Health inspection·May 9, 2025

F550 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(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. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. §483.24(a)(3) Quality of Life (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. California Code of Regulations, Title 22, § 72311, Nursing Service- General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient’s care plan according to the methods indicated. Each patient’s care shall be based on this plan. California Code of Regulations, Title 22, § 72523, Patient Care Policies and Procedures (a) Written patient care and policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. California Code of Regulations (CCR) Title 22, § 72527 - Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (4) To consent to or to refuse any treatment or procedure or participation in experimental research. The facility failed to protect, promote, and honor Resident 23’s right to not receive cardiopulmonary resuscitation (CPR - emergency measures including manual chest compressions and rescue breaths to revive a person when breathing or heartbeat has stopped) measures as indicated in the Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for end-of life decisions communicated by a resident able to make informed decisions and if unable, by the resident's representative), dated 2/9/2025. Resident 23's POLST indicated Do Not Resuscitate (DNR - a medical order written by a doctor to instruct health care providers not to do CPR) instructing staff not to do CPR. The facility failed to: 1. Verify Resident 23’s code status (a person's wishes regarding CPR and other life-sustaining treatments in the event of cardiac arrest ([heartbeats stop] or respiratory arrest [breathing stops]) in Resident 23's POLST and Admission Record that Resident 23 had a DNR order before Registered Nurse 1 (RN 1) and Licensed Vocational Nurse 1 (LVN 1) began performing CPR on Resident 23 on 03/25/2025 from the time they determined Resident 23 was not breathing until informed by paramedics (healthcare professional trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital). 2. Verify Resident 23's POLST that Resident 23 had a DNR order before RN 2 and Registered Nurse Consultant 1 (RNC 1) began assisting RN 1 and LVN 1 with performing CPR on Resident 23 on 3/25/2025. 3. Ensure that RN 1, RN 2, RNC 1, and LVN 1 followed the facility's policy and procedures (P&P) on Communication of Code Status which indicated the resident had the right to request, refuse and/or discontinue medical or surgical treatment and the facility is to adhere to the resident's rights. 4. Ensure that RN 1, RN 2, RNC 1, and LVN 1 followed the facility's P&P on POLST that indicated the facility will honor a resident's POLST. As a result, RN 1 and LVN 1 started CPR on Resident 23 without checking Resident 23’s code status or POLST based solely on an alleged unidentified person shouting that Resident 23 was a full code (all possible life-saving measures including CPR are attempted). The failure to verify Resident 23's code status in the POLST and performing CPR for seven minutes violated Resident 23's choice to be DNR. Not affording Resident 23's right to exercise his rights could cause distress to Resident 23 and his family had the CPR been effective. Resident 23 may have experienced unnecessary pain and suffering including broken ribs, unnecessary pain, and brain injury from lack of oxygen from receiving CPR. A review of Resident 23’s Admission Record indicated the facility admitted Resident 23 on 10/7/2024 with the most recent readmission on 2/6/2025. Resident 23’s diagnoses included malignant neoplasm (cancer) of the abdomen (the part of the body between the chest and the hips) and cachexia (a condition that causes significant weight and muscle loss). A review of Resident 23’s History and Physical (H&P) exam, dated 2/8/2025, the H&P indicated Resident 23 had the capacity to understand and make decisions. A review of Resident 23's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 2/9/2025, indicated Resident 23 had intact cognition (thought processes). The MDS also indicated Resident 23 required assistance with eating and dressing and was dependent on staff for bathing and toileting. A review of Resident 23's POLST, dated 2/9/2025, signed by Medical Doctor 1 (MD 1) and Resident 23, indicated Resident 23’s choice to be DNR and to allow natural death to occur. A review of Resident 23's Advance Directive (a legal document that expresses the resident’s wishes regarding medical care in the event the resident become unable to make those decisions, such as due to illness or injury) Acknowledgement form, signed dated by Resident 23 on 2/9/2025, indicated Resident 23 had completed a POLST form on 2/9/2025. A review of Resident 23's Advanced Directive Status Care Plan (CP) initiated on 2/7/2025, indicated a code status of DNR. The CP included interventions to follow the POLST. A review of Resident 23's Physician's Orders, dated 2/6/2025, indicated MD 1 ordered DNR. During a concurrent observation and interview with Resident 23 on 3/24/2025 at 9:42 am in Resident 23's room, Resident 23 was sitting up in bed and watching television. Resident 23 stated he lived at an assisted living facility (ALF) before he got sick and was admitted to a hospital where doctors found cancer in his abdomen. Resident 23 stated he was admitted to the facility because he was too sick to return to the ALF. Resident 23 stated he chose DNR because of his cancer diagnosis. A review of Resident 23’s Nurses Progress Notes dated 3/25/2025, the note indicated that at 1 p.m., Resident 23 reported having shortness of breath. During an observation on 3/25/2025 at 2:06 pm in the hallway, outside of Resident 23's room, the door was open, the privacy curtain drawn and the counting of “1,2,3, ....30” repeatedly could be heard coming from Resident 23's room. A crash cart was positioned outside Resident 23's room. At 2:11 pm paramedics arrived at Resident 23's room; Paramedic 1 (PM 1) went into the room immediately. A staff member met PM 2 outside Resident 23's room and handed PM 2 a packet of documents (copies of Resident 23's medical record). PM 2 reviewed the documents and verbally asked why facility staff was performing CPR against Resident 23's DNR wishes. PM 2 pointed at the Admission Record and the POLST and stated that DNR was written on both forms. LVN 1, RN 1, RN 2 and RNC 1 were in the room performing or assisting CPR on Resident 23. During an interview with LVN 2 on 3/25/2025 at 2:16 pm, LVN 2 stated he called "code blue" (term that signals a medical emergency) over the intercom and called 911 in the direction of his supervisor, RN 1. LVN 2 stated he did not check for Resident 23's code status because he heard a female voice yell out "full code." LVN 2 was unable to identify the person who yelled “full code.” LVN 2 stated he should have checked Resident 23's chart to ensure they had the right code status to respect Resident 23's wishes. During a concurrent interview and record review with LVN 3 on 3/25/2025 at 2:18 pm, Resident 23's POLST and Admission Record were reviewed. LVN 3 stated Resident 23's POLST and Admission Record indicated Resident 23 had a DNR order. LVN 3 stated the DNR order could also be found in the electronic medical record and staff must check and verify the resident's POLST before starting CPR to ensure the resident's end-of-life decisions are followed. LVN 3 stated he was assigned to nurse station 1 but ran over to help at nurse station 2 when he heard the overhead page "Code Blue." LVN 3 stated his role during the time CPR was being performed on Resident 23 was filling out a transfer form in case Resident 23 needed hospitalization. LVN 3 stated he did not check Resident 23's POLST because he heard a female voice calling out "full code" and assumed Resident 23 had a full code status. LVN 3 was unable to identify the person who yelled “full code.” During a phone interview with Physical Therapy Assistant (PTA) on 3/26/2025 at 9:35 am, the PTA stated she entered Resident 23's room to provide physical therapy at about 2:00 pm on 3/25/2025 and stated Resident 23 did not respond to questions when Resident 23 was normally very able to respond. PTA stated moments later the Certified Occupational Therapist Assistant (COTA) arrived and retrieved the vital signs machine. The PTA stated at that point they checked Resident 23's oxygen saturation level (amount of oxygen in the blood in percentage, normal reading is 95% to 100%) and the reading was 32% (indicating medical emergency). PTA stated that while the COTA stayed with Resident 23, she went to the nurses' station to get LVN 1. During an interview with LVN 1 on 3/25/2025 at 2:23 pm, LVN 1 stated she was the Charge Nurse at Nurses' Station 2 and PTA called her over to Resident 23's room at 2:03 pm. LVN 1 stated she quickly assessed Resident 23 and determined Resident 23 was not breathing, LVN 1 left the room to grab the crash cart as RN 1 entered the room. LVN 1 stated RN 1 yell out near the doorway to the hallway for Resident 23's code status and heard a female voice yelled back the resident was full code. LVN 1 was unable to identify the person who yelled “full code.” LVN 1 stated RN 1 began chest compressions (use of hands to push down hard and fast in a specific way on the person's chest to keep blood flowing to vital organs until a regular heartbeat returns) while she (LVN 1) began rescue breaths (to provide oxygenation of the blood) on Resident 23 with a bag-valve-mask (BVM - a handheld device used to manually ventilate to a person who is not breathing or having difficulty breathing). LVN 1 stated RN 1 switched compressions off with RNC 1 and RN 2. LVN 1 stated the staff members who assisted with CPR was herself, RN 1, RN 2 and RCN 1 and they did not stop CPR until paramedics arrived. LVN 1 stated PM 2 read Resident 23's Admission Record and POLST and asked why CPR was done on a person that is a DNR. LVN 1 stated she did not check Resident 23's code status but relied on the voice (unidentified) that yelled out full code. LVN 1 stated the staff did not respect Resident 23's right to be DNR and that chest compressions could result in broken ribs. During a concurrent interview and record review with RN 1 on 3/25/2025 at 2:29 pm, Resident 23's medical record including POLST and Admission Record were reviewed. RN 1 stated Resident 23's code status was DNR, and it could be found on his POLST, Admission Record and in the electronic health record (EHR). RN 1 stated when he went to Resident 23's room and he determined Resident 23 was unresponsive, he yelled out in the hallway for code status and heard a female voice yell back two times "full code.” RN 1 did not identify the person who yelled “full code” when it occurred and was unable to identify the person during the interview. RN 1 stated although he was already in Resident 23's room, he should have confirmed who yelled out full code or asked someone to bring the chart into the room so he could verify Resident 23's code status. RN 1 stated it was wrong to go against Resident 23's wishes to die naturally and if he was resuscitated, he could have suffered more pain from broken ribs or a punctured lung. During an interview with RN 2 on 3/25/2025 at 2:36 pm, RN 2 stated she was the supervisor of nurse station 1 and ran over to station 2 to help when she heard the code blue page. RN 2 stated while at nurse station 2, she saw Resident 23's chart open on the desk and made copies of the Admission Record and Orders Summary Report (list of current doctor's orders) to give to the paramedics when they arrived. RN 2 stated she never took the time to check for Resident 23's code status because she heard a voice yell out "full code". RN 2 did not identify the person who yelled “full code” when it occurred and was unable to identify the person during the interview. RN 2 stated she should have checked the Admission Record at that point to confirm Resident 23's code status. RN 2 stated she then went into Resident 23's room to help and switch off compressions with RN 1 and RNC 1. During a concurrent interview and record review, on 3/25/2025 at 3:45 pm, the facility's policy and procedures (P&P) on CPR, revised on 3/10/2025 and Resident 23's POLST, dated 2/9/2025 were reviewed with RNC 1. RNC 1 stated Resident 23 had a DNR code status. RNC 1 stated CPR should have stopped immediately after a staff member confirmed Resident 23 had a DNR, but the facility failed to check and confirm the resident's code status. RNC 1 stated she went into Resident 23's room during the emergency and assisted with giving chest compressions to Resident 23. RNC 1 stated she heard a female voice (unidentified) yell out from the hallway, "full code" when RN 1 asked for Resident 23's code status. RNC 1 did not identify the person who yelled “full code” when it occurred and was unable to identify the person during the interview. RNC 1 stated because of the facility's actions, Resident 23 did not have a peaceful death, very frail and could have suffered broken bones or other complications had Resident 23 been successfully revived. During a concurrent interview and record review, on 3/25/2025 at 4:05 pm, Resident 23's POLST dated 2/9/2025 and the facility's P&P on Communication of Code Status, revised on 3/10/2025, were reviewed with the DON. The DON stated Resident 23's code status was DNR. The DON stated Resident 23's wishes were not fulfilled because CPR went on for seven minutes until paramedics arrived and determined the resident's code status. The DON stated the staff should have followed the P&P which indicated the resident had the right to request, refuse and/or discontinue medical treatment. The DON stated Resident 23 had a signed POLST indicating DNR in the medical record and staff did not check and verify Resident 23's code status. The DON stated Resident 23 could have suffered broken ribs, a punctured lung or injury to his brain from the