Health inspection·January 5, 2026

Title 42 Code of Federal Regulations §483.10(e) Respect and Dignity The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). Title 42 Code of Federal Regulations §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- (2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. Title 22 California Code of Regulations §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 11/3/2025, the California Department of Public Health (CDPH) received a complaint alleging staff did not pay attention when Resident 2 was having a hard time breathing and as a result Resident 2 was transferred to the emergency room and was currently in the intensive care unit (ICU). On 11/18/2025, CDPH conducted an unannounced visit to the facility to investigate the complaint allegations. Upon investigation, CDPH determined, Resident 2 who had diagnoses of congestive heart failure (CHF), chronic obstructive pulmonary disease with acute exacerbation (COPD), chronic respiratory failure and dependence on supplemental oxygen (O2) received multiple psychotropic medications including antidepressants, antipsychotics sedative, anti-anxiety concurrently with narcotic-analgesic, all of which were central nervous system (CNS) depressants, experienced acute hypoxic hypercapnic respiratory failure (a life-threatening condition where the body has both too little O2 and too much carbon dioxide [a colorless odorless gas] in the blood) which led to cardiac arrest and transfer to a General Acute Care Hospital (GACH) where he was intubated, admitted to the ICU and died later that same day. The facility failed to: 1. Ensure licensed nurses recognized the increased effect of CNS depressants, Diazepam, Olanzapine, Buspirone Hydrochloride, in combination with Norco, causing Resident 2's oversedation and affecting Resident 2's ability to breathe. As a result, on 11/1/2025, after concurrent administration of Norco, Diazepam, Olanzapine and Buspirone Hydrochloride, Resident 1 became unresponsive, was without a pulse and stopped breathing. 2. Ensure licensed nurses monitored the black box warning for Buspirone HCL as ordered by the physician on 10/31/2025 to avoid concomitant (occurring at the same time) administration of benzodiazepines and narcotic-analgesic which could result in Resident 2's profound sedation, respiratory depression, coma, and death. 3. Ensure the Director of Staff Development (DSD) provided training to licensed vocational nurses, who administered medications in the facility, on black box warnings and use of narcotics-analgesics concurrently with psychotropic medications. 4. Ensure licensed nurses followed the facility's Policy and Procedure (P&P) titled, "Administering Medications" dated 1/2024, which indicated "If ...a medication has been identified as having potential adverse consequences (a negative or harmful result) for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medications will contact the prescriber, attending physician, or facility medical director to discuss concerns." These deficient practices resulted in Resident 2 experiencing a cardiac arrest on 11/1/2025, transfer to GACH 2 where Resident 2 was intubated and admitted to the ICU. A review of Resident 2's Admission Record (Face Sheet) indicated Resident 2, a 79-year-old male, was originally admitted to the facility on 8/14/2025, and readmitted on 10/31/2025 with diagnoses including CHF, COPD, chronic respiratory failure, and dependence on supplemental O2. A review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 8/21/2025, indicated Resident 2 had moderate cognitive impairment (the ability to think and reason). A review of Resident 2's Progress Note dated 10/19/2025, indicated Resident 2 had an unwitnessed fall at 10:30 p.m., 911 was called, and paramedics transported Resident 2 to GACH 1 at 11:05 p.m. A review of Resident 2's Paramedic Incident Report dated 10/19/2025 indicated Resident 2 had shortness of breath (SOB) for one hour and his lung sounds revealed rhonchi (a continuous, low-pitched, rattling lung sounds that often resemble snoring or gurgling caused by airflow obstruction). The Paramedic Incident Report indicated Resident 2 was transported to GACH 1 emergency department, where he was until 10/31/2025. A review of GACH 1's Plan and Goals for Admission dated 10/31/2025, indicated Physician (MD) 2, a pulmonary specialist (a physician specializing in the respiratory system, including the lungs, airways, and blood vessels), recommended to decrease Resident 2's sedative medications polypharmacy (the simultaneous use of multiple drugs to treat a single ailment or condition) as it was likely the culprit of Resident 2's recurrent respiratory failure. A review of Resident 2's Physician's Order dated 10/31/2025, indicated to readmit Resident 2 to the facility. A review of Resident 2's Physician's Order dated 10/31/2025 indicated the following orders: 1. Buspirone HCL oral tablet 10 mg a day for anxiety manifested by verbalizing persistent worry regarding his health and living circumstance. 2. Monitor the black box warning for Buspirone HCL that indicated concomitant (occurring at the same time) use of benzodiazepines and narcotics may result in profound sedation, respiratory depression, coma, and death. The black box warning indicated to reserve concomitant prescribing of these drugs for use in patients whom alternative treatment options are inadequate, to limit dosages and durations to the minimum required, and to follow patients for signs and symptoms (s/s) of respiratory depression and sedation every shift. 3. Diazepam 7.5 - milligram ([mg] a unit of dose measurement) three times a day for anxiety. 4. Norco 7.5 mg/325 mg every six hours as needed for moderate to severe pain. 5. Olanzapine 10 mg twice a day for a psychotic disorder (a serious mental illness characterized by a loss of contact with reality) related to a panic disorder (an anxiety disorder characterized by recurrent, unexpected panic attacks [sudden episodes of intense fear accompanied by physical symptoms like a pounding heart, sweating, and dizziness]). 6. Olanzapine 15 mg at bedtime for a psychotic disorder. 7. Administer O2 at three liters per minute (L/min) via a nasal at all times. A review of Resident 2's Medication Administration Audit Report (MAAR) dated 11/2025 indicated the following medications were administered to Resident 2 on 11/1/2025 by Licensed Vocational Nurse (LVN) 1: 1. Norco 7.5 mg-325 mg to Resident 2 at 8:30 a.m. 2. Buspirone HCL 10 mg to Resident 2 at 8:50 a.m. 3. Diazepam 7.5 mg to Resident 2 at 8:50 a.m. 4. Olanzapine 10 mg to Resident 2 at 8:50 a.m. A review of Resident 2's Progress Note dated 11/1/2025, indicated at 9:07 a.m., Certified Nursing Assistant (CNA) 1 made LVN 1 aware that Resident 2 was unresponsive. The Progress Note indicated upon entering Resident 2's room, LVN 1 noted Resident 2 was sitting up in bed, unresponsive to verbal commands, diaphoretic (profuse sweating), and still breathing. The Progress Note indicated a code blue (signifies a patient requires immediate resuscitation, most often due to cardiac or respiratory arrest) was called and before the crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations) arrived, Resident 2 stopped breathing. The Progress Note indicated Cardiopulmonary resuscitation (CPR) began at 9:09 a.m., 911 was called, and CPR continued until 9:20 a.m., until paramedics arrived and took over CPR. The Progress Note indicated Resident 2's pulse returned, and he was transferred to GACH 2 at 9:27 a.m. A review of Resident 2's Paramedic Incident Report dated 11/1/2025, indicated paramedics arrived at the facility at 9:13 a.m., and were informed that Resident 2 received Norco 7.5 mg/325 mg at 8:30 a.m. The Paramedic Incident Report indicated upon arrival Resident 2 had an altered level of conciseness (ALOC) with pinpoint pupils (abnormally constricted pupils that could be caused by opioid use, other medications, brain injuries, certain infections, or other medical conditions) and his Glascow Coma Scale ([GCS] a neurological assessment tool used to rate a person's level of consciousness based on their eye opening, verbal, and motor responses) was 3 (normal score being 15, and 3 being the lowest possible score indicating a coma). The Paramedic Incident Report indicated paramedics administered one dose of Narcan 2 mg via inhalation at 9:31 a.m., while enroute to the GACH but it did not yield a positive result and Resident 2 remained with an ALOC. The Paramedic Incident Report did not indicate the nursing staff informed the paramedics of the other medications Resident 2 had received at the facility. A review of the GACH's Emergency Department (ED) record dated 11/1/2025, and timed at 9:39 a.m., indicated upon arrival to the ED Resident 2 had agonal respirations (gasping, shallow, irregular breaths that occur when the brainstem is trying to compensate for a lack of O2) at six breaths per minute (normal respiration 12 to 20 breaths per minute for a healthy adult). The ED record indicated in the field, Resident 2 presented with pinpoint pupils and received Narcan with no change in level of consciousness. The ED record indicated Resident 2 was intubated shortly after arrival for airway protection. A review of the GACH's Discharge Summary dated 11/3/2025, indicated Resident 2 was brought to the ED and was intubated due to acute hypoxic hypercapnic respiratory failure. A review of the GACH 2's Discharge Summary dated 11/3/2025, indicated that on 11/3/2025, Resident 2 was admitted to the ICU where a bronchoscopy was conducted. The bronchoscopy showed Resident 2's left side mainstem bronchus was completely blocked by mucus. GACH 2's Discharge Summary indicated Resident 2 was extubated on 11/1/2025 and was transferred to the ward (a lower level of care due to a stable condition). GACH 2's Discharge Summary indicated on 11/3/2025, in the a.m. (time unknown) Resident 2 had hypoxic hypercapnic respiratory failure but improved with aggressive suctioning and was transferred to the telemetry unit. GACH 2's Discharge Summary indicated on 11/3/2025, at 5:16 p.m., Resident 2 became more somnolent (sleepy and drowsy) with labored breathing that was not improving with aggressive suctioning, and Resident 2 presented without a gag reflex (an involuntary, protective reflex triggered by touching the back of the throat, which causes the throat muscles to contract and the soft palate to lift) and hypercapnic respiratory failure. GACH 2's Discharge Summary indicated comfort measures were pursued at 5:43 p.m., and Resident 2 was pronounced dead at 7:20 p.m. During an interview on 11/19/2025, at 9:17 a.m., LVN 1 stated she gave Resident 2 Norco 7.5 mg/325 mg at approximately 8:30 a.m., and at approximately 9 a.m., she gave him Diazepam, Buspirone HCL, Olanzapine. LVN 1 stated at that time Resident 2 was awake, alert, and oriented. At 9:05 a.m. to 9:10 a.m., CNA 1 stood outside Resident 2's doorway and reported to her that something was wrong with Resident 2. LVN 1 stated when she went into Resident 2's room, he was sitting up in bed and was observed with SOB. LVN 1 stated Resident 2 was unresponsive to verbal stimuli and was leaning forward trying to catch his breath. LVN 1 stated she called a code blue due to Resident 2's unresponsiveness, but he still had a pulse at that time. LVN 1 stated one minute later, after the code blue was called, Resident 2 was no longer breathing and had no pulse. She (LVN 1) flattened his bed, placed a board under him, and Registered Nurse (RN) 1 began compressions. Someone from the team (unknown) called 911 and CPR continued until paramedics arrived. Paramedics took over CPR and transferred Resident 2 to GACH 2. During an interview on 11/20/2025 at 1:08 p.m., LVN 1 stated she did not recall what Olanzapine was indicated for when she administered it to Resident 2 at 9 a.m., with Diazepam, Buspirone and Norco medications on 11/1/2025. LVN 1 stated the side effects of Norco and Diazepam could cause drowsiness or depression of respirations. LVN 1 stated she was not aware of the interactions between Diazepam, Norco, and Buspirone, but stated she followed the physician's orders. LVN 1 stated she was not familiar with the black box warning for Buspirone, and she monitors side effects, but does so toward the end of her shift. During an interview on 11/19/2025 at 9:36 a.m., the facility's Pharmacy Consultant (PC) stated the combination of Norco 7.5 mg/325 mg and Diazepam 7.5 mg that Resident 2 received, had a high risk for oversedation and respiratory failure due to CNS depression since the combination had a synergistic effect to it. Buspirone HCL, narcotics, and benzodiazepines, or all three combined, could contribute to CNS depression resulting in respiratory failure. The combination of Norco, Diazepam, and Olanzapine could also synergistically and consequently cause a drug overdose, presenting as altered mental status (AMS), comatose, unresponsiveness, labored breathing and/or low breaths per minute. The PC stated "ideally," when LVN 1 administered Norco to Resident 2, she should have conducted a follow up assessment thirty minutes to an hour later and prior to giving any other medications to determine whether it was safe to give other medications to Resident 2. Since Diazepam and Olanzapine were new medications prescribed to Resident 2, and not something they routinely gave to Resident 2 at the facility; there should have been extra precautions and monitoring taken. Resident 2's history and tolerance of medications prior to administering a combination like Diazepam and Norco was important, but as a pharmacist he would not recommend giving these medications concurrently due to the high risk of oversedation and CNS depression. The PC stated pinpoint pupils were a cholinergic (parasympathetic nervous system [part of the nervous system that controls involuntary body functions when at rest, such as digestion, heart rate, and breathing response which decreases the heart rate, increases pupil constriction, and increased digestion and urination]) response from narcotics, oversedation, labored breathing, and respiratory distress. Resident 2 had a history of COPD so if he had respiratory depression and was intubated, his recovery would be more difficult because he was elderly and did not have the strength. Staff should have reported to the paramedics that Resident 2 received benzodiazepines concurrently with narcotic-analgesic because flumazenil ([Romazicon] an intravenous medication that acts as a specific antidote) could have been administered to Resident 2 to act as a reverse agent. During an interview on 10/19/2025, at 10:38 a.m., Resident 2's physician stated he did not recall if he ordered Olanzapine or Diazepam for Resident 2, but any new psychiatric and/or psychotropic medications prescribed for Resident 2 was likely transcribed from GACH 1's discharge summary because 93% of the time he does not prescribe psychiatric medications. Resident 2 displayed a lot of anxiety and was bei