Health inspection·May 15, 2025

F580 (i) A facility must immediately inform the Patient; consult with the Patient’s physician; and notify, consistent with his or her authority, the Resident representative(s) when there is— (A) An accident involving the Resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the Patient’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); § 483.24 Quality of life.

F675 Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. (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: (1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section, (2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene, and (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. (b) Activities of daily living. The facility must provide care and services in accordance with paragraph (a) of this section for the following activities of daily living: (1) Hygiene—bathing, dressing, grooming, and oral care, (2) Mobility—transfer and ambulation, including walking, (3) Elimination—toileting, (4) Dining—eating, including meals and snacks, (5) Communication, including (i) Speech, (ii) Language, (iii) Other functional communication systems. (c) Activities. (1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. (2) The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who— (i) Is licensed or registered, if applicable, by the State in which practicing; and (ii) Is: (A) Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; or (B) Has 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program; or (C) Is a qualified occupational therapist or occupational therapy assistant; or (D) Has completed a training course approved by the State. § 483.25 Quality of care.

F684 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 resident's choices, including but not limited to the following: § 483.35 Nursing services.

F726 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. (d) 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. On 4/2/2025 at 11 AM, California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding the quality of care and death of Resident 1. As a result of the investigation, CDPH determined that the facility failed to: 1. Notify Physician 1 or Physician Assistant (PA) 1 of Resident 1’s significant change in condition when Resident 1 had one episode of emesis (forceful expulsion of stomach contents through the mouth) on 2/25/2025 at 9 AM, in accordance with the facility’s policy & procedure (P&P) titled Anticoagulation-Clinical Protocol, Change in a Patient’s Condition or Status, and the physician order to monitor and notify the physician for adverse reactions (undesired effect of a drug) of anticoagulation (prevents blood clots) medication (Eliquis) that included but not limited to nausea, vomiting, lethargy (lack of mental alertness, sleepy), and bleeding. 2. Notify Physician 1 or PA 1 of Resident 1’s significant change in condition when Resident 1 had one more episode of emesis on 2/25/2025 at 11:30 AM, in accordance with the facility’s P&P titled Anticoagulation-Clinical Protocol, Change in a Patient’s Condition or Status, and the physician order to monitor and notify the physician for adverse reactions of anticoagulation medication that included but not limited to nausea, vomiting, lethargy (lack of mental alertness, sleep), and bleeding. 3. Contact 911/Emergency Medical Services (EMS) promptly on 2/25/2025, after two episodes of coffee-ground (a vomit that contains bits of food of what looks like coffee grounds due to presence of old blood, that may be coming from the stomach and may be a sign of a serious problem) emesis at 9 AM and 11:30 AM, in accordance with the facility’s P&P titled First Aid Treatment-Crash Cart/Emergency Response. As a result of these failures, immediate medical interventions and treatments were delayed for Resident 1’s significant change in condition when Emergency Medical Services (EMS) arrived at the facility on 2/25/2025 at around 1:38 PM. Resident 1 was in respiratory failure (a serious condition that makes it difficult to breathe on your own) upon EMS arrival on 2/25/2025. EMS suctioned Resident 1 multiple times and performed cardiopulmonary resuscitation (CPR- an emergency treatment that's done when someone's breathing or heartbeat has stopped) during transport to GACH 1. On 2/25/2025, at 1:55 PM, EMS arrived with Resident 1 to GACH 1, resuscitation efforts (procedures aimed at reviving someone after their heart and/or breathing has stopped) continued, but Resident 1 passed away and was pronounced dead at GACH 1 on 2/25/2025 at 2:44 PM. A review of Resident 1’s Admission Record (AR) indicated a 85-year-old, male patient, admitted to the facility on 5/1/2024, with diagnoses that included Parkinsonism (a term used to describe a collection of movement symptoms associated with several conditions), dysphagia (difficulty swallowing), and long-term use of anticoagulants (the ongoing and indefinite use of medication to prevent blood clots). A review of Resident 1’s History & Physical (H&P) Assessment dated 5/2/2024 signed by PA 1, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. The H&P indicated Resident 1 had the following present illnesses: orthostatic hypotension (a form of low blood pressure that happens when standing up from sitting or lying down), hypertension (high blood pressure), chronic kidney disease (progressive damage and loss of function in the kidneys), and seizures (a sudden, temporary alteration of behavior, movement, or consciousness caused by abnormal electrical activity in the brain). A review of Resident 1’s Minimum Data Set (MDS, a federally required assessment and screening tool) dated 2/13/2025, the MDS indicated Resident 1 had severely impaired (significantly limits one person’s physical or mental ability to do basic work activities) cognition (thought process). The MDS indicated Resident 1 required substantial/maximal assistance (a helper provides more than half of the effort required for a resident to complete an activity) for chair/bed-to-chair transfer, sit to stand position, and bathing. The MDS indicated Resident 1 required partial/moderate assistance for personal hygiene, eating, toileting hygiene, rolling left and right, and sit to lying position. A review of Resident 1’s care plan titled “Apixaban (generic name for Eliquis): At risk for adverse effect from black box medication (the most serious warning issued by the FDA. It highlights a drug's potential for serious or life-threatening adverse reactions, like injury or death, and is designed to alert healthcare providers and patients to the associated risks)” dated 8/13/2024, the care plan indicated Resident 1’s risk for the use of a black box medication and would be monitored/identified by the licensed nurse. The care plan indicated the physician would be notified promptly of any adverse reactions [discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle/joint pain, lethargy (lack of mental alertness, sleep), bruising, sudden changes in mental status and/or vital signs, shortness of breath, bleeding in any orifice. A review of Resident 1’s Order Summary Report, the Order Summary Report indicated the following physician orders: 1. A physician’s order dated 9/3/2024, to administer Eliquis Oral Tablet 2.5 milligrams (mg, unit of measure) give 1 tablet by mouth two times a day for deep vein thrombosis (DVT -a condition where a blood clot forms in a deep vein, typically in the lower legs or thighs) prophylaxis (action taken to prevent disease). 2. A physician’s order dated 9/28/2024, to monitor use of “anticoagulation medication (Eliquis)” for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle/joint pain, lethargy (lack of mental alertness, sleepy), bruising, sudden changes in mental status and/or vital signs, shortness of breath, bleeding in any orifice, and abnormal labs; to document ‘N’ (No), if monitored and none of the above observed. Document ‘Y’ (Yes), if monitored and any of the above observed. The order indicated to notify physician and document in nurses’ progress notes, every shift. A review of Resident 1’s Change of Condition (COC) Form - Situation Background Assessment Recommendation (SBAR) dated 2/25/2025 timed at 1:25 PM, written by LVN 1, the SBAR indicated on 2/25/2025 at 7:10 AM, Resident 1 was seen in bed by LVN 1 with chest rising up and down, responsive to verbal and tactile stimuli (any form of touch or physical contact that is perceived by the skin), Resident was provided breakfast and ate 20% of breakfast... The SBAR indicated at 8:42 AM, Resident 1’s vital signs obtained during medication administration indicated a BP at 108/84, pulse at 76 beats per minute (normal rate between 60 to 100 beats per minute), respiratory rate (normal rate between 12 to 20 breaths per minute) of 18 breaths per minute, oxygen saturation of 97% on room air, no pain, temperature of 97.8 degrees Fahrenheit (F, unit of measurement – normal range of temperature between 96 to 99 degrees Fahrenheit). Resident 1 received all due medication administered as ordered by the physician with no ASE (adverse side effects) noted. The SBAR indicated that at 9 AM, Resident 1 remained in bed awake and was assisted with activities of daily living (ADLs - basic tasks individuals perform daily for self-care and personal independence, such as bathing, dressing, toileting, and eating) by the CNA. The SBAR indicated Resident 1 had one episode of emesis. The SBAR indicated that at 11 AM, Resident 1 was in bed with nonlabored (easy, effortless, and comfortable) breathing, awaken to administer due medication. “No ASE noted. Resident kept clean and dry and comfortable.” The SBAR further indicated that at 11:30 AM, Resident 1 had another episode of emesis, no shortness of breath (SOB) or distress noted. The SBAR further indicated that at 12:40 AM, Resident 1 was in bed sitting up and awake, the CNA (unknown) tried to assist with lunch and Resident 1 did not eat. The SBAR noted Resident 1 was left in bed with the head of bed (HOB) elevated with bed in the lowest position, call light within reach. The SBAR further indicated that at 1 PM, “During rounds, [Resident 1] was in bed, no SOB or pain or discomfort noted.” The SBAR further indicated that at 1:25 PM, during [RNS 1] rounds, Resident 1 was noted with SOB and pale skin color. Vitals signs obtained with BP at 98/72 mm/Hg, pulse was 81 beats per minute, respiratory rate at 17 breaths per minute, oxygen saturation was 87% on room air and 92% with non-rebreather mask (an oxygen mask that delivers high concentrations of oxygen) at 15 liters (L, unit of measure) per minute... The SBAR indicated 911 emergency services was called due to Resident 1’s desaturation (abnormal drop in blood oxygen levels) and hypotension. The SBAR further indicated that EMS arrived (no time indicated) and took over. The SBAR indicated, during EMS assessment the Resident had one more episode of emesis. The SBAR Note indicated Resident 1’s Physician Assistant (PA 1) was made aware and Family member (FM) 1 was notified. The SBAR indicated that at 1:36 PM, Resident 1 was transferred to GACH 1 via 911 EMS. A review of Resident 1’s Transfer Record dated 2/25/2025 timed at 1:30 PM, handwritten by RNS 1, i