Health inspection·May 16, 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).  Code of Federal Regulations, Title 42, Section 483.21 (b)(1) Comprehensive Care Plans

F656  The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and (b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following —   §483.21(b)(3) Comprehensive Care Plans

F658  The services provided or arranged by the facility, as outlined by the comprehensive care plan, must—   (i) Meet professional standards of quality.     Code of Federal Regulations, Title 42, Section 483.25 Quality of care

F684  Quality of care is a fundamental principle that applies to all treatment and care provided to facility patients. Based on the comprehensive assessment of a patient, the facility must ensure that patients receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the patients’ choices[.]  California Code of Regulations., Title 22, Section 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:   (A) The admission of a patient.   (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).     California Code of Regulations, Title 22, Section 72313. Nursing Service – Administration of Medications and Treatments.  (a) Medications and treatments shall be administered as follows:  (1) No medication or treatment shall be administered except on the order of a person lawfully authorized to give such order.  (2) Medications and treatments shall be administered as prescribed.  (3) Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, shall be performed as required and the results recorded.     California Code of Regulations, Title 22, Section 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 4/3/25 at 9:46 AM, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding a resident’s death.  The facility failed to ensure Resident 1 who had diagnosis of Non- ST (represents the interval between ventricular depolarization [blood flow into the left ventricle [one of two large chambers located toward the bottom of the heart]]and repolarization [resting state of the heart]) segment elevation myocardial infarction (NSTEMI, a type of heart attack where a coronary artery is partially blocked, causing reduced blood flow to the heart and resulting in some heart muscle damage) received treatment and services in accordance with professional standards of practice, care plan and the physician's order for the management of the resident's chest pain. The facility failed to: 1. Administer Nitroglycerine tablet (medication used to treat chest pain) as ordered and as needed for chest pain. On 3/16/25 at 11:27 PM, after Resident 1 complained of chest pain, only one dose of Nitroglycerine was administered to Resident 1, however the medication was documented as Not effective (NE), and a second or third dose of Nitroglycerine was not administered to Resident 1. 2. Administer Nitroglycerine tablet as needed for chest pain after Resident 1 's chest pain was reevaluated as ‘somewhat effective’ (SE) on 3/17/2025 at 3:50 PM by licensed vocational nurse (LVN) 6, on 3/18/2025 at 11:58 AM by LVN 2 and on 3/19/2025 at 9:23 AM by LVN 2.  3. Monitor and document Resident 1 's complaints of chest pain every shift for 72 hours when Resident 1 complained somewhat relieved chest pain after LVN 1 administered one dose of Nitroglycerine tablet on 3/17/2025 at 3:50 PM, and on 3/18/2025 at 11:58 AM in accordance with the facility’s Policy and Procedure for Change in Condition.  4. Notify Resident 1’s attending physician (Physician 1) of Resident l's change of condition on 3/18/2025 when Resident 1 complained of unrelieved chest pain around 11:58 AM.  5. Ensure there was no delay in carrying out the physician's order on 3/19/2025 that was placed at around 11:58 AM to perform an electrocardiogram (EKG- a test to check the heartbeat) and to send Resident 1 to the General Acute Care Hospital (GACH) if Resident 1’s chest pain continues. Resident l's EKG was done on 3/19/2025, three (3) hours after the EKG order was placed. 911 Emergency Services (EMS, a system that provides emergency medical care) arrived at the facility approximately 5 hours after Resident 1 continued to complain of chest pain on 3/19/25.  As a result of the failure described above, on 3/19/2025 at 3:39 PM, 3 days after first complaining of chest pain, Resident l's EKG result indicated an acute myocardial infarction (MI) and at 4:50 PM. Resident 1 complained of chest pain of 8 out of 10 on a pain scale (a numerical rating scale used to measure the intensity of pain where 0 to 2 indicated mild pain, 3 to 6 indicated moderate pain, 7 to 10 indicated severe, excruciating pain), heart rate (HR) of 136 (regular heart rate range is 60-100 beats per minute [bpm]) bpm, and blood pressure (BP) of 81/54 (regular BP range is 120/90 millimeters of mercury (mm/Hg (unit of measurement). Resident 1 was sent to the General Acute Care Hospital (GACH) via 911 EMS on 3/19/2025 at 5 PM. While in the GACH on 3/20/25 at 2:30 AM, a code blue (a rapid response system developed for emergency resuscitation and stabilization of any sudden cardiac arrest [SCA]) was called for Resident 1 and a return of spontaneous circulation (ROSC, resumption of a sustained heart rhythm that perfuses the body after cardiac arrest.) after Resident 1 was intubated (the process of inserting a tube called an endotracheal tube (ET) into the mouth or nose and then into the airway ([trachea]). On 3/20/25 at 4:28 AM, Resident 1 was pronounced dead by the GACH's physician, 4 days after complaining of heart pain. The GACH’s Death summary, stated the cause of death was Myocardial Infarction (heart attack).  1. A review of Resident 1’s Admission Records (AR), indicated Resident 1 was a 93 year old female, initially admitted to the facility on 12/14/2018 and readmitted on 3/02/2025 with diagnoses that included NSTEMI, Parkinson’s disease ( progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement without involuntary, abnormal, and uncontrolled movements), and Atherosclerotic heart disease of the native coronary artery (heart disease caused by the buildup of plaque in the coronary arteries).  A review of Resident 1’s History and Physical (H&P, a comprehensive physician’s note regarding the assessment of the resident’s health status), dated 5/8/2024, indicated Resident 1 had fluctuating (sometimes) capacity to understand and make decisions.  A review of Resident 1’s Care Plan (CP) for At Risk for Chest Pain, dated 7/07/2024, indicated to administer medication as ordered, inform the physician for any changes and abnormalities in condition, and to monitor for chest pain.  A review of Resident 1’s “Minimum Data Set” (MDS, resident assessment tool), dated 1/28/2025, indicated the resident 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 maximum assistance (helper does more than half the effort) with sit to lying, lying to sitting, sit to stand, toilet transfer, tub/shower transfer.  A review of Resident 1’s “Physician Orders for Life-Sustaining Treatment ” (POLST medical order forms that tell medical staff what to do if you have a medical emergency and are unable to speak for yourself), dated 2/9/2023, and signed by Resident 1, indicated Resident 1 requested attempt resuscitation (the action or process of reviving someone from unconsciousness or apparent death) and medical interventions as full treatment with a primary goal of prolonging life by all medically effective means.  A review of Resident 1’s “Physician Order Report” dated from 03/01/2025 to 03/31/2025, indicated the following physician orders:  Nitroglycerin (a vasodilatory drug that causes blood vessels to widen [dilate], used primarily to provide relief from chest pain) tablet, sublingual (under the tongue); Special Instructions: Give 1 tablet sublingual every 5 min three times for chest pain, then call the physician. As needed Pro re Nata (PRN) 1, PRN 2, PRN 3 (may give three times every 5 minutes).  A review of Resident 1’s Medication Administration Record?(MAR), from 03/01/2025 to 03/19/2025, indicated the following:  1. On 3/16/2025, Nitroglycerin tablet sublingual 0.4 mg was administered by LVN 1 at 11:27 PM for chest pain. The MAR indicated one dose was administered and documented as “Not Effective (NE).”  2. On 3/17/2025, Nitroglycerin tablet sublingual 0.4 mg was administered by LVN 3 at 3:48 PM for chest pain. The MAR indicated this first dose was not effective (NE). A second dose of nitroglycerin 0.4mg was administered at 3:50 PM and this second dose was administered and documented as “SE.”  3. On 3/18/2025, Nitroglycerin tablet sublingual 0.4 mg was administered by LVN 2 at 11:58 AM for chest pain. The MAR indicated one dose was administered and documented as “Somewhat Effective (SE).”  4. On 3/19/2025, Nitroglycerin tablet sublingual 0.4 mg was administered by LVN 2 at 9:23 AM for chest pain. The MAR indicated one dose was administered and documented as “SE.”  5. On 3/19/2025, Nitroglycerin tablet sublingual 0.4 mg was administered by LVN 3 at 4:57 PM for chest pain. The MAR indicated one dose was administered and documented as “SE.”  A review of a facility provided text message obtained on the facility’s physician communication phone called “Red phone,” between Physician 1 and the facility’s Registered Nurse (RN)1, the text message indicated the following text on 3/19/25 at 11:55 AM, that facility RN1 texted Physician 1 that Resident 1 complained of chest pain with Nitroglycerine given and still complained of chest pain. The Text messages indicated on 3/19/25 at 11:58 AM, Physician 1 responded to RN1 with an order to perform an EKG and chest X-ray, and that Resident 1 had been hospitalized twice. The text message indicated that Physician 1 told RN 1 if Resident 1’s chest pain continued, to send Resident 1 to the GACH emergency room (ER).  A review of Resident 1’s Physician 1 Telephone order documented by RN 1, dated 03/19/25 at 1:03 PM, indicated: “Stat EKG today.”  A review of Resident 1’s Progress Notes for the MAR, dated 3/19/25, documented by RN1, indicated at 2:37 PM, RN 1 documented that Physician 1 ordered a Stat (immediately/without delay) Xray (a type of medical imaging that uses radiation to take pictures of the inside of your body) and EKG test.  A review of Resident 1’s electrocardiogram EKG result (test to record the electrical signals in the heart. It helps doctors diagnose and monitor various heart conditions by measuring the heart's rate, rhythm, and electrical activity) dated 3/19/2025, indicated an Acute myocardial infarction (MI, a serious medical condition where blood flow to the heart muscle is suddenly blocked, leading to tissue damage).  A review of a facility provided text message obtained on the facility’s physician communication phone called “Red phone,” between Physician 1 and LVN 2, the text messages indicated on 3/19/2025 at 3:52 PM, LVN 4 texted Physician 1 an image of Resident 1’s EKG and chest x ray results. On 3/19/2025 at 4:29 PM, LVN 4 texted Physician 1 and asked if there were any physician orders. On 3/19/2025 at 4:38 PM, Physician 1 responded via text message to send Resident 1 to the GACH ER.  A review of Resident 1’s Progress Notes for MAR at 4:50 PM, RN 2 documented that Resident 1 complained of chest pain with pain rated at 8 out of 10 on a pain scale. The Note indicated that Resident 1 was a full code (all medical interventions are permitted to resuscitate a patient in the event of cardiac or respiratory arrest) and 911 EMS was called. The Note indicated at 5 PM, RN 2 documented that the 911 EMS arrived at the facility and Resident 1 was transferred to the GACH ER at 5:05 PM for further evaluation.  A review of the GACH records, Titled Death Summary, dated 3/21/25, the Death Summary indicated Resident 1 was brought to the GACH ER on 3/19/2025 for chest pain. Resident 1's cardiac enzyme (substances released into the bloodstream when the heart muscle is damaged or stressed) results indicated with brain natriuretic peptide (BNP, a hormone produced by the heart, released when the heart has to work harder than usual, particularly in cases like heart failure) of 4700 picogram per millimeter (pg/mL, a unit of measurement normal range is less than 100 pg/mL) and High-sensitivity Troponin (a test to detect protein released due to hearth muscle damage) of 7686 ng/L (nanogram per liter) (level above 14ng/l are considered elevated and heart damage or a heart attack). The Death Summary indicated on 3/20/25 while in the GACH, a code blue was called for Resident 1 at 2:30 AM and a return of spontaneous circulation (ROSC refers to the resumption of a sustained, effective heart rhythm and breathing after a period of cardiac arrest) after Resident 1 was intubated (a tube has been inserted into someone's trachea (windpipe) to help them breathe). The GACH record indicated another code blue was called at 3:55 AM and Resident 1 was pronounced dead by the GACH's physician at 4:28 AM.  A review of the State of California, Certificate of