Health inspection·January 14, 2026

Amended §483.24(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. §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 11/25/2025, the California Department of Public Health (CDPH) received a complaint alleging a communication problem between the facility staff and a resident's (Resident 1) Family Member (FM)1, when facility staff contacted her twice to ask her permission to perform cardiopulmonary resuscitation (CPR) an emergency lifesaving procedure that is done when someone's breathing or heartbeat has stopped) on Resident 1. On 10/26/2025, CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. Upon investigation, the CDPH determined the facility did not obtain the 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) from Resident 1, who was capable of signing her own consent, instead they allowed FM 1 to sign Resident 1's POLST. The facility failed to: 1. Obtain the POLST from Resident 1, who was capable of signing her own consent instead of allowing FM 1, who was designated as Resident 1's emergency contact (a person designated by the resident to be notified first in the event of a medical or general emergency), and who only interpreted for Resident 1, to sign Resident 1's POLST, which indicated ([DNR] a medical order written by a doctor to instruct health care providers NOT to do CPR 2. Prevent confusion by not determining before an emergency situation occurred with Resident 1 what her code status (a physician ordered directive outlining whether or not they should receive full life-saving interventions like CPR if their heat or breathing stops) was, instead of inquiring with FM 2 who was at Resident 1's bedside and then phoning FM 1 to ask what they wanted to do. 3. Follow their Policy and Procedure (P/P), titled, "Physician Orders for Life Sustaining Treatment (POLST)" which indicated California law required a POLST form be followed by health care providers who will issue appropriate orders consistent with the patient's preference. These deficient practices resulted in the inability of the facility to determine Resident 1's code status during Resident 1's medical emergency and a delay in life sustaining procedures CPR. When the paramedics arrived to the facility, they performed CPR on Resident 1. Resident 1 expired at the facility. Resident 1, an 89-year-old female, was admitted to the facility on 11/1/2025 with a diagnosis including type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing), generalized muscle weakness and an anxiety disorder (a mental health condition where a person experiences constant worrying). A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 11/4/2025, indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding ability) was moderately impaired. A review of Resident 1's POLST dated 11/3/2025, signed by FM 1 on 11/3/2025, indicated DNR and to provide comfort-focused treatment (relieve pain and suffering with medication). During an interview on 11/26/2025 at 11:54 a.m., FM 1 stated sometime after 3 p.m., on 11/17/2025 she received a telephone call from a nurse (unknown), stating Resident 1 did not look good and she wanted to know if she (FM 1) wanted Resident 1 to have CPR. FM 1 stated she told the nurse that she (FM 1) was not Resident 1's Responsible Party (RP) and only translated for Resident 1. FM 1 stated she changed her mind and told the nurse on the telephone, "yes you can do CPR." During an interview on 12/1/2025 at 12:15 p.m., FM 2 stated he arrived at the facility at 1:30 p.m., to visit Resident 1. FM 2 stated Resident 1 was agitated, moving around and she told him she wanted to go to a General Acute Care Hospital (GACH). FM 2 stated he told a nurse (unknown) his mom did not feel well and did not look good. FM 2 stated a nurse (unknown) came to Resident 1's room, assessed Resident 1 and left the room. Later the nurse told him the paramedics (transportation) would arrive in 45 minutes. FM 2 stated around 3:45 p.m., Resident 1 looked worse, so he went to the door to call for assistance from a nurse. FM 2 stated Certified Nurse Assistant (CNA) 1, who was in the room with him and Resident 1, stated I think you should sit next to Resident 1 because she was not breathing. FM 2 stated he looked at Resident 1, she was pale, and her mouth was open. FM 2 stated LVN 1 arrived in the room and asked him if it was ok to give Resident 1 CPR. FM 2 stated he told LVN 1 you have to call FM 1 because he does not make the decisions. During an interview on 12/1/2025 at 12:30 p.m., LVN 1 stated he saw that Resident 1 did not look well, he checked Resident 1's pulse and it was weak. LVN 1 stated he checked Resident 1's POLST, which indicated DNR. LVN 1 stated, FM 2 was in the room with Resident 1, so he asked FM 2, "what do you want us to do?" LVN 1 stated FM 2 said call FM 1. LVN 1 stated he usually called the family to report a change of condition (COC) because the family might change their mind regarding resident's code status. LVN 1 acknowledged and stated what he did could cause confusion and go against Resident 1's right to have their wishes met, per the POLST. During an interview on 12/1/2025 at 1 p.m., Registered Nurse (RN) 1, stated, when a resident stops breathing, she (RN 1) always calls the family to let them know the resident's condition because sometimes the family changes their mind about the resident's code status. During an interview on 12/1/2025 at 3:10 p.m., LVN 2 stated CPR was not started on Resident 1 until after FM 1 was called. LVN 2 stated this was not a good practice because life saving measures could be delayed and it went against Resident 1's wishes. During an interview on 12/2/2025 at 1:57 p.m., the Director of Nursing (DON), stated calling the family during an emergency to see if they wanted to change the DNR status was not the correct practice. The DON stated calling FM 1 and doctors caused a delay in starting CPR. A review of the facility's P/P, titled "Resident's Rights" dated 2022, indicated the resident had the right to a dignified existence, and self-determination. The P/P indicated the resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident. A review of the facility's P/P titled, "Physician Orders for Life Sustaining Treatment (POLST)" dated 4/1/2017 indicated completing a POLST form is voluntary. California law requires that a POLST form be followed by health care providers and provides immunity to those who comply in good faith. In the hospital setting, a patient will be assessed by the physician, or a nurse practitioner (NP) or a physician assistant (PA) acting under the supervision of the physician, who will issue appropriate orders that are consistent with the patient's preference. The facility failed to: 1. Obtain the POLST from Resident 1, who was capable of signing her own consent instead of allowing FM 1, who was designated as Resident 1's emergency contact, and who only interpreted for Resident 1, to sign Resident 1's POLST, which indicated DNR. 2. Prevent confusion by not determining before an emergency situation occurred with Resident 1 what her code status was, instead of inquiring with FM 2 who was at Resident 1's bedside and then phoning FM 1 to ask what they wanted to do. 3. Follow their Policy and Procedure (P/P), titled, "Physician Orders for Life Sustaining Treatment (POLST)" which indicated California law required a POLST form be followed by health care providers who will issue appropriate orders consistent with the patient's preference. These deficient practices resulted in the inability of the facility to determine Resident 1's code status during Resident 1's medical emergency and a delay in life sustaining procedures CPR. When the paramedics arrived to the facility, they performed CPR on Resident 1. Resident 1 expired at the facility. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 1.