Health inspection·April 16, 2026

§483.25(d)(1)(2) Accidents The facility must ensure that (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. Code of Federal Regulations, Title 42, Section 483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be- (i)Developed within 7 days after completion of the comprehensive assessment. (ii)Prepared by an interdisciplinary team, that includes but is not limited to- (A)The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. 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: (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. §72523(a) 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 3/3/2026, the California Department of Public health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident (FRI) indicating an unusual occurrence when Resident 1 experienced an acute change in condition of decreased oxygen saturation and altered responsiveness. The facility failed to: 1. Follow its policy and procedure (P&P) titled "Safety and Supervision of Residents," which indicated proper resident supervision was a key part of maintaining safety, when a visitor (Family Member [FM] 2), known to pose a safety risk to Resident 1, was unsupervised in the facility. 2. Ensure FM 2, who had documented evidence of providing Resident 1 with illicit substances (drugs that are prohibited by law due to their potential for abuse, addiction, and harm) at the current and previous facility, was not allowed to visit Resident 1 without staff's supervision on 2/27/2026. 3. Develop and implement a comprehensive care plan to address Resident 1's psychoactive substance abuse as identified in the resident's diagnoses and FM 2 providing Resident 1 with illicit substances at the previous facility. These failures resulted in Resident 1 becoming unresponsive, with hypoxia (condition when the body does not get enough oxygen), bradypnea (abnormally slow breathing rate), and altered mental status (change in a residents' baseline consciousness). Resident 1 required emergency administration of Narcan (emergency treatment for known or suspected drug overdose) and transfer to the General Acute Care Hospital (GACH) for evaluation and treatment on 2/27/2026. Resident 1, a 67-year-old female admitted to the facility on 9/17/2025 and re-admitted to the facility on 12/10/2025. Resident 1's diagnoses included psychoactive substance abuse (the harmful or use of substances [alcohol, illicit drugs, prescription medications] that change how a person thinks, feels, or behaves), respiratory failure (when the lungs cannot adequately supply oxygen to the blood), chronic kidney disease (CKD- kidneys are permanently damaged and cannot properly filter waste and extra fluid from the blood), ventilator (a medical device to help support or replace breathing) and gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach). A review of Resident 1's previous facility Progress Note dated 10/15/2025 indicated Resident 1 was "briefly altered today (3rd episode in several days)," occurs only during FM 2's visits. The Progress Note indicated the nurse suspects possible outside substance exposure. A review of Resident 1's previous facility Progress Note dated 11/2/2025, indicated FM 2 provided Resident 1 suspected drugs. A review of Resident 1's previous facility Progress Note dated 11/3/2025, indicated, positive urine drug screen (UDS- laboratory test used to detect the presence of drugs in a person's urine) reflecting barbiturates (sleep inducing drug), and the suspected drugs provided by FM 2. A review of Resident 1's Interdisciplinary Team (IDT) Meeting Notes dated 11/7/2025, indicated the IDT addressed concerns from Resident 1's previous facility stay, that FM 2 had been placed on supervised visits at the previous facility due to suspected drugs provided to Resident 1 by FM 2. A review of Resident 1's Respiratory Therapy (RT- specialized healthcare field focused on treating and managing residents with breathing problem) Notes dated 1/30/2026, indicated FM 1 expressed concerns regarding FM 2 visiting Resident 1 and stated FM 1 did not trust FM 2. The RT Note indicated FM 1 believed FM 2 was giving Resident 1 "something" that could affect Resident 1's breathing. A review of Resident 1's RT Notes dated 2/5/2026, indicated after FM 2 left, Resident 1' s ventilator began alarming, Resident 1 was noted to have an altered level of consciousness (medical emergency representing any deviation from a normal, alert waking state) and was breathing at a rate of four breaths per minute ( normal breathing ranges from 12 to 20 breaths per minute). The RT Note indicated Resident 1 became more arousable after aggressive stimulation (forceful or intense approach to stimulation). A review of Resident 1's Physician Progress Note dated 2/26/2026, indicated there was a suspicion that Resident 1 may have been using drugs besides the medication prescribed by the physician to Resident 1 due to her altered mental status. A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 2/27/2026, indicated Resident 1 cognition was intact. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) with activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily). A review of Resident 1's Nurse's Note dated 2/27/2026, indicated Resident 1's ventilator was alarming and Resident 1 was noted to have altered responsiveness, bradypnea, hypoxia, and pinpoint pupils (black, circular opening in the center of the eye that remain very small, even in bright light). The Nurse's Note indicated Resident 1 received Narcan (a life-saving medication that rapidly reverses opioid [strong pain medicine] overdose). The Nurse's Note indicated Resident 1 responded to the Narcan when Resident 1 became responsive and stable. The Nurse's Note indicated FM 1 was overheard stating Resident 1 "may have taken something," and handed the ADM a clear box containing a powdery substance. The Nurse's Note indicated Resident 1's room belongings were gathered and a white powdery substance and straw wrapped with a napkin were found. A review of Resident 1's Paramedic Run Sheet dated 2/27/2026, indicated Resident 1's family admitted to giving Resident 1 "some sort of narcotic (drug used for pain relief and inducing sleep) substance causing patient to overdose." The Paramedic Run Sheet indicated Resident 1's family stated FM 2 and a "drug dealer" (individual involved in the illegal sale of illicit substance) visited Resident 1 at the facility before, and both (FM 2 and drug dealer) gave Resident 1 drugs. A review of Resident 1's GACH Emergency Department Provider Note dated 2/27/2026 at 5:11 p.m., indicated Resident 1 presented to the emergency department for drug overdose (excessive, dangerous amount of a substance is consumed). The Note indicated Resident 1 was visited by FM 1 when found unresponsive. The Note indicated facility staff were called and noted Resident 1 to be apneic (breathing stop) with pinpoint pupils. The Note indicated facility gave Resident 1 Narcan 4 milligram (mg-unit of measurement) intramuscular (IM-injection to the muscle) and Resident 1 woke up and was responsive. Resident 1 was visited by FM 2 or "drug dealer", likely given substances. Resident 1 did defecate (pass stool) herself and has been slightly combative. A review of Resident 1's GACH Psychiatric Consult Note dated 2/28/2026 at 1:09 p.m., indicated, on 2/27/2026 Resident 1 was found by FM 1 and facility staff to have pinpoint pupils. Facility staff gave Narcan 4 mg and Resident 1 became responsive. The Note indicated per FM 1, FM 2 and a "drug dealer" provides Resident 1 with drugs. The Psychiatric Consult Note indicated Resident 1 reported accidental overdose on medication. During an interview on 3/3/2026 at 8:15 a.m., the Administrator (ADM), stated FM 2 was restricted to supervised visits starting 2/26/2026 because he had previously interfered with Resident 1's care (unknown date). The ADM stated on one occasion, FM 2 arrived at the facility at 3:00 a.m. and was banging on the front door, which led the facility to limit his visiting hours and require supervision. On 02/27/2026, he (ADM) instructed FM 1, who was at Resident 1's bedside with FM 2, to supervise FM 2 due to FM 2's history of providing illicit substances to Resident 1. During an interview on 3/3/2026 at 11:10 a.m., FM 1 stated she had a feeling Resident 1 was on "something" because she (FM 1) knew the types of drugs Resident 1 used in the past and Resident 1 kept nodding off (unintentionally falling into a light sleep). FM 1 stated prior to Resident 1 being transferred to the GACH on 2/27/2026, Resident 1 handed her a box with a white powdered "substance" inside but did not indicate where she got it. FM 1 stated on 2/27/2026 the ADM asked her to monitor FM 2 during a bedside visitation. During an interview on 3/3/2026 at 11:25 a.m. FM 3 stated FM 2 was asked to leave the previous facility in October or November of 2025 because he was suspected of giving Resident 1 "something" that caused Resident 1 to exhibit unusual behavior. The previous facility conducted a urine test, on Resident 1 which was positive for "some drug" (unknown). FM 3 stated she did not know what specific drug the urine test detected. During an interview on 3/3/2026 at 12:31 p.m. Certified Nurse Assistant (CNA) 1, stated FM 2 was placed on supervised visits because he tried to bring unauthorized items (alcohol) into the facility. CNA 1 stated facility staff should be responsible for supervising FM 2's visits and no other family members, as family members could potentially be involved if inappropriate items (alcohol) were being brought in. During a concurrent interview on 3/3/2026 at 12:53 p.m., Licensed Vocational Nurse (LVN) 1, stated FM 2 was placed on supervised visits because he would bring drinks to Resident 1 even though Resident 1 was not allowed to eat or drink anything. LVN 1 stated on 1/14/2026 she observed a beer inside a clear bag that FM 2 had brought into the facility. FM 2's visits should have been supervised only by facility staff to ensure family members did not provide unauthorized items to Resident 1. During an interview on 3/4/2026 at 9:55 a.m. Respiratory Therapist (RT) 1, stated on 2/27/2026 at approximately 4:00 p.m., she responded to Resident 1's ventilator alarm and found Resident 1 difficult to arouse. RT 1 stated she suspected Resident 1 had consumed "something" (alcohol or drugs), and FM 1 told RT 1 Resident 1 had consumed "something." During an interview on 3/4/2026 at 1:00 p.m. the Director of Nursing (DON), stated facility staff, not FM 1, should have supervised FM 2 during his bedside visit on 2/27/2026 for the safety of Resident 1. The DON stated the incident on 2/27/2026 could have been avoided if all visitors had been supervised by facility staff, as FM 2 appeared suspicious, agitated, and restless at the time of the event (2/27/2026). The DON stated there was no care plan to address Resident 1's psychoactive substance abuse and FM 2 providing Resident 1 with illicit substances at the previous facility. A review of the facility's policy and procedure (P&P) titled, "Safety and Supervision of Residents," dated 7/2017, indicated, "Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify specific accident hazards or risks for individual residents. Resident supervision is a core component of the systems approach to safety." The facility failed to 1. Follow its P&P titled "Safety and Supervision of Residents," which indicated proper resident supervision was a key part of maintaining safety, when a visitor FM 2, known to pose a safety risk to Resident 1, was unsupervised in the facility. 2. Ensure FM 2, who had documented evidence of providing Resident 1 with illicit substances at the current and previous facility, was not allowed to visit Resident 1 without staff's supervision on 2/27/2026. 3. Develop and implement a comprehensive care plan to address Resident 1's psychoactive substance abuse as identified in the resident's diagnoses and FM 2 providing Resident 1 with illicit substances at the previous facility. These failures resulted in Resident 1 becoming unresponsive, with hypoxia, bradypnea, and altered mental status. Resident 1 required emergency administration of Narcan and transfer to the General Acute Care Hospital (GACH) for evaluation and treatment on 2/27/2026. These violations jointly, separately or in any combination, presented either imminent danger that death or serious harm would result, or a substantial probability of death or serious physical harm would result to Resident 1.