Health inspection·June 20, 2025

Code of Federal Regulations, Title 42, §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the resident representative(s) when there is— (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. Code of Federal Regulations, Title 42, Section 483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following — (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40 Code of Federal Regulations, Title 42, Section 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices. California Code of Regulations, Title 22 § 72311. Nursing Service – General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (E) Any untoward response or reaction by a patient to a medication or treatment. (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety, or security of the patient. (b) All attempts to notify licensed healthcare practitioners acting within the scope of his or her professional licensure shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending licensed healthcare practitioner acting within the scope of his or her professional licensure or his or her designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g). California Code of Regulations, Title 22 § 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 5/7/2025 at 9 am, the California Department of Public Health (CDPH) conducted an unannounced complaint visit at the facility to investigate allegations regarding quality of care and patient death. As a result of the investigation, the CDPH determined the facility failed to promptly notify the Resident 1’s Physician/Medical Doctor (MD) 1, when Resident 1 experienced a change of condition (COC) in accordance with the facilities policies and procedures (P&P) titled, "Change in a Resident's Condition or Status," "Resident Assessment and Examination," and Resident 1's Care Plan (CP) titled, "Constipation.” The facility failed to: 1. Ensure Registered Nurse (RN) 2 and RN 3 notified Resident 1’s Physician/Medical Doctor 1 (MD 1) of Resident 1's COC, on 5/6/2025 at 8 am, when Resident 1 experienced abdominal distension (bloating and swelling in the belly area), abdominal firmness (abdomen feeling hard or tight to the touch), and complained of (unspecified/unrated) abdominal pain. 2. Ensure RN 4 notified MD 1 on 5/6/2025 when Resident 1's constipation, abdominal distension, and abdominal firmness did not improve after Resident 1 received magnesium citrate (medication used to treat occasional constipation that usually results in a bowel movement [BM, ] within 30 minutes from the time of medication administration) on 5/6/2025 at 4:38 pm. 3. Ensure RN 4, and Licensed Vocational Nurse (LVN) 4 notified MD 1 on 5/6/2025 at 11:10 pm when Resident 1 was noted to have shortness of breath (SOB), required supplemental oxygen (O2), had abdominal distension with hypoactive bowel sounds (decreased/reduced sound made by the movement of the intestines/bowel as the intestines push food through, indicating slowed intestinal activity and the intestines are not working properly), and had a hard abdomen. 4. Ensure RN 4, and LVN 4 notified MD 1 on 5/7/2025 at 12:15 am, when Resident 1 complained of acute (fast/sudden) onset of 8 out of 10 pain (pain scale 0 to 10, 0 means no pain and 10 means the worst possible pain felt, 7 to 9 indicates severe pain) to Resident 1's abdomen. These violations resulted in LVN 4 finding Resident 1 unresponsive in Resident 1's bed on 5/7/2025 at 1:09 am. Resident 1 had coffee ground emesis (act of vomiting, appears dark brown, coffee-ground-like substance). Resident 1 was not breathing and did not have a pulse. LVN 4 asked Certified Nursing Assistant (CNA) 5 to called 9-1-1 and began cardio-pulmonary resuscitation (CPR). Resident 1 was pronounced dead by Emergency Medical Technician (EMT,) at the facility on 5/7/2025 at 1:42 am. A review of Resident 1’s Admission Record (AR), indicated the facility initially admitted Resident 1, a 64-year-old male, on 10/24/2022 and readmitted the resident on 1/25/2023 with diagnoses that included psychosis (refers to symptoms that happen when a person is disconnected from reality), muscle wasting, and atrophy (wasting away). A review of Resident 1's CP titled, "Constipation," initiated on 1/25/2023, reevaluated 4/2025, indicated Resident 1 was at risk for constipation due to medication use and decreased mobility. The CP indicated Resident 1 had a history of constipation. The CP's interventions indicated for Licensed Nurses (LNs including RNs and LVNs) to monitor medications that may cause constipation and to notify MD 1 if Resident 1 was unable to relieve constipation. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/7/2025, indicated Resident 1 had intact cognition. The MDS indicated Resident 1 required substantial/maximal assistance with toileting hygiene. A review of Resident 1's Progress Notes (PN), dated 5/6/2025, timed at 7:51 am, indicated on 5/6/2025, at 6:05 am, Resident 1 complained of not having a BM for two days. The PN indicated Resident 1 complained of abdominal pain (unrated), bloating, and feeling uncomfortable during the night shift (11 pm to 7 am, from 5/5/2025 to 5/6/2025). A review of Resident 1's Situation, Background, Assessment, and Recommendation (SBARs, structured communication framework that helps teams share information about the condition of a resident) form, dated 5/6/2025, timed at 8 am, indicated Resident 1 had a COC due to constipation or impaction (hardened stool that is stuck in the rectum and the anus due to long lasting constipation). The SBAR indicated Resident 1's last BM was on 5/4/2025. The SBAR indicated RN 3 notified MD 1 regarding Resident 1's constipation and received the recommendation to administer magnesium citrate. A review of Resident 1's Physician Telephone Orders (PO), dated 5/6/2025, timed at 10:20 am, indicated to administer magnesium citrate oral solution, give 296 milliliters (ml) by mouth, one time only, for constipation until 5/6/2025 at 11:59 pm. The PO indicated RN 2 signed the PO. A review of Resident 1's Medication Administration Record (MAR) dated 5/6/2025, timed at 4:38 pm, indicated LVN 3 administered 296 ml of magnesium citrate oral solution to Resident 1. A review of Resident 1's SBAR Communication Form, dated 5/7/2025, untimed, indicated Resident 1 had a COC. The SBAR indicated on 5/6/2025 at 10:55 pm, Resident 1 was in bed with Resident 1's eyes closed, and Resident 1 had stable vital signs (VS). The SBAR indicated at 11:10 pm (on 5/6/2025), Resident 1 was heard, by LVN 4, calling out for O2. The SBAR indicated Resident 1's O2 saturation (sats, percentage of O2 in the blood) was 97 percent while receiving 3 liters (L) per minute (LPM) of O2 via nasal cannula (NC). The SBAR indicated Resident 1's abdomen was distended. The SBAR indicated on 5/7/2025 between 12:15 am and 12:30 am, Resident 1 complained of 8 out of 10 pain (severe/intense pain) to Resident 1's abdomen. The SBAR indicated Resident 1 accepted Norco (medication used to treat moderate to severe pain) for abdominal pain. The SBAR indicated MD 1 was notified of Resident 1's expiration (death) on 5/7/2025, at 2 am. A review of Resident 1's untitled Emergency Medical Services (EMS) Report (EMSR), dated 5/7/2025, timed at 1:10 am, indicated the facility notified the EMS on 5/7/2025 at 1:10 am. The EMSR indicated the EMTs arrived at the facility on 5/7/2025 at 1:17 am and were with Resident 1 at 1:18 am. The EMSR indicated Resident 1 was found supine (face up), unresponsive, and pulseless. The EMSR indicated the EMTs administered O2, performed CPR, administered two rounds (doses) of one milligram (mg) of epinephrine (primary drug administered during CPR used to improve blood flow) for cardiac arrest via intraosseous (IO, insertion of a needle into the bone to deliver fluids, medications, and blood products), and a total of 1000 ml of Intravenous (IV, soft, flexible tube placed inside a vein used to administer fluids and medication directly into the bloodstream) fluids were administered to Resident 1. The EMSR indicated Resident 1 did not have a return of spontaneous circulation (ROSC, when the heart begins to beat on its own and blood circulates after CPR is performed) after 20 consecutive minutes [of CPR]. The EMSR indicated Resident 1's time of death was on 5/7/2025 at 1:42 am. A review of Resident 1's PN, dated 5/7/2025, time at 8:25 am, indicated LVN 4 documented (on 5/7/2025) between 1:06 am and 1:09 am, LVN 4 made rounds (visually checking residents) to assess the effectiveness of Resident 1's pain medication (Norco), and LVN 4 found Resident 1 unresponsive. The PN indicated the RN [RN 4] was notified and 9-1-1 was called. The PN indicated resuscitative efforts were immediately initiated while waiting for EMS. The PN indicated (on 5/7/2025), between 1:16 am and 1:42 am, the EMTs arrived, assumed care, and continued resuscitative efforts for Resident 1. The PN indicated the EMTs pronounced Resident 1's time of death on 5/7/2025, at 1:42 am. During a telephone interview on 5/7/2025 at 3:37 pm, LVN 4 stated on 5/6/2025 at 11:10 pm, Resident 1 asked for an increase in O2 because Resident 1, "felt like it was hard to breathe." LVN 4 stated LVN 4 increased Resident 1's O2 from 2 LPM to 3 and a half LPM via NC. LVN 4 stated, on 5/7/2025 at 12:15 am, Resident 1 complained of 8 out of 10 abdominal pain and Resident 1 had abdominal distension. LVN 4 stated Resident 1 received Norco for the abdominal pain. LVN 4 stated, 30 minutes after administering Norco, LVN 4 went to reassess Resident 1's pain, but Resident 1 was found unresponsive. LVN 4 stated Resident 1 had emesis coming out of Resident 1's nose and mouth and went down the sides of Resident 1's face. LVN 4 stated, the emesis was thick, watery, chunky, burgundy and black in color. LVN 4 stated there was, "A lot" of emesis mixed with blood. LVN 4 stated, "It smelled like blood." LVN 4 stated LVN 4 checked Resident 1's carotid and radial pulses, and both pulses were missing. LVN 4 stated Resident 1's eyes did not respond to light. LVN 4 stated LVN 4 immediately started CPR and called a code blue (activation of an alert during a medical emergency such as cardiac arrest). LVN 4 stated LVN 4 informed RN 4 when LVN 4 increased Resident 1's O2 (on 5/6/2025 at 11:10 pm) and when Resident 1 complained of 8/10 abdominal pain, on 7/5/2025 at 12:15 am, because these situations were COCs for Resident 1. LVN 4 stated when Resident 1 experienced a COC, LVN 4 was supposed to assess Resident 1 and notify MD 1. LVN 4 stated LVN 4 only informed RN 4 but did not notify MD 1 of Resident 1's COC. During an interview on 5/8/2025 at 7:50 am, CNA 5 stated on 5/6/2025 at 11 pm, Resident 1 complained Resident 1's whole stomach was hurting. CNA 5 stated CNA 5 touched Resident 1's stomach, and it was, "rock hard." CNA 5 stated CNA 5 asked LVN 3 and LVN 4 when Resident 1 was going to be sent to the hospital because Resident 1 was requesting to be sent to the hospital. CNA 5 stated LVN 4 responded by stating LVN 4 needed to speak to RN 4 to see what RN 4's opinion was. CNA 5 stated Resident 1 continued to complain of stomach pain throughout the night. CNA 5 stated CNA 5 attempted to make Resident 1 as comfortable as possible within CNA 5's scope of practice (activities and duties that a healthcare professional is permitted to undertake). CNA 5 stated CNA 5 also went to the nurses' station to talk to LVN 4 and RN 4. CNA 5 stated CNA 5 asked LVN 4 and RN 4 if they were going to send Resident 1 out [to the hospital] because Resident 1 did not look like Resident 1 was in good condition. CNA 5 stated LVN 4 told CNA 5 they needed to wait for RN 4's instruction. CNA 5 stated LVN 4 went to check on Resident 1 after administering the pain medication (Norco) and LVN 4 came out of Resident 1's room asking CNA 5 to call 9-1-1. CNA 5 stated CNA 5 called 9-1-1. CNA 5 stated after the EMTs pronounced Resident 1 dead, RN 4 asked CNA 5 to clean Resident 1. CNA 5 stated as soon as CNA 5 walked into Resident 1's room, CNA 5 observed Resident 1's skin was pale, and there was, "Black sludge [thick, soft, wet mixture of liquid and solid components]," all around Resident 1's head area, bed railing, and all over the floor. CNA 5 stated, "It [the emesis] looked like black bean chunks." CNA 5 stated, "It [the emesis] smelled rotten." CNA 5 stated CNA 5 finished cleaning Resident 1, but Resident 1 continued to bleed out of Resident 1's nose. During a telephone interview on 5/8/2025 at 9:29 am, LVN 4 stated on 5/6/2025 at 11:10 pm, when LVN 4 increased Resident 1's O2, LVN 4 told RN 4 that LVN 4 wanted to send Resident 1 to the hospital because Resident 1's, "Stomach" was distended. LVN 4 stated Resident 1's abdomen was, "hard." LVN 4 stated Resident 1's abdominal distension, "scared," LVN 4 because LVN 4 had cared for Resident 1 the last six months and LVN 4 had never seen Resident 1's stomach look like that (distended). LVN 4 stated, "I don't know why Resident 1 was not sent out [to the hospital] earlier for some kind of test." LVN 4 stated, even hours after receiving magnesium citrate, Resident 1's abdomen was still distended and hard. LVN 4 stated LVN 4 called RN 4 a second time on 5/7/2025 between 12:15 am and 12:30 am, to inform RN 4 Resident 1 had 8 out of 10 pain on Resident 1's abdomen. LVN 4 stated RN 4 and RN 5 suggested giving Norco first to Resident 1 for the severe abdominal pain. LVN 4 stated LVN 4 wanted to, "Use the chain of command [a formal transfer of authority and responsibility for a unit from one commanding to another]" and LVN 4 did not know if it was okay for LVN