/2025 and authored by Medical Doctor (MD) 3, the PN indicated, “Rhonchi present, diminished lung sounds.” During another review of Resident 1’s PN dated 11/9/2025, authored by Registered Nurse (RN) 5, the PN indicated, “shortness of breath noted. Resident [1] reported shortness of breath (while lying flat). Nurse observed shortness of breath (while lying flat). Right lung clear, left lung clear… Oxygen via nasal cannula.” During another review of Resident 1’s PN dated 11/15/2025, authored by RN 5, the PN indicated, “shortness of breath noted. Resident [1] reported shortness of breath (while lying flat). Nurse observed shortness of breath (while lying flat). Right lung clear, left lung clear… Oxygen via nasal cannula.” During another review of Resident 1’s PN dated 11/17/2025, authored by RN 5, the PN indicated, “shortness of breath noted. Resident [1] reported shortness of breath (while lying flat). Nurse observed shortness of breath (while lying flat). Right lung clear, left lung clear… Oxygen via nasal cannula.” During a review of Resident 1’s physician PN dated 11/30/2025 and authored by NP 1, the PN indicated Resident 1 was on three liters of oxygen with no respiratory distress noted. Plan was to continue regular breathing treatments as scheduled. During a review of Resident 1’s physician Progress Notes dated 12/20/2025, authored by NP 1, the note indicated NP 1 assessed Resident 1’s medical condition at the facility. The note further indicated Resident 1’s lung exam exhibited rales (abnormal crackling sounds in the lungs when breathing). The note indicated Resident 1 was on oxygen at 3 liters per minute (LPM- a unit measuring the flow rate of oxygen through a delivery device) with an oxygen saturation (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage [normal for COPD is 88% to 92%]) level of 93%, with respiratory distress noted, and coughing. The note indicated to continue regular breathing treatments as scheduled, chest percussion therapy (CPT- a technique that uses rhythmic clapping on the chest and back to loosen and clear mucus from the lungs) two times a day with Mucomyst (Acetylcysteine- a medication used to thin mucus in the lungs), wean off of oxygen, chest x-ray, and labs that included CBC (complete blood count) and CMP (comprehensive metabolic panel) to rule out infection etiology. During a review of Resident 1’s Orders Report for December 2025, the Report indicated the following physician orders: 1. Chest x-ray 2 view due to congestion and cough, ordered on 12/20/2025 by MD 1 at 3:50 PM as confirmed by RN 5 2. CBC and CMP due to congestion and cough, ordered on 12/20/2025 by MD 1 at 4:01 PM as confirmed by RN 5 3. Acetylcysteine Inhalation Solution 20% 3 mL (milliliter- a measure of volume) inhale orally two times a day for cough, CPT with [Acetylcysteine] 3 mL 20% solution, ordered on 12/20/2025 by MD 1 at 4:17 PM as confirmed by RN 5 During a review of Resident 1’s lab results dated 12/21/2025, the results indicated WBC of 16.85 x10*3/ul (Normal range 4.0-11.0 x10*3/ul). The lab results indicated a collected date of 12/21/2025 at 8:10 AM and a result date of 12/21/2025 at 12:59 PM, faxed to the facility on 12/21/2025 at 1:10 PM. During a review of Resident 1’s Final X-ray report dated 12/21/2025, the report indicated mild patchy opacity (an area that appears white or dense on an x-ray) in left lower lung represents infectious process and a suggestion for radiographic follow-up examination to look for resolution, faxed to the facility on 12/21/2025 at 11:13 PM. During a review of RN 5’s text messages (a standa