Health inspection·February 18, 2026

REGULATORY VIOLATIONS: 42 C.F.R. §483.25(d) 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. 42 C.F.R. §483.24 Quality of Life (a)(3) 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. California Code of Regulations, Title 22, § 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: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B)Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (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. (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. (c) Licensed nursing personnel shall ensure that patients are served the diets as ordered by the attending licensed healthcare practitioner acting within the scope of his or her professional licensure. Title 22 § 72339. Dietetic Service -Therapeutic Diets. Therapeutic diets shall be provided for each patient as prescribed and shall be planned, prepared and served with supervision and/or consultation from the dietitian. Persons responsible for therapeutic diets shall have sufficient knowledge of food values to make appropriate substitutions when necessary. Title 22 California Code of Regulations § 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 1/2/2026, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate intakes regarding Resident 1's death. As a result of the investigation, CDPH determined that the facility failed to ensure: -Resident 1's food consistency and texture (refers to the physical sensations of food in the mouth [like crunchy, smooth, chewy, or creamy]) brought from outside the facility was checked before being fed to Resident 1, and that Resident 1 was assisted, supervised, and monitored for choking when eating. -Family Member (FAM) 3 (Resident 4's family member/visitor ) did not share/distribute food (chocolate chip cookie/unidentified size) from outside the facility to Resident 1, Resident 4's roommate, who was at risk for aspiration (when something enters the airway or lungs by accident), had a diagnosis of dysphagia oropharyngeal phase (inability/difficulty swallowing food or drink, can also cause breathing difficulties, choking, and drooling), and was on a pureed (a pudding-like texture that is smooth, blended) oral gratification (providing pleasurable oral taste) diet on 12/31/2025 at approximately 1PM. -Staff asked FAM 3 to inform the nursing staff when FAM 3 brought food (unidentified) from outside the facility on 12/31/2025 as indicated in the facility's "Foods Brought by Family/Visitors" Policy and Procedure (P&P). -Develop and implement interventions to address Resident 1's pureed gratification diet (providing pleasurable oral taste) and Resident 1's diagnosis of dysphagia oropharyngeal phase. -Educate, FAM 3, residents (in general), residents' representatives (in general) on the importance of informing the facility nursing staff (in general) regarding food brought in for residents by families/visitors including not sharing/distributing foods to other residents without clearing it first with facility staff. -Licensed Vocational Nurse (LVN) 1, Certified Nursing Assistant (CNA) 1, and Restorative Assistant (RNA) 1 performed cardiopulmonary resuscitation (CPR, a life-saving procedure used when someone's heart or breathing has stopped) with no delays to Resident 1, who was found with no mobility (movement), no reaction, not responding, and lifeless, on 12/31/2025 at approximately 1:10 PM to 1:15PM. -LVN 1, CNA 1, and RNA 1 implemented the facility's P&P titled, "Emergency Procedure - Cardiopulmonary Resuscitation" dated 8/28/2025, when LVN 1, CNA 1, and RNA 1 failed to check Resident 1's pulse and breathing, failed to begin CPR when CNA 1, LVN 1, and RNA 1 found Resident 1 who was a full code (resident who chooses to be resuscitated [saved] if he or she stops breathing of if the heart stops beating or wishes to have full treatment in life-threatening situations to do CPR) with no mobility, not responding, and with no reaction in bed inside Resident 1's room on 12/31/2025, from approximately 1:10 PM to 1:15PM. -CNA 1, LVN 1, and RNA 1 had the competencies necessary to perform Basic Life Support (BLS, is the foundational level of emergency medical care focused on maintaining a resident's airway, breathing, and circulation until advanced care arrives, primarily through high-quality CPR, and clearing airway obstructions [like choking] for victims of cardiac arrest [loss of heart function] or respiratory distress [trouble breathing] measures). As a result, Resident 1 received food inconsistent with the ordered diet, choked, did not receive prompt CPR, and died on 12/31/2025, at 1:34 PM. On 12/31/2025, at approximately 1 PM, FAM 3 gave a chocolate chip cookie (unidentified size) to Resident 1 while Resident 1 was in bed. At approximately 1:05 PM to 1:10PM, FAM 3 saw Resident 1 shaking, choking, pale, and FAM 3 called for help. CNA 1 went inside Resident 1's room and saw Resident 1 in bed with no mobility, with no reaction, with his mouth a "little open," and saw food running down from Resident 1's mouth. RNA 1 went inside Resident 1's room and performed a Heimlich maneuver (a lifesaving first-aid technique used to remove an object [like food] stuck in a person's throat or windpipe) while Resident 1 was on his bed. LVN 1 went inside Resident 1's room and asked CNA 1 and RNA 1 to place Resident 1 on a foldable metal chair. Respiratory therapist (RT) 1 identified Resident 1 did not have a pulse and looked "lifeless\." RT 1 instructed CNA 1, RNA 1, and LVN 1 to place Resident 1 back to bed to perform CPR . The facility called 911 (phone number for emergency services) at 1:20PM, and the paramedics (a person trained to give emergency medical care) to people who are seriously ill) declared Resident 1 dead on 12/31/2025, at 1:34 PM at the facility. During a review of Resident 1's Admission Record, the facility admitted Resident 1, a 70-year-old-male on 9/10/2025, with diagnoses that included dysphagia, oropharyngeal phase, dementia (a progressive state of decline in mental abilities), encounter for attention to gastrostomy (care needed for gastrostomy tube [GT] a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube), pneumonitis (inflammation of the lungs) due to inhalation of food and vomit, and chronic obstructive pulmonary disease (COPD, a disease that damages the lungs in ways that make it hard to breathe). During a review of Resident 1's History and Physical (H&P) dated 9/10/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. The H&P indicated Resident 1 was hospitalized prior to the facility's admission due to Resident 1 ingesting Lysol (cleaning solution product). During a review of Resident 1's POLST dated 9/11/2025, the POLST indicated to attempt CPR. To provide full treatment to Resident 1 with the primary goal to prolong life by all medically effective means. During a review of Resident 1's Care Plan Report dated 9/15/2025, the Care Plan Report indicated Resident 1 was at risk for aspiration related to dysphagia. The Care Plan Report indicated no nursing interventions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 9/15/2025, the MDS indicated Resident 1 had severe cognitive (ability to think, read, learn, remember, reason, express thoughts, and make decisions) impairment. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) for eating, oral hygiene, lower body dressing, personal hygiene, putting on footwear, and taking off footwear. The MDS indicated Resident 1 was dependent on help for toileting hygiene, showering, and bathing himself. The MDS indicated Resident 1 had a feeding tube. During a review of Resident 1's Care Plan Report dated 9/19/2025, the Care Plan Report indicated the resident's POLST specified to attempt resuscitation and to provide full treatment to Resident 1 with the primary goal of prolonging life by all medically effective means. The Care Plan Report indicated an intervention to respect Resident 1 and his family's wishes. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated Resident 1 had a physician order dated 9/23/2025 to provide CPR and to attempt resuscitation (is an emergency, life-saving procedure designed to restore spontaneous breathing and heartbeat) according to Resident 1's POLST. During a review of Resident 1's Order Summary Report dated 10/30/2025, the Order Summary Report indicated for Resident 1 to receive enteral feeding (getting liquid nutrition directly into stomach via a tube) Jevity (nutritional formula) 1.5 (1.5 calories per milliliter [ml, unit of measurement]) at 65 ml/hr (hour) for 20 hours daily. During a review of Resident 1's Order Summary Report dated 12/22/2025, the Order Summary Report indicated Resident 1 was to receive a pureed texture regular diet for oral gratification. During a review of Resident 1's Progress Notes dated 12/31/2025, at 2:45 PM, the Progress Notes indicated that on 12/31/2025, at 1:15 PM, a code blue (alert for a life-threatening medical emergency) was called. Resident 1 was seated on a chair across from Resident 1's bed and RNA 1 was performing a Heimlich maneuver while licensed staff (LVN 1) and RT 1 suctioned Resident 1's secretions (mucus/fluids) from Resident 1's mouth. FAM3 gave a chocolate chip cookie to Resident 1 and to Resident 4. Resident 1 was pale and Resident 1 did not have a pulse. Resident 1 was transferred back to bed and staff-initiated CPR and called 911 at around 1:20 PM. The paramedics declared the time of Resident 1's death at 1:34 PM. During a review of Resident 1's Progress Notes dated 12/31/2025, at 8:30 PM, it was indicated that FAM 3 told the Social Services Designee (SSD) that she (FAM 3) gave a chocolate cookie (unidentified size) around 1PM to Resident 1 because Resident 1 asked for the cookie. The Progress Notes indicated the local police officers (unidentified) arrived at the facility before 2 PM and the coroner picked up Resident 1's body at around 5:30 PM. During an interview on 1/5/2026, at 12:54 PM, with CNA 1, CNA 1 stated that on 12/31/2025, at around 1:10 PM to 1:15 PM, she (CNA 1) was in the hallway when FAM 3 called for her attention saying "come in, come in" to Resident 1's room. She (CNA 1) entered Resident 1's room, Resident 1 was looking in front, was sitting straight up in bed, not moving, and with his mouth a little open. She (CNA 1) saw food running down from Resident 1's mouth. CNA 1 stated she told Resident 1 to "spit out, spit out." Resident 1 looked very scary; the resident's eyes were open and big. CNA 1 stated Resident 1 did not move, was not gasping, and was not trying to spit out. Resident 1 was pale and had no reaction when CNA 1 touched him. She (CNA 1) tried to bring out the food in Resident 1's mouth by using her finger to clean his mouth, but Resident did not blink, did not move, did not react, and did not push her (CNA 1's) hand. Resident 1 did not push back or cough when she (CNA 1) put her finger in Resident 1's mouth. Resident 1's lips were pale to bluish in color. CNA 1 stated FAM 3 stated she (FAM 3) gave Resident 1 a cookie. CNA 1 stated she (CNA 1) told FAM 3 to call for help. She (CNA 1) started to do the Heimlich maneuver because she (CNA 1) saw food in Resident's mouth. Resident 1 did not react or show any movement during or after the Heimlich maneuver. CNA 1 stated Resident 1 did not have any rise and fall of his chest. CNA 1 stated she (CNA 1) did the Heimlich two to three times on Resident 1. RNA 1 and LVN 1 came to Resident 1's room. RNA 1 helped her (CNA 1) transfer Resident 1 from the bed to a chair to perform the Heimlich maneuver. RNA 1 told her (CNA 1) to call a code blue. When she (CNA 1) left Resident 1's room Resident 1 was still not moving and not reacting to touch. During a telephone interview on 1/5/2026, at 1:10 PM, FAM 1 stated that on 12/31/2025 the facility called to inform FAM 1 that a visitor took cookies to Resident 1's roommate (Resident 4) and fed a cookie to Resident 1. FAM 1 stated Resident 1 had dementia and was forgetful and had poor safety awareness and required constant supervision. Resident 1 was admitted to the facility after being hospitalized for swallowing laundry detergent thinking it was milk. The facility did not hold any meeting with FAM 1 to discuss Resident 1's plan of care. She (FAM 1) would frequently express concerns to facility staff (unidentified) about Resident 1 eating or being fed when Resident 1 was not supposed to because Resident 1 had such poor memory and would put things in his mouth. There were no signs or anything in place to help Resident 1 remember not to eat or tell people not to feed him. She (FAM1) had asked the staff (unidentified) for signs to be put up (unidentified date). FAM 1 stated on 12/31/2025 (unidentified time) the facility called to inform FAM 1 that a visitor (FAM 3) took cookies for Resident 4 and fed a cookie to Resident 1. Resident 1 was very forgetful and would not remember that he (Resident 1) was not allowed to eat food. Resident 1 could not safely swallow solid foods and was supposed to be on a pureed diet. She (FAM 1) was not informed of the policy for outside food or what steps would be taken to prevent Resident 1 from being fed food from outside. FAM 1 stated outside food was not communicated in any plan of care. There were no meetings held to discuss the plan of care. She (FAM 1) would worry very much that Resident 1 would accidentally eat something or drink something that he (Resident 1) was not supposed to. During a concurrent interview and record review on 1/5/2026, at 2:08 PM, with the Director of Nursing (DON), Resident 1's Admission Record and Resident 1's Care Plan Reports (in general) were reviewed. The DON stated Resident 1 had a diagnosis of dysphagia on admission and Resident 1 was at risk for aspiration. The DON stated staff (in general) were informed of the residents (unidentified) who were on aspiration precautions (specialized safety measures, often termed dysphagia precautions or feeding precautions, designed to prevent food, fluids, saliva, or vomit from entering the airway and lungs, reducing the risk of choking) verbally at morning huddles (brief meetings). The DON stated each diagnosis needed a specific care plan (in general) to have interventions such as aspiration precautions, type of diet, monitor swallowing, and proper positioning. Resident 1's care plan