Health inspection·March 25, 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 omplications); 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. 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. 42 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. 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. (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. (E) Any untoward response or reaction by a patient to a medication or treatment. 22 CCR § 72313. Administration of Medications and Treatments (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. 22 CCR § 72301. Required Services (a) Skilled nursing facilities shall provide, but shall not be limited to, the following required services: physician, skilled nursing, dietary, pharmaceutical and an activity program. 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 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 2/5/2025, the California Department of Public Health (CDPH) conducted an unannounced standard annual recertification survey at the facility. During the recertification survey, CDPH determined the facility failed to immediately provide Resident 44, who had a Full Code status (resident wants all life saving measures in case of life-threatening emergencies), with cardiopulmonary resuscitation ([CPR]- an emergency procedure to restart a person's heart, chest compressions) to increase the resident’s chances of survival and reduce adverse health outcomes. The facility failed to: 1. Notify the facility’s staff of Resident 44’s change of condition by announcing a Code Blue (an announcement that signifies a medical emergency where a patient is experiencing a life-threatening situation) when facility staff observed at 8:30am on 2/6/2025 that Resident 44 was not breathing because her chest did not rise and fall and then progressed to Resident 44 having no palpable (detectable by touch) pulse (heartbeat) by 8:44am. 2. Identify promptly Resident 44’s care needs to receive CPR when Registered Nurse (RN) 2 could no longer detect a pulse manually. 3. Provide basic life support to Resident 44, such as CPR, immediately without neglect and loss of critical time when Resident 44 no longer had a palpable pulse. 4. Implement Resident 44's care plan entitled “Advance Directives” revised on 10/26/2022, which indicated to follow Resident 44’s advance directive entitled Life-Sustaining Treatment ([POLST]-resident’s preferences for medical treatment) dated 2/8/2024, and provide treatment as prescribed in the physician’s order dated 1/21/2025, all of which indicated to perform CPR. 5. Implement the facility's policies and procedures (P&P) titled "Emergency Procedure - Cardiopulmonary Resuscitation", revised February 2018, which indicated if an individual was found unresponsive and not breathing normally, a licensed staff, certified in CPR/BLS shall initiate CPR. As a result, the facility’s staff delayed providing life-saving resuscitation attempts, such as CPR, to Resident 44, when the resident had cardiopulmonary arrest (the heart suddenly stops beating potentially resulting in death) on 2/6/2025. On 2/6/2025, paramedics arrived at the facility and achieved Resident 44's return of spontaneous circulation ([ROSC] - when heartbeat and breathing return to normal) by performing CPR, and transported Resident 44 to a general acute care hospital (GACH) Emergency Department (ED) and the resident was admitted to the intensive care unit ([ICU] GACH Unit that cares for seriously ill patients that need constant observation). The failure of the facility to begin immediate resuscitative efforts led to interruption in R44’s blood and oxygen circulation, placing the resident at risk for irreversible brain damage or death. A review of Resident 44's Admission Record indicated Resident 44, a 77-year-old-female, was admitted to the facility on 2/18/2022 and readmitted on 1/21/2025, with diagnoses including Type II diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), sepsis (an overwhelming and life-threatening response to a severe infection, which can lead to tissue damage, organ failure, and death), and urinary tract infection (UTI- infection due to disease-causing bacteria in the urinary tract). A review of Resident 44's Nursing Admission Assessment, dated 1/21/2025, indicated Resident 44 had an admitting diagnosis of pneumonia (a lung infection that can make breathing difficult). The Nursing Admission Assessment indicated Resident 44 had completed antibiotics (medicines that treat bacterial infections by killing bacteria or stopping them from growing) at the GACH prior to admission to the facility. A review of Resident 44's History and Physical (H&P), dated 1/22/2025, indicated Resident 44 did not have the capacity to understand and make decisions. A review of Resident 44's Minimum Data Set ([MDS]- a resident assessment tool), dated 1/8/2025, indicated Resident 44 had severely impaired cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making. The MDS indicated Resident 44 had functional limitation in range of motion (the distance and direction a joint can move) of upper extremity (arm, including the shoulder, elbow, wrist, and hand) and lower extremity (leg, including the hip, thigh, knee, shin, ankle, and foot). The MDS indicated Resident 44 needed assistance from two or more helpers to transfer to and from a bed to a wheelchair. A review of Resident 44's Order Summary Report, as of 2/7/2025, indicated there was an order on 1/21/2025 to provide CPR. A review of Resident 44's POLST, dated 2/8/2024, indicated that the facility must attempt CPR if Resident 44 had no pulse and was not breathing. A review of Resident 44's care plan for Advance Directives, revised on 10/26/2022, indicated that CPR was to be performed, with interventions including respecting Resident 44's or Resident 44’s family's wishes regarding resuscitation efforts. A review of Resident 44's Change of Condition (COC)/Interact Assessment Form (situation, background, assessment, and recommendation [SBAR] a verbal or written communication tool that helps provide essential, concise information, usually during crucial situations), dated 2/4/2025 at 11p.m., indicated Resident 44's oxygen saturation (amount of oxygen in blood) level to 88 to 90 percent (%) on room air (RA) ( oxygen saturation range is 95%-100%). The COC indicated facility staff placed Resident 44 on oxygen at 2 liters (L)/ minute (min) via nasal canula (NC) and Resident 44's oxygen saturation went up to 94-95%. The COC indicated Resident 44 was placed on 72-hour monitoring, and her physician (MD) was notified on 2/4/2025 at 11:30 p.m. A review of Resident 44's COC dated 2/6/2025 and timed at 8:40 a.m., indicated, at 7:30 a.m., on 2/6/2025, Resident 44 was in her wheelchair. The COC indicated Resident 44's vital signs (VS) prior to the incident on 2/6/2025 at 7:30 a.m. were as follows: a. Blood Pressure 103/64 millimeters of mercury ([mmHg]- unit of measure. Reference range 90/60 mmHg - 120/80 mmHg). b. Heart rate (HR) 84 beats per minute ([bpm] reference range 60 to 100 bpm). c. Oxygen saturation 93% with oxygen 2L/min via NC. d. Temperature 97.9 degree (Reference range 96.8 degree to 98.6 degree). e. Respiration Rate 16 breaths per minute. (Reference range 12 to 20 /min). The COC indicated on 2/6/2024 at 8:40 a.m., Resident 44 was up in a wheelchair, diaphoretic (sweating heavily), with eyes closed and her VS included HR 40-42 bpm, oxygen saturation 88% with oxygen at 2L/min via NC. The COC indicated Resident 44 had a palpable pulse of 50 bpm and Resident 44 was transferred to bed. The COC indicated Resident 44's heart rate started to fluctuate from 40-42 bpm and her oxygen level with oxygen at 2L/min via NC dropped to 80%. The COC indicated staff observed Resident 44's chest did not rise and fall (indicating Resident 44 was not breathing), so staff grabbed the Ambu-bag (a handheld device that helps patients to breathe when they aren't breathing well or at all) and started providing breaths until the paramedics arrived at 8:45 a.m. and initiated CPR. The COC indicated RN 1 and RN 2 were aware that Resident 44 was Full Code before calling paramedics at 8:41 a.m. There was no supportive documentation that the facility’s staff started chest compressions. A review of the Paramedics Report dated 2/6/2025, indicated Resident 44 had cardiac arrest on 2/6/2025 at 8:30 a.m., (time of Resident 44’s cardiac arrest based on the information paramedics received from facility staff) witnessed by staff. The Paramedics Report indicated the emergency medical staff ([EMS] - Paramedics) arrived at the resident's room at 8:44 a.m. and found Resident 44 lying in bed pulseless, apneic (an involuntary pause in breathing), with fixed and dilated pupils (a person's pupils are wide open and do not respond to light, indicating a serious medical condition, often associated with brain damage or severe head injury). The Paramedics Report indicated facility staff noticed Resident 44 was breathing with increased effort, so they began “ambuing” (the act of using an Ambu-bag) the resident. The Paramedics Report indicated facility staff never initiated chest compressions, even though Resident 44 was observed to be in full cardiac arrest. The Paramedics Report indicated the paramedics immediately initiated CPR on Resident 44 and achieved Resident 44's ROSC. A review of Resident 44's Emergency Documentation-MD notes from the GACH, dated 2/6/2025, indicated EMS brought Resident 44 to the GACH's Emergency Department (ED) from the facility after EMS provided emergency services, including CPR, at the facility (where Resident 44 resided). The Emergency Documentation-MD notes indicated according to EMS, upon EMS's arrival, Resident 44 was pulseless. The Emergency Documentation-MD note indicated EMS initiated CPR, provided emergency services and Resident 44's ROSC was achieved. The Emergency Documentation-MD note indicated Resident 44's diagnoses at the ED included cardiopulmonary arrest. The note indicated Resident 44 was admitted to the ICU. During an interview on 2/6/2025 at 9:38 a.m., CNA 1 stated on 2/6/2025 at approximately 8:30 a.m., she entered Resident 44's room to assist Resident 44 with her breakfast and observed Resident 44 sitting in her wheelchair and sweating. CNA 1 stated she called CNA 2 to check on Resident 44. CNA 1 stated CNA 2 entered the room, looked at Resident 44, and told her (CNA 1) not to feed Resident 44 her breakfast. CNA 1 stated she stayed with Resident 44 while CNA 2 went to get help. During an interview on 2/6/2025 at 10:17 a.m., RN 2 stated on 2/6/2025 at approximately 8:35 a.m., when she entered Resident 44's room, she observed Resident 44 lying down in her bed. RN 2 stated Resident 44 appeared sweaty and pale. RN 2 stated she checked Resident 44's pulse manually and Resident 44 had a pulse. RN 2 stated the pulse oximeter (an electronic device that is placed on a finger that measures the level of oxygen carried in the blood) readings of Resident 44’s heartbeat fluctuated between 36 to 46 bpm, and Resident 44's oxygen saturation on oxygen at 2L/min NC, dropped from 88% to 70%. RN 2 stated she left Resident 44's room and returned with a crash cart (cart stocked with emergency medical equipment, supplies, and drugs for use by medical personnel especially during efforts to resuscitate a patient experiencing cardiac arrest). RN 2 stated she suctioned (to suck out or remove something, like thick liquids using a force created by a vacuum) Resident 44's mouth to remove secretions. RN 2 stated after suctioning Resident 44, she manually checked Resident 44's pulse, and it was 50 bpm. RN 2 stated, when Resident 44's pulse was no longer detectable manually, she relied on the pulse oximeter readings of Resident 44's pulse, which still indicated a pulse at 32 bpm. RN 2 stated she did not initiate CPR because the pulse oximeter indicated Resident 44 had a pulse, although she could not obtain Resident 44's pulse manually. During an interview on 02/07/2025 at 10:14 a.m., Treatment Nurse (TXN) 1 stated, she was aware Resident 44 was a Full Code. TXN 1 stated staff should have initiated chest compressions when Resident 44 stopped breathing and had no palpable pulse. During an interview on 02/07/2025 at 10:52 a.m., RN 2 stated she did not initiate chest compressions when she (RN 2) could no longer detect Resident 44's pulse from the resident's carotid artery (the main blood vessels that supply blood to the brain face, and neck). RN 2 stated the pulse oximeter still displayed a pulse reading. RN 2 stated, to her knowledge if the heart rate was not palpable manually, but the pulse oximeter showed numeric values of 30 bpm, 40 bpm, and 50 bpm, it indicated the resident had a regular heart rhythm. RN 2 stated she did not announce a Code Blue, because she believed Resident 44 still had a heartbeat based on the pulse oximeter reading. During an interview on 02/07/2025 at 12:15 p.m., the Director of Nursing (DON) stated if the COC involved a Resident's unresponsiveness, staff must assess the Resident's lung function and pulse immediately. The DON stated if the resident did not have a manually detectable pulse, staff must start chest compressions immediately, provide breathing support, and call a Code Blue for emergency intervention. The DON stated if a pulse oximeter indicated numbers like 30, 45 and 50 bpm and Resident 44 did not have a palpable pulse, it could be an indication that the resident was “not okay,” and it was important to provide timely CPR. During an interview on 2/7/2025 at 4:17 p.m., Resident 44's MD stated Resident 44 was a Full Code, and the staff should have provided CPR when Resident 44 experienced a cardiac arrest. A review of th