Other·May 5, 2026

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. (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: (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). §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 for all facility personnel. Each program shall include, but not be limited to: (1) Problems and needs of the aged, chronically ill, acutely ill and disabled patients. (2) Prevention and control of infections. (3) Interpersonal relationship and communication skills. (4) Fire prevention and safety. (5) Accident prevention and safety measures. (6) Confidentiality of patient information. (7) Preservation of patient dignity, including provision for privacy. (8) Patient rights and civil rights. (9) Signs and symptoms of cardiopulmonary distress. (10) Choking prevention and intervention. (b) In addition to (a) above, all licensed nurses shall have training in cardiopulmonary resuscitation. § 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. § 72557. Equipment and Supplies. (a) Equipment and supplies in each facility shall be of the quality and in the quantity necessary for care of patients as ordered or indicated. At least the following items shall be provided and properly maintained at all times: (8) Emergency oxygen supply and equipment for administration. F678 Title 42, Code of Federal Regulations § 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 advance directives. On 3/6/2026 at 3:53PM, the California Department of Public Health (CDPH) conducted an unannounced visit to investigate a complaint regarding quality of care and treatment. During the investigation, CDPH determined that the facility failed to provide immediate, effective and uninterrupted Basic Life Support (BLS-the level of care provided to victims of life-threatening illnesses or injuries until full medical care is available, including recognition of cardiac arrest [when the heart stop beating and the person becomes unresponsive, no normal breathing, and no pulse] and activation of the emergency response system), that included cardiopulmonary resuscitation (CPR, an emergency procedure combining chest compressions and rescue breaths to circulate blood and oxygen when the heart stops or breathing ceases) on 3/5/2026 to Resident 1, who was identified as full-code ((a code used when resident wished to be resuscitated if breathing or heart stopped),) when Resident 1 was found weak, with shallow breathing, no longer talking and became unresponsive. The facility failed to ensure: 1. Registered Nurse Supervisor (RNS) 1 and Licensed Vocational Nurse (LVN) 1 initiated CPR immediately when Resident 1 was found weak and unresponsive with an oxygen saturation (a measurement of oxygen in the blood with normal range of 94-100%) of 89% without delay on 3/5/2026, at 6:45PM. 2. RNS 1 placed Resident 1 flat on the back on a firm, flat surface and use the head-tilt, chin-lift maneuver to open the airway while delivering oxygen (to ensure optimal oxygen flow and blood circulation during CPR) via a simple mask (a lightweight, clear plastic medical device that fits over a resident’s nose and mouth, secured with an elastic strap, to deliver oxygen), but instead placed Resident 1 at a 70-90 degree angle while Resident 1 remained unresponsive. 3. RNS 1, LVN 1 and LVN 2 performed continuous and uninterrupted CPR until emergency medical services (EMS- ambulance services or emergency services that provide treatment and stabilization for residents) assumed care. 4. Immediate CPR was provided without delay due to the unavailability of an oxygen regulator that could deliver 15 L/min flow required to keep the Bag-valve-mask (BVM - a manual resuscitation technique that provides positive pressure ventilation to residents with inadequate or absent spontaneous breathing) fully inflated to deliver 100% oxygen. As a result of the deficient practice, Resident 1 was found with no measurable blood pressure, pulse rate, respirations, or oxygen saturation and no CPR actively performed by the facility staff on 3/5/2026 at 6:52 PM upon 911 Emergency Medical Services (EMS)’s arrival at the facility. A facility staff reported to EMS that the resident's (Resident 1) last known well time (a time someone was last seen acting normally or without new symptoms) was approximately "30 minutes prior." Resident 1 was then pronounced dead at 7:29 PM, after 34 minutes of continuous CPR efforts by the EMS. A review of Resident 1’s Admission Record, dated 2/26/2026, indicated that Resident 1 was admitted to the facility from another Skilled Nursing Facility (SNF) 2 on 2/26/2026 for long term care. Resident 1’s diagnoses included Diabetes Mellitus (DM-a disorder characterized by high blood sugar), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), dementia (a progressive state of decline in mental abilities), and atrial fibrillation (A-Fib - a heart condition causing an irregular and rapid heart rate). A review of Resident 1’s Physician’s Orders for Life Sustaining Treatment (POLST - a record signed by the resident/representative and the physician that indicates the resident’s medical treatment wishes so that emergency personnel know what treatments the resident wants during a medical emergency) dated 2/27/2026, indicated resuscitation/CPR should be attempted and that Resident 1 had full treatment status. This information was known to facility staff and available for review by staff in the event of a code. A review of Resident 1’s Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) with assessment dated 3/2/2026, indicated that Resident 1 had a severe cognitive (thought process or ability to think and reason) impairment. A review of Resident 1’s Physician Orders, dated 2/27/2026, indicated an order to administer oxygen 2-5 liters (L) via nasal cannula (a small plastic tube, which fits into the person’s nostrils for providing supplemental oxygen) as needed for shortness of breath or oxygen saturation below 92% as needed. A review of Resident 1’s Care Plan, dated 2/27/2026, indicated Resident 1 was potential for cardiac distress related to A-Fib, heart failure, and atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the artery walls). Resident 1’s care plan indicated to monitor and observe for signs of elevated blood pressure (the force of your blood pushing against the walls of your arteries, dizziness (feeling lightheaded, unsteady), chest pain, dyspnea (difficulty breathing), shortness of breath, tachycardia (fast heart rate), edema (fluid retention) congestion, nausea, and vomiting. The care plan indicated to promptly contact the medical doctor if any symptoms occurred. A review of Resident 1’s Progress Notes, dated 3/5/2026, timed at 6:45 PM, indicated RNS 1 was called to Resident 1’s room by the Certified Nurse Assistant (CNA) 2. RNS 1 indicated that LVN 2 made him aware that Resident 1 was having difficulty breathing. RNS1 indicated when he entered Resident 1’s room and found the resident (Resident 1) sitting up in a 90-degree angle with the head tilted back, RNS 1 proceeded to “start” taking vital signs (VS - measurement of the body temperature, blood pressure, respiratory rate, oxygen and pain level). RNS1 indicated Resident 1 was not verbally responsive and made noises. RNS1 then indicated he went to verify Resident 1’s code status with LVN 1 and proceeded to grab the crash cart. VS were obtained with a blood pressure measuring at 126/72 (normal ranges between 120/80 to 100/60), heart rate 71 (heart rate per minute, normal range is 60 to 100), respiratory rate 18 (number of breaths per minute normal range is between 12 to 20) and oxygen level of 98%. RNS1 indicated that he listened to Resident 1’s lung sounds and were clear, eye pupils were normal at 3 millimeters (mm) (normal pupil size 2 to 4 mm) RNS1 indicated Resident 1 had shallow breathing. RNS1 indicated that on 3/5/2026 at 6:54 PM oxygen level was rechecked but dropped to 96%, and at 7 PM Resident 1’s oxygen level quickly dropped to 89%. RNS1 indicated a 911 emergency call was initiated and he increased the resident’s oxygen to 2-5 L via mask. RNS1 indicated that VS were obtained and the resident was still breathing. RNS1 indicated that the paramedics arrived and started CPR. CPR included chest compressions, the use of mechanical breathing [a device used to help someone breathe]) for approximately 20 minutes and at 7:25 PM Resident 1 was pronounced dead by the paramedics. RNS 1 indicated the paramedics arrived and started CPR. CPR included chest compressions and breathing help. After about 20 minutes, at 7:25 PM, the paramedics pronounced Resident 1 dead. A review of Resident 1’s Emergency Medical Services (EMS) report dated 3/5/2026, at 6:52 PM, indicated that the paramedic's dispatched time was 6:46 PM and that they arrived at the facility at 6:52 PM. The report indicated EMS was at Resident 1’s bedside at 6:55 PM and found Resident 1 lying supine (lying on one’s back with face upward) in bed with the complaint of cardiac arrest and no CPR being done by the facility staff. Paramedics found Resident 1 in asystole (heart completely stops beating) at 6:55 PM; paramedics-initiated CPR at 6:57 PM; Resident 1 was found to have no blood pressure, no pulse, no respiratory rate, and no pulse oximeter; The report indicated at 7:07 PM the paramedics report indicated that Resident 1 had fixed and dilated (enlarge) pupils and pale skin. At 7:29 PM, after 34 minutes of continuous CPR efforts by paramedics, Resident 1 was pronounced dead. During a concurrent observation and interview on 3/6/2026, at 3:50 PM with RNS 1, RNS 1 was unable to determine that the oxygen tank on the crash cart was empty. RNS 1 could not demonstrate the proper procedure to connect the suction tube to the suction machine. During the interview, RNS 1 stated he did not know how to determine whether the oxygen tank was empty or how to properly connect the suction machine. Upon inspection of the first drawer of the crash cart, an oxygen valve regulator with a maximum output of only 8 liters per minute (LPM) was found and verified by RNS 1. During an interview on 3/6/2026, at 4:28 PM, with LVN 2, LVN 2 stated that on 3/5/2026 Resident 1 was stable throughout the day and ate 100% of her dinner. LVN 2 stated, on 3/5/2026 at 6:54 PM, CNA 1 and CNA 2 asked her to come see Resident 1 who was unresponsive. LVN 2 stated, at 7PM a 911 was called and the paramedics arrived at approximately 7:05 PM who placed Resident 1 on a (BVM) and started chest compressions and respiratory resuscitation. During an interview on 3/6/2026, at 4:55 PM, with CNA 1, CNA 1 stated, on 3/5/2026 before dinner time, Resident 1 was talking and wanted to make a phone call to her Family Member (FM) 1. CNA 1 stated, after dinner, CNA 1 and CNA 2 assisted Resident 1 to reposition in bed to keep the resident comfortable. CNA 1 stated as soon as CNA 2 stepped out of the room, CNA1 noticed Resident 1’s “eyes rolled back” and became unresponsive, so she immediately called CNA 2 to go get help. CNA 1 stated RNS1 came into the room and looked at Resident 1 and immediately left to go to the nursing station. CNA 1 reported that LVN 1 entered the room with the crash cart; however, no CPR was initiated by facility staff. CNA 1 stated that when paramedics arrived, Resident 1 was pulseless, and the paramedics began chest compressions and provided respiratory resuscitation. During an interview on 3/9/2026, at 1:40 PM, with RNS1, RNS 1 stated on 3/5/2026 at 6:45 PM, he was called by CNA 2 to go check on Resident 1 who did not” look good.” RNS 1 stated that Resident 1 was unresponsive, and he proceeded to obtain the resident’s VS. According to RNS 1, the initial pulse oximetry reading was 96%, but when he repeated the reading, it had decreased to 89%. He instructed staff to place Resident 1 on oxygen via a simple mask. RNS 1 reported that he touched Resident 1’s ear, and the resident responded by making a noise. RNS 1 stated he did not initiate CPR because the resident demonstrated responsiveness to pain. He reported administering 2–5 LPM of oxygen by simple mask when the oxygen saturation dropped to 89%; and did not reassess the breaths per minute or the pulse every 2 minutes as recommended by the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. RNS 1 also stated that the VS were obtained but were not documented. During a continued interview on 3/9/2026, at 1:40 PM, RNS 1 stated that Resident 1 was becoming weak, exhibited shallow breathing, and was not talking. RNS 1 reported that Resident 1 remained in a seated position at an angle of approximately 70–90 degrees while unresponsive. RNS 1 further stated that he did not attempt to place the resident in a supine position to open the airway using a head-tilt chin-lift maneuver because the resident made a “noise” in response to pain when he touched the resident’s ear. RNS 1 also stated that staff did not initiate chest compressions while Resident 1 remained unresponsive with shallow breathing. During an interview on 3/9/2026, at 5:15 PM, the Director of Nurses (DON) stated that several oxygen regulators in the facility only provide up to 8 LPM; however, the facility also has regulators capable of delivering up to 15 LPM. The DON stated she was unsure why the crash cart did not contain a regulator capable of delivering up to 15 LPM. During an interview on 3/10/2026, at 8:30 AM, the Paramedic Captain (PC) who responded to the 911 call stated the department received a report of an unresponsive resident with CPR in progress. The PC stated that upon arrival to the facility, no CPR was being performed to Resident 1 by facility staff. The resident (Resident 1) was found unresponsive, pulseless, and apneic. The PC immediately requested a backboard (a CPR backboard is a rigid, flat board designed to be placed underneath a resident to provide a firm surface for effective chest compressions) and was informed by RNS1 that the facility did not have one. The PC stated that the crash cart contained only one (BVM), and the oxygen tank valve being used delivered a maximum of 8 LPM of oxygen. The PC