Health inspection·July 9, 2025

F678 §483.24(a)(3) Personnel provide basic life support, including CPR, to a patient requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident’s advance directives.

F695 §483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a Patient who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the Patients’ goals and preferences, and 483.65 of the subparts. On 5/19/2025, the California Department of Health (CDPH) made an unannounced visit to the facility to conduct an Annual Recertification Survey. Based on interviews and record review, the facility failed to provide immediate, effective and uninterrupted basic life support (BLS, a set of emergency procedures designed to save the lives of patients whose heart or lungs stop working) with cardiopulmonary resuscitation (CPR) on 3/17/2025 to Resident 1, who was found unresponsive and not breathing, in accordance with the standard of professional practice and facility's policy and procedure (P&P). The facility failed to: 1. Implement Resident 1's Physician Orders for Life Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner, or a physician assistant which specifies what a resident's lifesaving treatment wishes) as Full Code (a term indicating the resident preferred to receive all life-saving measures when the resident's heart stopped beating and/or the resident stopped breathing to keep them alive). 2. Ensure that facility staff, including Licensed Vocational Nurse (LVN) 8, LVN 9 and Registered Nurse (RN) 4 activated the facility's emergency response system for a “Code blue” (the facility's emergency response code system that signifies a resident medical emergency, specifically a cardiopulmonary arrest, requiring immediate resuscitation efforts) and implemented BLS sequence of events (airway, breathing, chest compressions), and contacted 911 emergency services (EMS) when Resident 1 was found unresponsive, not breathing, and with O2 sat (a measurement of oxygen in the blood with reference range 90-100%) fluctuating between 50% to 80 % on 3/17/25 between the hours of 7:45 PM to 8:11 PM in accordance with the facility's P&P on "CPR." 3. Ensure LVN 8, LVN 9 and RN 4 performed effective and continuous CPR to Resident 1 by performing chest compressions and rescue breaths at a ratio of 30:2, 30 chest compressions-to- 2 breaths or chest compressions at a rate of 100 to 120 per minute and to a depth of at least 2 inches (5 cm) until 911 EMS arrived and took over the CPR, in accordance with professional standard of practice specified by the American Heart Association guidance on 3/17/2025 when resident was found without pulse and not breathing. 4. Ensure RN 4 did not perform CPR by "rubbing" Resident 1's chest gently in a circular motion rather than providing chest compression in accordance with the American Heart Association’s guidance when resident was found without pulse and not breathing. 5. Ensure LVN 8, LVN 9, and RN 4 administer oxygen and titrate oxygen up to 4 liters (L) per minute for O2 sat of less than 90% (normal range 90-100%) every shift as ordered by the physician to Resident 1 who was at risk for respiratory distress (the body's struggle to breathe characterized by difficulty or labored breathing) and O2 sat was fluctuating between 50% to 80 % on 3/17/25. 6. Ensure LVN 8, LVN 9, and RN 4 assessed and monitored Resident 1 for signs and symptoms of acute respiratory failure (lungs failure to release enough oxygen into the blood) abnormal vital signs (the measurement of the blood pressure [BP-the measurement of the pressure or force of blood inside the blood vessels], heart rate [HR], O2 sat, respiratory rate [RR], body temperature) and document these in the resident's records, when Resident 1 was observed with low and fluctuating BP and O2 sats on 3/17/25 and provide immediate respiratory interventions as indicated in the resident's care plan at around 3:30 PM. 7. Ensure LVN 8 and RN 1 assessed, monitored, and documented in Resident 1's clinical record and informed the physician when Resident 1 was observed with systolic BP (pressure in the arteries when heart beats and pumps blood out) of 80’s millimeters of mercury (mm HG) and diastolic BP (pressure in the arteries when heart is resting between heart beats) 40s mm Hg (normal BP range systolic 120/diastolic 80 mm Hg) on 3/17/25 at around 3:30 PM and before LVN 8 went on meal break on 3/17/25 prior to 8 PM. As a result of these deficient practices, 911 EMS arrived at the facility on 3/17/2025 at 8:18 PM and found the resident "Dead prior to Arrival" of the EMS. The EMS Report indicated "DOA (Dead on Arrival)/Obvious Death" and "No care or support services required." The EMS Report further indicated Resident 1 was found by 911 EMS personnel on 3/17/2025 unresponsive, both eyes dilated (indicates brain injury) and absent breath sounds to both lungs, skin was clammy and showed signs of lividity (bluish-purple discoloration of skin that is noticeable within 1 to 2 hours after death). Resident 1’s was pronounced dead by the paramedics on 3/17/2025 at 8:23 PM. Resident 1's Certificate of Death (COD) indicated Resident 1’s died on 3/17/2025 with the immediate cause of death of cardiopulmonary arrest and with underlying cause of death due to COPD (chronic obstructive pulmonary disease-a progressive lung disease causing restricted airflow and difficulty breathing). A review of Resident 1's Admission Record (AR), indicated Resident 1 was an 71 years old female originally admitted to the facility on 2/4/2025 and readmitted on 3/12/2025 with diagnoses that included pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), acute respiratory failure with hypoxia (low oxygen blood level) and COPD with acute exacerbation (sudden worsening of a disease or an increase in its symptoms). A review of Resident 1's care plan dated 2/5/2025 indicated Resident 1 was receiving oxygen therapy due to Acute Respiratory failure and COPD exacerbation. The interventions indicated to provide oxygen to the resident as ordered by the physician, monitor O2 sat, and notify the physician of any significant change. A review of Resident 1‘s care plan initiated on 2/22/2025 and revised on 2/26/2025, indicated "Resident [1] was transferred to the GACH secondary to desaturation (low oxygen blood level) and altered mental status." To reduce risk of further complications, the care plan interventions included to apply oxygen as needed, assess the resident's level of consciousness, call 911 as needed, monitor O2 sats, monitor vital signs and initiate CPR if indicated. A review of Resident 1's care plan, dated 2/14/2025 and revised on 3/18/2025, indicated Resident 1 was at risk for respiratory distress related to COPD. To prevent unrecognized signs and/or symptoms of respiratory distress, reduce episodes and symptoms of respiratory distress, the facility will assess the resident for SOB (shortness of breath), irregular respiration (abnormal rate, rhythm and pattern when breathing), wheezing (high-pitched, whistling sound, often associated with narrowed airways) crackles (clicking, bubbling or rattling sound heard during inhalation that can be caused by fluid in the lungs), rhonchi (low-pitched, snoring or rattling sounds that often caused by mucus or other secretions obstructing the larger airways), coughing, weakness, activity intolerance, excessive secretions, and inform physician promptly of the respiratory distress symptoms. A review of Resident 1's POLST, dated 2/19/2025 indicated Resident 1 preferred to receive life sustaining measures and was Full Code. A review of Resident 1's General Acute Care Hospital (GACH) 1 admission record and History and Physical (H&P) dated 3/5/2025 indicated the resident presented to the emergency room from the facility on 3/5/2025 with respiratory distress, hypoxia at 88% O2 sat, low BP of 54/32 and body temperature 101 degrees Fahrenheit (°F), higher than the normal range 97 to 99°F. The GACH 1 H&P indicated Resident 1 was subsequently intubated (a medical procedure where a tube is inserted into a person's airway to help with breathing) for hypoxic respiratory failure and had lactic acidosis (a condition where too much lactic acid builds up in the body, causing the blood to become too acidic) as well as leukocytosis (a condition where there is a high number of white blood cells in the blood] and initial chest x-ray was unremarkable. The GACH 1 H&P indicated Resident 1 was started on broad-spectrum intravenous antibiotics (medications that are given directly into vein and are effective against a wide variety of pathogens) for presumed healthcare-associated pneumonia (HCAP, facility acquired pneumonia resident while the resident is at the facility). The GACH 1 H&P indicated Resident 1 was septic (a serious condition where the body's response to the infection is severe and causes organ damage) on admission. A review of GACH 1 Discharge Summary (undated), the GACH 1 Discharge Summary indicated Resident 1 was admitted to GACH 1 on 3/5/2025 and discharged from GACH 1 on 3/12/2025 with discharge primary diagnoses that included but not limited to acute hypoxic respiratory failure status post [s/p] intubation, suspected HCAP, severe sepsis with shock, acute COPD exacerbation, NSTEMI (non-ST-elevation myocardial infarction, a type of heart attack that usually happens when the heart’s need for oxygen can’t be met) and left pleural effusion (the buildup of excess fluid between the layers of tissue lining the lungs and chest cavity) s/p thoracentesis (a medical procedure where a needle is inserted into the space between the lungs and chest wall to remove fluid or air). The Discharge Summary indicated the pulmonary and cardiology physicians from GACH 1 cleared Resident 1 for discharge from GACH 1 back to the facility. A review of Resident 1’s physician orders indicated Resident 1 was readmitted back to the facility from GACH 1 on 3/12/2025 with the admission order that included "Attempt Resuscitation (CPR).” A review of Resident 1's Order Summary Report, dated 3/13/2025, the report indicated a physician order to administer Oxygen at 2L per minute via nasal cannula (a flexible tube used to deliver supplemental oxygen to a person through the nose), may titrate oxygen up to 4L per minute for O2 sat less than 90% every shift. A review of Resident 1's History and Physical (H&P), dated 3/16/2025 indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Change of Condition (COC)/Interact Assessment Form dated 3/17/2025 timed at 8:23 PM, indicated “During facility rounds at 8 PM, Resident 1's O2 sat level was 90% while receiving 2L per minute of oxygen with no respiratory distress and was titrated up to 5L per physician’s order and the oxygen level increased to 97%.” A review of the Fire Department (FD) Paramedics (911 EMS) Report, dated 3/17/2025, indicated the facility called 911 on 3/17/2025 at 8:11 PM for dispatch complaint of cardiac arrest. The Fire Department (FD) Paramedics Report indicated the paramedics arrived at the facility at 8:18 PM and reached Resident 1's room at 8:20 PM. The FD report indicated Resident 1 was DOA required no care or support services, no transport to the acute hospital needed. Further physical assessments performed by the paramedics showed Resident 1 was unresponsive, not breathing, no heart sounds, both eyes fixed and dilated, absent breath sounds to both lungs, skin was clammy and showed signs of lividity to both lower back and legs, and no evidence of obvious trauma. The FD Report indicated "Patient (Resident 1) determined to be dead (pronounced dead) at 8:23 PM. The FD report indicated Patient (Resident 1) was found by staff in bed unresponsive and was provided compressions only CPR provided by staff, no BVM (A bag-valve-mask, a handheld device used to provide high level of oxygen by manual ventilation [the flow of air into and out of the lung] to patients who are not breathing or not breathing adequately). The FD Paramedics Repost indicated “Per staff patient last seen alive 2-3 hours ago. No complaints prior, per staff patient bedridden." A review of Resident 1's Certificate of Death (COD) signed by the physician on 3/20/2025, indicated Resident 1 died on 3/17/2025 with the immediate cause of death of cardiopulmonary arrest (also known as sudden cardiac arrest, a sudden and unexpected loss of heart and breathing function) and with underlying cause of death due to COPD. During an interview on 5/21/2025 at 11:48 AM, LVN 8 stated she was assigned to Resident 1 on 3/17/2025. LVN 8 stated before she took her break between 7:30 to 8:00 PM, she observed Resident 1 was "stable," able to open eyes when called by name and had “shallow breathing and mouth breathing” with O2 sat fluctuating between 90 to 93% while receiving continuous oxygen at 2 liters via nasal cannula. LVN 8 started before she left for her break at 7:30 PM, she could not recall the color of Resident 1's skin, but the resident "appeared weak and tired." LVN 8 stated when she returned from her break at around 8:06 PM, she observed LVN 9 rushing to Resident 1's room and RN 4 at the Nursing Station calling 911 EMS preparing paperwork for Resident 1's possible transfer to GACH. LVN 8 stated she was informed by LVN 9 that there was an e