Health inspection·February 7, 2025

42 CFR § 483.10 Resident rights. (g) Information and communication (14) Notification of changes. (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); 42 CFR § 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. (a) The facility must- (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; CFR §483.24 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. 42 CFR 483.30 Physician Services A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. Physician supervision. The facility must ensure that- (1) The medical care of each resident is supervised by a physician; and (2) Another physician supervises the medical care of residents when their attending physician is unavailable. 42 CFR § 483.5 - Definitions Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 22 CCR §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. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (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: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. 22 CCR § 72517 - Staff Development (b) In addition to (a) above, all licensed nurses shall have training in cardiopulmonary resuscitation 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. 22 CCR § 72527 - Patients' Rights 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 (10) To be free from mental and physical abuse. On 1/18/2025, the California Department of Public Health (CDPH) conducted an unannounced standard annual recertification survey. CDPH determined the facility's licensed nurses did not provide needed services to prevent Resident 45, who had a Full Code status (indicates a patient's consent to receive all possible life-saving measures in the event of a cardiac or respiratory arrest), had difficulty breathing and became unresponsive (a person not reacting to touch, sound or means of communication) received Cardiopulmonary Resuscitation ([CPR] an emergency procedure to restart a person's heart (chest compressions) to increase the chances of the resident's survival. The facility failed to: 1. Prevent neglect of Resident 45 when Licensed Vocational Nurse (LVN) 1 and two Certified Nurse Assistants (CNA) CNA 1 and CNA 2 failed to carry out their duty of care to provide a clinically appropriate assessment and CPR efforts to Resident 45 when the resident was found unresponsive. 2. Follow the facility's policy and procedures (P&P) titled, "Abuse Prevention and Prohibition Program," dated February 9, 2024, which indicated residents would be protected from neglect as required by the regulation. 3. Provide nursing services consistent with professional standards of care when LVN 1 failed to assess Resident 45's vital signs (measurements of the body's basic functions including oxygen saturation [amount of oxygen in blood], blood pressure [force of blood pushing against the blood vessels walls in the heart], respiration [process of breathing in and out], heart rate ( pulse : number of times the heart beats per minute), and temperature (measure how well the body can make and get rid of heat) and update the resident care plan as necessary, reflecting Resident 45's clinically observed signs of difficulty breathing. 4. Ensure LVN 1 announced a Code Blue (an announcement that signifies a medical emergency where a patient is experiencing a life-threatening situation) when he found Resident 45 unresponsive. 5. Follow the facility's P&P, titled, "Cardiopulmonary Resuscitation," dated February 21, 2024, by providing CPR including continuous chest compressions in response to clinically observed signs of Resident 45 being unresponsive. 6. Ensure CNA 1 and CNA 2 did not stop delivering chest compressions during CPR to Resident 45 before the Paramedics (emergency medical responders) were able to take over Resident 45's CPR. 7. Provide nursing services consistent with professional standards of care and to ensure RN 1 notified Resident 45's physician of Resident 45's refusal to wear a medically indicated LifeVest (a wearable device to monitor for abnormal heart rhythms and deliver a shock to restore normal rhythm) intended to lessen the risk of life-threatening abnormal heart rhythms. 8. Ensure LVN 1 had Resident 45's vital signs taken and monitored when CNA 1 notified LVN 1 on 12/13/2024 at 11:10 p.m., that the resident was having difficulty breathing. 9. Provide nursing services consistent with professional standards of care by ensuring that RN 1 monitored Resident 45's condition when she noted Resident 45's oxygen saturation level (measure of how much oxygen is in the blood cells) on room air was out of range. Resident 45 had a diagnosis of Chronic Obstructive Pulmonary disease (COPD a progressive lung disease that causes difficulty breathing). The oxygen saturation reference range for a resident with COPD is 88 percent (%) to 92%. These deficient practices resulted in Resident 45 not being monitored by the licensed nurses when Resident 45 had difficulty breathing and weakness on 12/13/2024 at 11:10 p.m. There was delay in delivery of life saving measures such as CPR for Resident 45 when she was found unresponsive on 12/14/2024 at 4:25 a.m. Resident 45 was pronounced dead on 12/14/2024 at 5:07 a.m. The deficient practice placed 38 residents, who had a Full Code status, at risk of not receiving timely CPR. Finally, these deficient practices placed 38 residents in the facility who were full code status at risk of being neglected by licensed nurses in case the residents' physical condition emergently declined. A review of Resident 45's Admission Record, indicated Resident 45 was a 66-year-old female initially admitted to the facility on 5/18/2020 and was readmitted from a general acute care hospital (GACH) on 12/13/2024 with diagnoses including COPD, End Stage Renal Disease ([ESRD] irreversible kidney failure), Congestive Heart Failure ([CHF] a disorder which causes the heart not to pump blood efficiently, sometimes resulting in leg swelling), and Type II Diabetes Mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 45's History and Physical (H&P) dated 12/13/2024, indicated Resident 45 had fluctuating (varied) capacity to understand and make decisions. The H&P indicated Resident 45 was a full code status. A review of Resident 45's Minimum Data Set ([MDS] a resident assessment tool), dated 9/24/2024 indicated Resident 45's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making were mildly impaired. The MDS indicated Resident 45 required moderate assistance for most of her activities of daily living (sit to stand, chair/bed to chair transfer, walking 10 feet, shower transfer, dressing, bathing, oral and toileting hygiene), required supervision (no physical assistance) for personal hygiene, and required set up for eating. The MDS indicated Resident 45 utilized a wheelchair and did not have any impairments on both upper (arms/shoulders) and lower extremities (hip/legs). A review of Resident 45's Order Summary Report (Physician's orders) indicated an order dated 12/13/2024 to monitor the resident's vital signs every shift for 72 hours (every 8-hour shift for three days to establish a baseline [normal way of being]). A review of the Nurses Progress Notes dated 12/13/2024 at 8:49 p.m., documented by RN 1, indicated Resident 45 was alert and oriented, her respirations were even and unlabored (easy, effortless breathing, without any signs of difficulty or struggle), her blood pressure was 146/88 millimeters of mercury ([mmHg] unit of measure. Reference range 120/80 mmHg), heart rate of 80 beats per minute (reference range 60 to 100), respiratory rate of 17 breath per minute (reference range 12 to 20 breaths per minute), and 94 % oxygen saturation on 3.0 ([L]unit of measure) per minute (min) L/M through a nasal cannula ([NC] device that delivers oxygen through thin tubes placed into nostrils). A review of the Nurses Progress Notes, dated 12/14/2024 at 7:25 a.m., completed by LVN 1, indicated that on 12/14/2024 around 2:20 a.m., Resident 45 was resting and was responsive to verbal (sounds or words produced by a speaker to get attention) stimulus (anything that can cause a physical or behavioral change) with no complications. The Nurses Progress Notes indicated at 4:25 a.m., Resident 45 was unresponsive even after a Sternal Rub (painful stimulus with the knuckles at the center of the chest) to the center of the chest, CPR was initiated, 911 was called, and the doctor was notified. The Nurses Progress Notes indicated at 4:41a.m., Paramedics arrived at the facility and took over Resident 45's CPR. The Nurses Progress Notes indicated at 5:07 a.m., Paramedics pronounced Resident 45 deceased. A review of the Paramedics report dated 12/14/2024 at 4:45 a.m., indicated when the Paramedics arrived to Resident 45's room, Resident 45 was lying on her back, pulseless (no heart beat), apneic (involuntarily and temporarily stops breathing), had an oxygen saturation of 79 % and a blood glucose (amount of sugar in blood) level of 45 (reference range 70 milligrams per deciliter ([mg/dL] unit of measure used to report concentration of a substance in a fluid) to 100mg/dL). The Paramedics report indicated the staff did not conduct CPR prior to the Paramedics arrival. The report indicated the Paramedics initiated CPR at 4:45a.m., and after 20 minutes of performing CPR with no change, Resident 45 was pronounced dead at 5:07 a.m. During an interview on 1/16/2025 at 2:32 p.m., RN 1 stated she was uncomfortable with the way Resident 45 presented on admission to the facility as she (Resident 45) seemed "out of it". RN 1 stated Resident 45 was too weak to sign the admission documents and the Physician Orders for Life-Sustaining Treatment ([POLST] residents' preferences for medical treatment) and said she would do it tomorrow on 12/14/2024. RN 1 stated when a resident is newly admitted or readmitted, the nurse that admits the resident completes a head-to-toe assessment, reviews the residents' medications and notifies the admitting physician for admission orders. RN 1 stated Resident 45 came to the facility with her LifeVest, but she was not wearing it. RN 1 stated the nurse, who gave report over the phone from the GACH, told her (RN 1) Resident 45 refused the LifeVest. RN 1 stated she relayed this information to LVN 1 to ensure LVN 1 monitored Resident 45 closely. RN 1 stated she should have informed the doctor that Resident 45 was not doing well upon admission. RN 1 stated the interventions to implement when a resident is found unresponsive and pulseless (no heartbeat) include the following: 1. Do an assessment. 2. Get the crash cart (trays and drawers on wheels that contains emergency medication and equipment for life threatening emergencies). 3. Put the back board under the resident. 4. Announce a Code Blue (an announcement that signifies a medical emergency where a patient is experiencing a life-threatening situation) through the overhead paging system. 5. Take vital signs. 6. Put a nonrebreather mask (oxygen mask that delivers high concentrations of oxygen) on the resident. 7. Initiate chest compressions immediately. RN 1 stated the chest compressions should continue until the paramedics arrive at the room and take over care. During an interview on 1/16/2025 at 3:55 p.m., LVN 1 stated he worked on 12/13/2024 during the night shift (11 p.m. to 7 a.m.). LVN 1 stated when he came to work, he made rounds and visual checks on all residents to see if the residents were breathing. LVN 1 stated he received report from RN 1, read Resident 45's H&P, and continued to provide care to other residents after he observed Resident 45 "was doing okay" at 2:20 a.m., on 12/14/2024. LVN 1 stated he normally makes rounds every one to two hours. LVN 1 stated facility residents' vital signs are usually taken at the beginning of the shift. LVN 1 stated around 4:25 a.m., he noticed Resident 45 was not communicating and unresponsive. LVN 1 stated Resident 45 was lying in bed and was warm to the touch. LVN 1 stated assessing a resident included to check vital signs and to document in the progress notes. LVN 1 stated vital signs are taken to identify the actual state of the resident since he would not know what is going on with the resident otherwise. During an interview on 1/17/2025, at 9:15 a.m., CNA 1, stated on 12/13/2024 at 11:10 p.m., she notified LVN 1 that Resident 45 was "gasping for air and did not look well." CNA 1 stated she went to Resident 45's room with LVN 1. CNA 1 stated she did not witness LVN 1 assessing the resident or taking Resident 45's vital signs. CNA 1 stated LVN 1 told her he would go and look in Resident 45's chart. CNA 1 stated she went to check on Resident 45 again between 4:00 a.m. and 4:05 a.m., and she was still breathing. CNA 1 stated she went back to Resident 45's room around 4:26 a.m., after she heard LVN 1 in Resident 45's room calling Resident 45's name out loud four times. CNA 1 stated LVN 1 told her that Resident 45 was unresponsive, and they did not need to do any lifesaving measures. CNA 1 stated LVN 1 told her, "We do not need to check Resident 45's vitals." CNA 1 stated she still went to get the vital signs machine and asked CNA 2, who was in the hallway, to assist with Resident 45. CNA 1 stated when CNA 2 and her went back into Resident 45's room with the vitals machine, LVN 1 instructed CNA 2 and her (CNA 1) to initiate CPR. CNA 1 stated when they started CPR Resident 45 was