Other·May 14, 2026

Code of Federal Regulations, Title 42, Section 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 advanced directives. Code of Federal Regulations, Title 42, Section 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: Code of Federal Regulations, Title 42, Section 483.35 Nursing Services 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. (c) 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. California Code of Regulations, Title 22, Section 72311 Nursing Services - 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. California Code of Regulations, Title 22, Section 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: (9) Signs and symptoms of cardiopulmonary distress. 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 3/27/2026, the California Department of Public Health (CDPH) conducted an unannounced visit to investigate a complaint alleging that delayed emergency response to a resident who required emergency services resulted in the resident's death. Upon investigation, CDPH determined the facility failed to implement its policy and procedure (P&P) titled "Cardiopulmonary Resuscitation" (CPR, an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) which required staff to immediately activate a Code Blue (announcement used in facilities when a resident is experiencing medical emergency), call 911(phone number used to contact the emergency services), and provide basic life support (BLS, a set of emergency medical procedures designed to sustain life by maintaining breathing and circulation), including CPR for Resident 1 who was a full code (a medical term indicating a patient's consent to receive all possible life-saving measures in the event of a cardiac arrest [when the heart stops breathing] or respiratory arrest [when a person stops breathing]). The facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 1 who was CPR certified (successfully completed a training course and received a credential that qualifies a person to perform BLS) initiated CPR and stayed with Resident 1 per the facility's policy and procedure (P&P) titled, "Cardiopulmonary Resuscitation," and the American Heart Association (AHA) Guidelines when Resident 1 was found unresponsive, not breathing, and without pulse on 3/26/2026 at approximately 10:30 p.m. 2. Ensure staff called 911 as soon as Resident 1 was found unresponsive, not breathing, and without a pulse on 3/26/26 at approximately 10:30 p.m. The Paramedics Run Sheet records indicated the Paramedics were dispatched to Resident 1 at 10:39 p.m. and arrived at the facility at 10:49 p.m. 3. Ensure Licensed Vocational Nurse (LVN) 1 and Registered Nurse (RN) 1 did not delay the initiation of CPR by checking Resident 1's blood pressure (pressure that occurs when blood pushes against the walls of patient arteries [blood vessel]), oxygen saturation (measures the percentage of oxygen in the blood), and checking Resident 1's eyes when Resident 1 was found unresponsive and without a pulse by CNA 1. As a result, staff delayed providing CPR, and called 911 on Resident 1 who was found unresponsive, not breathing, and without a pulse on 3/26/2026 at approximately 10:30 p.m. Resident 1 was pronounced dead at 11:12 p.m. A review of Admission Record, indicated Resident 1, a 94-year-old male, was admitted to the facility on 3/18/2026 with diagnoses including elevated white blood cell count (a condition where the number of white blood cells in the blood is higher than normal), anemia ( low blood count), acute kidney failure (AKI, the sudden loss of kidney function), and chronic kidney disease (CKD, slow, progressive loss of kidney function over months or years). A review of Resident 1's History and Physical (H&P), dated 3/21/2026, indicated Resident 1 had the capacity to make medical decisions. A review of Resident 1's Physician Orders for Life Sustaining Treatment (POLST, a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end of life) dated 3/20/2026, indicated if Resident 1 was in cardiopulmonary arrest (a sudden stop of function of the heart) CPR was required. A review of Resident 1's Nursing Progress Note, dated 3/26/2026, indicated at about 10:30 p.m., RN 1 was notified that Resident 1 was unresponsive, and upon assessment, CPR was initiated (unknown time) and 911 was called at 10:37 p.m. The Nursing Progress Note indicated paramedics arrived at the facility at 10:47 p.m. and took over CPR. The Nursing Progress Note indicated Resident 1 was pronounced dead at 11:13 p.m. A review of Resident 1's Fire Call History, dated 3/26/2026, indicated the 911 call regarding Resident 1 was placed at 10:37 p.m. A review of Resident 1's Paramedic Run Sheet, dated 3/26/2026, indicated paramedics were dispatched at 10:39 p.m., and were at Resident 1's bedside at 10:49 p.m. The Paramedic Run Sheet indicated Resident 1 was treated per their cardiac arrest protocol with high quality CPR initiated, ventilation (delivery of rescue breaths [artificial respiration] to provide oxygen) provided via bag valve mask (BVM, a handheld, self-inflating device used to provide emergency ventilation to patients who are not breathing or are breathing inadequately), and three rounds of cardiac epinephrine (lifesaving medication) given, but no change in condition throughout the efforts. The Paramedic Run Sheet indicated resuscitation efforts ceased. A review of Resident 1's Certificate of Death (undated), indicated Resident 1 died on 3/26/2026 at 11:13 p.m., and the immediate cause of death was cardiopulmonary arrest and the underlying cause was arteriosclerotic cardiovascular disease (disease that affects the heart or blood vessels). During an interview on 3/31/2026, at 2:40 p.m., CNA 1 (who was CPR certified), stated on 3/26/2026 at around 10:30 p.m. she found Resident 1 unresponsive, not breathing and without a carotid pulse (the pulse felt on the neck) after checking the pulse twice. Instead of calling code blue and initiating CPR, at 10:30 p.m., she left the room to get help from LVN 1. CNA 1 stated she did not return to Resident 1's room after she informed LVN 1 and continued with her assignment. During an interview on 3/31/2026 at 3:10 p.m., RN 1 stated on 3/26/2026 at around 10:30 p.m., LVN 1 informed her Resident 1 was unresponsive, and LVN 1 and RN 1 went to Resident 1's room with a crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations). When RN 1 and LVN 1 arrived, no other staff was in the room. RN 1 stated LVN 1 checked Resident 1's blood pressure and placed a pulse oximeter (device that measures blood oxygen saturation [blood oxygen level] and heart rate) on Resident 1's finger to detect a pulse, while she shook the resident to assess for responsiveness. When the pulse oximeter did not detect a pulse, she then checked Resident 1's carotid pulse and confirmed Resident 1 did not have a pulse. RN 1 began chest compressions, called out for someone to call 911 and LVN 1 provided rescue breathing (used on a resident who has stopped breathing). RN 1 stated three to four minutes passed between the time LVN 1 notified her Resident 1 was unresponsive and the time 911 was called. LVN 2 called 911 at 10:37 p.m., and the paramedics arrived at 10:47 p.m., and took over CPR. The paramedics stopped CPR and resuscitation efforts at 11:13 p.m., RN 1 stated she was not aware Resident 1 had no pulse when CNA 1 found him at 10:30 p.m. RN 1 stated if she was aware, she could have initiated CPR immediately for a possibility of saving Resident 1's life. RN 1 stated any delay in initiating CPR can cause brain damage (injury of brain cells) or death. RN 1 stated even a one-minute delay in starting chest compression after observing a resident without a pulse was too long. During an interview on 4/1/2026, at 11:05 a.m., the Director of Staff Development (DSD) stated when staff finds a resident unresponsive, staff should not leave the resident alone. The DSD stated staff should call a Code Blue or call for help and delegate someone to call 911 and get the crash cart. As soon as staff discovered Resident 1 without a pulse, chest compressions should have been initiated immediately. The DSD stated she did not know that CNAs were allowed to check for a pulse. CNA 1 leaving Resident 1 alone on 3/26/2026 after finding him unresponsive with no pulse did not follow the facility's P&P and AHA BLS guidelines. During an interview on 4/1/2026, at 12:03 p.m., LVN 1 stated on 3/26/2026 (unknown time), CNA 1 approached her near the Nursing Station 1 and reported Resident 1 was unresponsive. LVN 1 immediately informed RN 1 and they both went down to Resident 1's room with the crash cart while LVN 2 looked up Resident 1's code status in the resident's medical record (chart). LVN 1 stated when they entered the room no other staff were present and Resident 1 was unresponsive. RN 1 attempted to open the resident's eyes while she attempted to take Resident 1's blood pressure on the left arm and applied a pulse oximeter to his finger. LVN 1 stated they were unable to obtain blood pressure or pulse using the pulse oximeter. RN 1 then checked Resident 1's carotid pulse. LVN 2 arrived in the hallway outside the room and informed them (LVN 1 and RN 1) Resident 1 was a full code and they initiated CPR. During an interview on 4/2/2026, at 10:26 a.m., LVN 2 stated at around 10:35 p.m., LVN 1 and RN 1 told her Resident 1 was unresponsive. LVN 1 and RN 1 took the crash cart to Resident 1's room. She checked Resident 1's medical record for his POLST status and called 911. She later heard one of the nurses in Resident 1's room call out "Code blue." LVN 2 stated she did not enter Resident 1's room but confirmed from outside the doorway that CPR was initiated. During an interview on 4/2/2026 at 11:05 a.m., the Director of Nursing (DON) stated their policy titled "Cardiopulmonary Resuscitation" based on AHA guidelines did not include taking a blood pressure when a resident was found unresponsive. The DON stated if a resident had no pulse, the heart was not pumping blood, and a blood pressure reading could not be obtained. The DON stated if a resident was pulseless, within three to seven minutes it could result in tissue damage to the brain from the lack of oxygen. The DON stated 911 was called so paramedics could administer cardiac (heart) medications to help revive Resident 1 as staff at the facility were not trained to give advanced cardiac medications such as epinephrine. A review of facility's P&P titled "Cardiopulmonary Resuscitation" dated 4/15/2025, indicated "Properly trained personnel will be available to provide basic life support, including CPR, to those requiring emergency care, prior to arrival of emergency medical personnel, and subject to accepted professional guidelines, advance directives, and physician orders". The P&P indicated the facility shall follow current AHA guidelines regarding CPR. The P&P indicated the general procedural guidelines include: a. Immediately initiating a code blue emergency response in a cardiopulmonary emergency to facilitate additional assistance and activating emergency services. b. Engage in concurrent/coordinated emergency response efforts such as quickly evaluating resident responsiveness, breathlessness, and pulselessness, and activating 911, positioning the individual for CPR, initiating chest compressions and performing rescue efforts, retrieving crash cart, verifying code status, and preparing records for emergency transfer. A review of the AHA Guidelines, dated 2025, indicated for adult basic life support for healthcare professionals the algorithmic steps were to: 1. Verify scene safety 2. Check for responsiveness. 3. Shout for help nearby. 4. Activate the emergency response system. 5. Send someone to get the AED. 6. Look for breathing and check a pulse simultaneously within 10 seconds. 7. If there is no pulse start CPR by performing 30 compressions to 2-breath until an AED/defibrillator arrives. 8. Once AED arrives check for a shockable rhythm. 9. If not shockable resume CPR immediately for 2 minutes until prompted by the AED machine, and to continue until Advanced Life Support professionals take over or the person starts to move. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc guidelines/algorithms The facility failed to: 1. Ensure CNA 1, who was CPR certified, initiated CPR and stayed with Resident 1 per the facility's P&P titled, "Cardiopulmonary Resuscitation," and the AHA Guidelines when Resident 1 was found unresponsive, not breathing and without pulse on 3/26/2026 at approximately 10:30 p.m. 2. Ensure staff called 911 as soon as Resident 1 was found unresponsive, not breathing, and without a pulse on 3/26/26 at approximately 10:30 p.m. The Paramedics Run Sheet records indicated the Paramedics were dispatched to Resident 1 at 10:39 p.m. and arrived at the facility at 10:49 p.m. 3. Ensure LVN 1 and RN 1 did not delay the initiation of CPR by checking Resident 1's blood pressure, oxygen saturation, and checking Resident 1's eyes when Resident 1 was found unresponsive and without a pulse by CNA 1. As a result, staff delayed providing CPR, and calling 911 for Resident 1 who was found unresponsive, not breathing, and without pulse on 3/26/2026 at approximately 10:30 p.m. Resident 1 was pronounced dead at 11:12 p.m. These violations, jointly, separately or in any combination, presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.