Health inspection·May 9, 2025

F600 (Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22) §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms. §483.12(a) The facility must— §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

F684 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) § 483.25 Quality of care 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 residents’ choices, including but not limited to the following: 22 CCR § 72315 Nursing Service - Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 22 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 3/25/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate complaints regarding quality of care/treatment and resident death when Resident 1 went into respiratory distress on 3/12/2025. Based upon observation, interview, and record review, the facility failed to ensure Resident 1 was provided with treatment and care in accordance with professional standards of practice when the facility failed the following: 1. Ensure Resident 1’s physician was notified of a change of condition (COC – a major decline in a resident’s status) when Resident 1’s blood pressure dropped after having high blood pressure in accordance with the regulations and policy and procedure. 2. Ensure Resident 1 was free from neglect when Resident 1 was not provided with treatment and care in accordance with professional standards of practice after Resident 1’s blood pressure and heart rate dropped below normal levels in accordance with the above regulations. As a result, Resident 1 experienced severe respiratory distress (a life-threatening condition characterized by difficulty breathing, rapid breathing, and low oxygen levels, often requiring immediate medical intervention) and was transferred to a General Acute Care Hospital (GACH) on 3/13/2025 at 12:37 a.m., and pronounced dead on 3/13/2025 at 4:27 p.m. A review of Resident 1’s Admission Record indicated the facility admitted Resident 1, a 73-year old male, on 3/4/2025 with diagnoses including unspecified hypothyroidism (unidentified cause for thyroid gland to not produce thyroid hormone, causing weakness), essential hypertension (persistent elevated blood pressure), and occlusion and stenosis of left carotid artery (complete blockage and narrowing of carotid artery, a major blood vessel supplying the brain). A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 3/12/2025, indicated Resident 1 was severely impaired with thought process and required substantial assistance from staff to complete activities of daily living (ADLs – activities such as bathing, dressing, and toileting a person performs daily). A review of Resident 1’s record titled, “eINTERACT (a tool used in healthcare that helps care teams prevent unnecessary hospitalizations and improve resident outcomes to alert staff to changes in a resident’s condition) Change of Condition Evaluation,” dated 3/12/2025 at 11:40 p.m., indicated Resident 1 had a change of condition of “Abnormal vital signs (measurements of the body’s most basic functions) and altered mental status (a change in a resident’s mental state, including changes in awareness, alertness, and mental function).” The evaluation indicated on 3/12/2025 at 5 p.m., Resident 1’s BP on a sitting position taken on Resident 1’s right arm was 86/57 mmHg and HR of 111 beats per minute. The evaluation indicated there were no other BP and HR assessments collected for Resident 1 after 5 p.m. on 3/12/2025. A review of the physician’s Progress Notes for Resident 1, dated 3/13/2025 at 1:06 a.m., indicated Resident 1’s physician (MD 1) called Registered Nurse (RN) 1 multiple times before RN 1 answered. The physician Progress Notes indicated MD 1 instructed RN 1 to check and examine Resident 1, then to call back MD 1. The physician’s Progress Notes indicated RN 1 called back and told MD 1 Resident 1’s BP was 86/57 mmHg, and HR was 111 bpm (these vital signs were the same readings taken on 3/12/2025 at approximately 5 p.m.). The physician’s Progress Notes indicated RN 1 told MD 1 that it was unclear if Resident 1 was responsive or not, so MD 1 ordered Resident 1 to be transferred to the GACH. A review of Resident 1’s Physician’s Orders, dated 3/13/2025 at 6:48 a.m., indicated Resident 1 was sent out to the GACH for abnormal vital signs and for altered level of consciousness. During an interview on 3/25/2025 at 3:54 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated she was working on 3/12/2025 during the 3 p.m. to 11 p.m. shift and was assigned to Resident 1. CNA 1 stated she checked Resident 1’s vital signs approximately “four to five times” using both arms, and the BP readings were “consistently low”. CNA 1 stated she informed Licensed Vocational Nurse (LVN) 1, who was assigned to Resident 1 about Resident 1’s low BP and increased HR. CNA 1 stated LVN 1 told her (CNA 1) that she (LVN 1) will recheck Resident 1’s vital signs. CNA 1 stated, “to be honest, I don’t know if she (LVN 1) checked since I went to my other residents….” During an interview on 3/26/2025 at 7:05 a.m., with RN 1, RN 1 stated on 3/12/2025, he arrived at the facility at approximately 11:35 p.m., for the 11 p.m. to 7 a.m. shift. RN 1 stated he received a call from Resident 1’s primary physician asking if RN 1 was the supervisor on duty, and for a report on Resident 1’s condition. RN 1 stated, upon observing Resident 1, “I was stunned, like he (Resident 1) was dying or towards the end of life….” RN 1 stated the previous shift staff failed to act to save Resident 1. RN 1 stated the previous shift staff should have notified the RN on duty or called a code blue (an emergency code typically indicating a resident experiencing a life-threatening medical emergency that requires immediate medical attention) for Resident 1. RN 1 stated, “When I saw the resident (Resident 1), to me, it looked like he (Resident 1) was gone.” RN 1 stated the previous shift staff failed to notify Resident 1’s physician about the decreased blood pressure and failed to call emergency services sooner for Resident 1. RN 1 stated, “This was … negligence because the vital signs were known since 5 p.m. and the documents show the doctor was not notified until 11:40 p.m., that’s almost 7 hours.” During a concurrent interview and record review on 3/26/2025 at 7:47 a.m., with LVN 2, Resident 1’s COC, dated 3/12/2025 documented at 11:40 p.m., and progress notes were reviewed. LVN 2 stated she worked on 3/12/2025 for the 11 p.m. to 7 a.m. shift, and was assigned to Resident 1. LVN 2 stated she did not recall if Resident 1 was receiving any oxygen. LVN 2 stated LVNs were to notify the RN on duty first for any residents with a COC. LVN 2 stated, “from what I saw, he (Resident 1) was in code blue status because of his shallow breathing.” LVN 2 stated Resident 1’s COC, dated 3/12/2025 documented at 11:40 p.m., indicated Resident 1’s last assessed BP of 86/57 mmHg and HR of 111 beats/minute recorded at 5 p.m. LVN 2 stated, “for his (Resident 1’s) blood pressure, it was very low. When the emergency personnel (paramedics - health professionals certified to perform advanced life support procedures) came, she (LVN 1) mentioned it was taken around 6 p.m. … 7 hours from the last collected vital signs. Per progress notes, the LVN (LVN 1) failed to notify the RN as there were no RN notification, no doctor (physician) notification, no code blue announced, and no interventions done on records (Resident 1’s medical records). The LVN (LVN 1) stated to the emergency personnel that was the resident’s (Resident 1’s) baseline. From what I saw, that was not the resident’s (Resident 1) baseline.” LVN 2 stated, “The LVN (LVN 1) failed to notify the RN on duty, failed to notify the doctor of the change of condition, failed to call a code blue, and failed to (immediately) call (the) emergency first responders (paramedics).” LVN 2 further stated, “It was about seven hours from when LVN (LVN 1) knew of the COC, so I feel this was neglect.” During an interview on 3/26/2025 at 2:16 p.m. with LVN 1, LVN 1 stated she was informed of Resident 1’s change in vital signs on 3/12/2025, at approximately 5 p.m. LVN 1 stated she did not discuss Resident 1’s COC with the on-duty RN (RN2), and did not notify Resident 1’s physician. LVN 1 stated she did not call emergency services for Resident 1 and the incoming night shift (11 pm. to 7 a.m.) staff (LVN 2) notified the emergency services for Resident 1’s COC. During a phone interview on 3/26/2025 at 4:20 p.m. with MD 1, MD 1 stated on 3/12/2025, approximately after 11:30 p.m., she called the facility to get an update on Resident 1. MD 1 stated no facility staff notified her (MD 1) earlier in the day. MD 1 stated she was concerned about Resident 1’s kidney function, so MD 1 called the facility for an update on Resident 1. MD 1 stated staff knew on 3/12/2025 at 5 p.m., Resident 1’s BP was 86/57 mmHg and HR of 111 beats per minute. MD 1 stated doctors (in general) should be made aware of this. MD 1 stated she spoke to an RN (RN 1) who told her “The patient does not look good.” MD 1 stated, “I would expect the nurses in general, when the BP is that low, the RN should evaluate the resident (Resident 1).” MD 1 stated she was not informed of Resident 1’s COC on 3/12/2025 at 5 p.m. and the facility should have informed her (MD 1). During an interview on 3/28/2025 at 10:15 a.m. with Unit Manager 1 (LVN), Unit Manager 1 stated Resident 1 had no nursing progress notes from the 3 p.m. to 11 p.m., shift, no documented interventions and no physician notifications. Unit Manager 1 stated, “The vital signs provide an internal baseline or anything happening for the residents, like blood pressures dropping or an increase in temperature could be related to possible infection, so vital signs help notify us (nursing staff) an indication of how the resident is doing, or to identify if any changes need to be addressed. There was about six hours and 40 minutes from when the MD was informed of the resident’s (Resident 1’s) condition." Unit Manager 1 stated, “For this case, after finding the vital signs at 5 p.m., the LVN (LVN 1) failed to reassess the resident’s (Resident 1’s) vital signs, failed to notify the RN to assess the resident, and failure to notify the doctor of the COC. He (Resident 1) had a care plan for hypertension (high BP) initiated on 3/4/2025, on his admission date. The interventions by licensed nurses (LVNs and RNs) are to observe for signs and symptoms of abnormal blood pressure and complications related to hypertension, and notify the physician as needed. In this scenario, the LVN (LVN 1) failed to implement this (Resident 1) care plan’s intervention.” During a concurrent interview and record review with MD 1 on 3/28/2025 at 11:30 a.m., Resident 1’s “eINTERACT Change of Condition Evaluation,” dated 3/12/2025 at 11:40 p.m., was reviewed. MD 1 stated she called the facility on 3/12/2025 approximately 11:30 p.m. MD 1 stated she did not realize the vital signs provided to her (MD 1) over the phone for Resident 1’s BP of 86/57 mmHg and HR of 111 bpm were the same collected vital signs from 5 p.m., earlier in the day (3/12/2025). MD 1 stated, “I’m talking to them on the phone, so I didn’t know they (RN 1) used the same vital signs from 5 p.m. I thought it was a recent set of vital signs.” During a concurrent interview and record review with the Director of Nursing (DON) on 3/28/2025 at 5:50 p.m., Resident 1’s paramedics’ report, dated 3/13/2025 at 12:19 a.m., and the facility’s undated policy and procedure titled, “Change in a Resident’s Condition or Status,” were reviewed. The DON stated on 3/12/2025, staff knowing the changes in vital signs for Resident 1 at 5 p.m., to the time the physician called the facility at approximately 11:40 p.m., was almost seven hours of no interventions. The DON stated the paramedics’ report indicated the paramedics were contacted on 3/13/2025 at 12:19 a.m., arrived at the facility by 12:28 a.m., at bedside with Resident 1 at 12:30 a.m., and left the facility with Resident 1 by 12:37 a.m. The DON stated the report described Resident 1 as having decreased breath sounds and the vital signs collected by the paramedics on 3/13/2025 at 12:30 a.m. were a BP of 74/50 mmHg, HR of 56 beats per minute, respiratory rate (RR – refers to the number of breaths a person takes per minute) of 4 breaths per minute, and oxygen saturation (percentage of oxygen to the blood measuring how well the lungs deliver oxygen to the body) of 74 percent (% - per one hundred). The DON stated the paramedics described Resident 1 as lying in bed with the current concern of respiratory failure (occurs when the lungs are unable to adequately perform their primary function: taking in oxygen and removing carbon dioxide from the blood). The DON stated the report indicated Resident 1 was found in severe respiratory distress and had a nasal cannula (a small plastic tube which fits into nostrils to provide supplemental oxygen) and staff were standing by with no interventions to Resident 1’s RR. The DON stated the report indicated Resident 1 was assisted by the paramedics with a bag valve mask (a handheld device used to deliver breaths to someone who cannot breathe on their own) and transported on advanced life support (ALS – a set of life-saving protocols and skills to provide urgent care during critical conditions) to the nearest GACH 1. The DON stated, “This resident passed away on 3/13/2025.” The facility’s policy and procedure titled “Change in a Resident’s Condition or Status” was also reviewed with the DON. The DON was asked to clarify what “Promptly” meant as indicated in the policy. The DON stated, “For the notification of promptly, whatever the change of condition was from the resident’s baseline, licensed staff (LVNs & RNs) need to assess and inform the attending physician. There is no time indicated, but for emergent needs, like for this case, the doctor should have been notified from the initial identification of the 5 p.m. decreased blood pressure of Resident 1.” A review of Resident 1’s GACH records titled, “Discharge Summary,” indicated Resident 1 passed away on 3/13/2025 at 4:27 p.m., and the preliminary cause of Resident 1’s death was septic shock (a life-threatening condition that happens when the BP drops