Health inspection·March 13, 2026

42 CFR § 483.24(a)(3) Cardio-Pulmonary Resuscitation (CPR) 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 § 483.35 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 §483.70(e). (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. 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. 72517. Staff Development. (b)In addition to (a) above, all licensed nurses shall have training in cardiopulmonary resuscitation. On 1/26/2026, the California Department of Public Health (CDPH) conducted an unannounced recertification survey at the facility. During the investigation CDPH determined Resident 93 who was a full-code (the medical team will initiate every possible measure to restart the heart and breathing. This includes chest compressions, rescue breaths, emergency medications and mechanical ventilation), was found unresponsive and facility staff did not start Cardiopulmonary Resuscitation ([CPR] an emergency lifesaving procedure to restore breathing and circulation, performed when the heart stops beating) immediately. The facility failed to: 1. Initiate CPR to Resident 93, who had Full Code status, when Resident 93 was found unresponsive on 12/30/2025 at 5:30 a.m. in accordance with the facility’s policy and procedures (P&P) titled “Cardiopulmonary Resuscitation”, which required the facility to provide CPR, to any resident requiring such care prior to the arrival of emergency medical personnel, in the absence of an advance directive (record of residents’ wishes for life saving measures if they are unable to make the decision) or a do not resuscitate ([DNR] a legally binding medical order signed by a doctor, often in consultation with a resident or their representative instructing healthcare providers not to perform CPR if the resident’s breathing or heartbeat stops) order. 2. Page or “yell loudly for Code Blue” (an emergency alert signaling that a person was experiencing a life-threatening situation, typically cardiac (heart) or respiratory arrest, requiring immediate resuscitation). on 12/30/2025 at 5:300 a.m., when Certified Nurse Assistant (CNA) 1 observed Resident 93 unresponsive (not reacting to touch, sound or smell), not breathing, and without a pulse (heartbeat), per facility’s policy titled “Cardiopulmonary Resuscitation” 3. Call 911 on 12/30/2025 at 5:30 a.m. immediately after Resident 93 was observed unresponsive. According to the Emergency Medical Technician Run Sheet, the incident was called in to their dispatch center at 6:05 a.m. 4. Ensure CNA 1, Licensed Vocational Nurse (LVN) 1 and LVN 2 initiated CPR immediately, without a 30-minute delay, and as soon as Resident 93 was observed unresponsive and without a pulse. As a result, Resident 93 was not provided timely CPR on 12/30/2025. This deficient practice placed 40 current residents, who had a full code status, at risk of not receiving life saving measures immediately and increased the residents’ chances of being successfully revived.  Resident 93 was an 80-year-old male, admitted to the facility on 5/18/2021 with diagnoses including end stage renal disease ([ESRD], irreversible kidney failure), anemia (a condition where the body does not have enough healthy red blood cells), diabetes mellitus ([DM], a disorder characterized by difficulty in blood sugar control and poor wound healing) dependent on dialysis, and dementia (a progressive state of decline in mental abilities). A review of Resident 93’s history and physical (H&P) dated 9/14/2025, indicated Resident 93 did not have the capacity to understand and make decisions. A review of Resident 93’s Minimum Data Set ([MDS], a resident assessment tool) dated 12/18/2025, indicated Resident 93 had severe cognitive (thinking process) impairment. Resident 93 was dependent (helper does all the effort while the resident does none to complete the task) on staff for activities of daily living (ADL) such as hygiene, getting dressed and transfers to the shower. A review of Resident 93’s physician order for life sustaining treatment dated 9/15/2025 ([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) indicated Resident 93 was a full code including resuscitation and CPR. A review of Resident 93’s Nurses Progress Notes dated 12/30/2025, at 7:03 a.m., indicated on 12/30/2025 at 5:30 a.m., CNA 1 found Resident 93 cold to the touch and unresponsive. CNA 1 left Resident 93’s room and went to find and ask LVN 1 to assess Resident 93. LVN 1 found Resident 93 with no heartbeat upon auscultation (listening to a heartbeat using a stethoscope [device used to detect and listen to heartbeat]). Resident 93 had no detectable vital signs (measurements of the body’s basic function, heartbeat, respiration rate [breathing], and blood pressure that indicate the state of a patient's essential body functions), no rise and fall of chest (not breathing). The Nursing Progress Notes indicated CNA 1 last saw Resident 93 coughing one hour prior to finding the resident unresponsive. A review of the Emergency Medical Technician (EMT’s) run sheet (official document completed by the EMT), dated 12/30/2025, indicated the incident was called in at 6:05 am, and EMT arrived at the facility at 6:10 a.m. During a telephone interview on 1/28/2026 at 5:51 p.m., LVN 1 stated on 12/30/2025, at approximately 5:00 a.m., CNA 1 notified her (LVN 1) that Resident 93 was not responding, and CNA 1 could not wake the resident up. LVN 1 stated she got her stethoscope and asked LVN 2 to come with her to check on Resident 93 in his room. She (LVN 1) checked Resident 93’s vital signs and the machine could not detect any vital signs. She (LVN 1) checked Resident 93’s carotid pulse (the beating of blood flow in the vein on the side of the neck that supplies oxygenated blood to the brain) and there was no pulse. Resident 93 was a full code, and she (LVN 1) initiated CPR on Resident 93, until the emergency medical services arrived. The EMT did not perform CPR, and pronounced Resident 93 dead at 6:15 a.m. During an interview on 1/29/2026 at 8:38 a.m., LVN 2 stated on 12/30/2025 at approximately 5:15 a.m., LVN 1 informed her that she (LVN 1) could not detect any vital signs on Resident 93 and asked her (LVN 2) to verify the lack of vital signs on Resident 93. LVN 1 went to check Resident 93’s chart for the resident’s code status and call the emergency services. LVN 2 checked Resident 93’s vital signs twice, and the machine could not detect a reading. LVN 1 was back in the room and started CPR around 5:30 a.m. LVN 1 asked LVN 2 to go to the front door to wait for the EMT’s arrival. LVN 2 stated if staff knew the resident’s code status, they could have started CPR as soon as Resident 93 was observed unresponsive and without a heartbeat. LVN 2 stated there was a delay in initiating CPR on Resident 93 when he was found unresponsive. During an interview on 1/29/2026 at 11:28 a.m., the Director of Staff Development (DSD) stated LVN 1, LVN 2 and CNA 1 should have performed CPR on Resident 93, right away when Resident 93 was pulseless and not breathing (unresponsive). Staff starting CPR right away would have a higher chance of saving Residents 93’s life. The facility’s practice was for licensed staff (general) to check a resident’s (general) code status in the electronic medical record, and initiate CPR, until emergency medical services personnel take over. During a concurrent interview and record review on 1/29/2026 at 3:25 p.m., with the Director of Nursing (DON), the Nurses Progress Note dated 12/30/2025 was reviewed. The DON stated the Nurses’ Progress Note did not indicate the staff members started CPR immediately on Resident 93 when three different staff members, CNA 1, LVN 1 and LVN 2 found Resident 93 unresponsive. When CNA 1 found Resident 93 unresponsive CNA 1, LVN 1 and LVN 2 should have initiated CPR. A review of the American Heart Association 10/22/2025 CPR and Emergency Cardiovascular Care (ECC) Guidelines (https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-basic-life-support), the guidelines indicated after identifying an individual that was not responsive and not breathing, the rescuer should activate the emergency response system first, then immediately begin CPR, beginning with chest compressions at a rate of 100 to 120 a minute and delivering 2 breaths in between compressions. The guidelines indicated immediate chest compression was critical to improving the individual’s outcomes by providing high-quality CPR. A review of the American Red Cross Training Services Program article (https://www.redcross.org/take-a-class/cpr/performing-cpr/what-is-cpr), the article indicated CPR increased the likelihood of surviving cardiac arrest, when the heart stopped beating and/or fails to circulate (to move in a circle) blood to the brain and other vital organs. CPR can double or triple the chance of survival by giving continuous chest compressions. A review of the facility’s P&P titled Cardiopulmonary Resuscitation, revised 12/2023, indicated, the facility will provide CPR, to any resident requiring such care prior to the arrival of the emergency medical personnel, in the absence of an advance directive or a DNR order. The P&P indicated Staff must: 1. Check for responsiveness, quality of breathing and pulse simultaneously. 2. If unresponsive, not breathing and no pulse activate the Emergency Medical System, Page or yell loudly for “Code Blue” to the area. Call 911. 3. Start CPR per American Heart Association guidelines for any resident in cardiac or respiratory arrest for residents who have requested CPR in their Advance Directive. The facility failed to: 1. Initiate CPR to Resident 93, who had Full Code status, when Resident 93 was found unresponsive on 12/30/2025 at 5:30 a.m. in accordance with the facility’s P&P titled “Cardiopulmonary Resuscitation”, which required the facility to provide CPR, to any resident requiring such care prior to the arrival of emergency medical personnel, in the absence of an advance directive (record of residents’ wishes for life saving measures if they are unable to make the decision) or a DNR order. 2. Page or “yell loudly for Code Blue” on 12/30/2025 at 5:300 a.m., when CNA 1 observed Resident 93 unresponsive, not breathing, and without a pulse, per facility’s policy titled “Cardiopulmonary Resuscitation” 3. Call 911 on 12/30/2025 at 5:30 a.m. immediately after Resident 93 was observed unresponsive. According to the Emergency Medical Technician Run Sheet, the incident was called in to their dispatch center at 6:05 a.m. 4. Ensure CNA 1, Licensed Vocational Nurse (LVN) 1 and LVN 2 initiated CPR immediately, without a 30-minute delay, and as soon as Resident 93 was observed unresponsive and without a pulse. As a result, Resident 93 was not provided timely CPR on 12/30/2025. This deficient practice placed 40 current residents, who had a full code status, at risk of not receiving life saving measures immediately and increased the residents’ chances of being successfully revived. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result for the 40 residents in the facility that were full code.