Health inspection·September 5, 2025

The following reflects the findings of the California Department of Public Health during the investigation of complaint number 2570157. Representing the Department, HFEN # 45524 A Class AA Citation was written. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations Free of Accident Hazards/Supervision/Devices §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. Title 22, California Code of Regulations: § 72311. Nursing Service - General (a)Nursing service shall include, but not be limited to, the following: (2) Implementing each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 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 7/24/2025, the California Department of Public Health (CDPH, the Department) made an unannounced visit to the facility to investigate a complaint allegation regarding resident's death. The facility failed to ensure Resident 1, who was at an increased risk of choking after experiencing a prior choking incident, was provided adequate support and monitoring to prevent injury or death from choking on ingested food. The facility failed to ensure: 1.The physician's order was followed to monitor choking signs and symptoms while feeding the resident. 2. Certified Nursing Assistant (CNA 1) did not feed Resident 1 while the resident was drowsy, when Resident 1 had a diagnosis of dysphagia (difficulty swallowing) oropharyngeal phase (second stage of swallowing when the food goes from the back of the mouth into the esophagus [tube that connects the throat to the stomach]). 3. Constant monitoring during feeding was provided for Resident 1 on 9/19/2023, who was at an increased risk of choking after having a choking incident a day prior (9/18/2023). 4. Facility's Policies and Procedures and industry best practices were followed regarding monitoring and assistance during meals. As a result of these failures, Resident 1, after suffering a choking incident at dinner on 9/18/2023, experienced a second choking incident while unsupervised during breakfast the next morning on 9/19/2023, which resulted in Resident 1 being found in his room by LVN (Licensed Vocational Nurse) 1 unresponsive (not reacting or moving at all) with no pulse (the number of times the heart beats) and not breathing with food inside her mouth. Resident 1 expired at the facility on 9/19/2023. A review of Resident 1's "Record of Admission" (undated), indicated Resident 1 was admitted to the facility on 6/27/2023 with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body), lack of coordination, muscle weakness (generalized), dysphagia oropharyngeal phase A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/7/2023, indicated Resident 1 had severe cognitive (ability to think, understand and make daily decisions) impairment. The same MDS further indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-person physical assist when eating. A review of Resident 1's "History and Physical" (H&P), dated 7/10/2023, indicated Resident 1 did not have the capacity to understand and make decisions. The H&P further indicated the resident had left side weakness due to a cerebrovascular accident (stroke), and dementia (a progressive state of decline in mental abilities). A review of Resident 1's care plan for high risk for choking due to dysphagia indicated Resident 1 required assistance during meals but she wants to initiate eating by herself (undated), and further indicated an intervention of monitoring for signs and symptoms of aspiration (the inhalation of food, liquid, or other material into the lungs, instead of the esophagus and stomach) such as coughing, trouble breathing, choking, wheezing, etc. and use of a Restorative Nurse Assistant (RNA, a specialized certified nursing assistant, CNA, who is trained to help patients regain or maintain their physical abilities and independence) if needed. A review of Speech Therapist (ST) notes titled, "Recertification & Updated Plan of Treatment, Dysphagia Therapy," certification period 8/6/2023 - 9/4/2023, indicated objective progress/short-term goals' "Patient will safely swallow mechanical soft and thin liquids, successive swallows using lingual sweeps/re-swallow, rate modification, bolus size modification, hard throat clear/re-swallow techniques/precautions with 80% of attempts and with 20% verbal cues in order to decrease s/s (signs and symptoms) of oral and/or pharyngeal dysphagia." The same ST notes indicated to place Resident 1 in an upright posture during meals and up to 30 minutes after meals. A review of Resident 1's physician's orders dated 8/25/2023 indicated an order for mechanical soft finely chopped diet (foods that are modified in texture to be easier to chew and swallow, i.e., ground, chopped or mashed) with thin liquids. A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers when there is a change of condition among the residents) progress note dated 9/18/2023, indicated the resident had an incident of choking at dinner time (at 5:30 pm), requiring the Heimlich maneuver (a first-aid procedure used to treat choking by dislodging a foreign object from a person's airway) to be performed in addition to a finger sweep (a first aid technique used to remove a visible foreign object from a choking victim's mouth or throat) of mouth and suction of oropharynx (middle part of the throat, behind the mouth, soft palate (the back muscular part of the roof of the mouth), the side and back walls of the throat, the tonsils, and the back one-third of the tongue), to remove the food and clear the airway. A review of Resident 1's physician's orders dated 9/18/2023 at 5:30 pm, indicated an order to have oral suction (procedure to remove mucus or saliva from a person's mouth when they are unable to clear it themselves through coughing or swallowing with a suction device) as needed and monitor every shift for signs and symptoms of choking. A review of Resident 1's Nursing Assistant Activities of Daily Living (ADL, fundamental self-care tasks that individuals perform independently to maintain their well-being and independence such as eating and dressing) flow sheet for September 2023 indicated the resident needed supervision (oversight, encouragement, cueing) with one-person physical assist for breakfast and lunch and was dependent (full staff performance) at dinner times. No reason was given for the discrepancy in the amount of help the resident needed during different mealtimes. Further review of the same ADL flow sheet indicated no entries for breakfast on 9/19/2023, lunch and dinner were strike through and indicated "expired 9/19/2023". A review of Resident 1's Nursing Notes dated 9/19/2023 at 8:30 am, indicated a CNA passed the breakfast tray at 7:20 am, and helped the resident get up in bed in sitting position... resident had no SOB (shortness of breath) or respiratory distress (difficulty breathing, often involving rapid, shallow breaths or gasping), no cough, no complaint of pain, no facial grimacing during passing the breakfast tray. When the charge nurse went to give the resident her morning medications around 7:35 am, the resident was found with a yellow face, lips were not blue or purple in color, closed eyes, unresponsive to verbal and tactile (touching) stimuli, with soft egg pudding spilled on her bib. Charge nurse stated he didn't hear any coughing sounds or sounds of choking this morning...resident is unresponsive, no pulse, no breathing noted... removed about one tablespoon of visible soft egg pudding from mouth and provided oral suctioning nothing came out... started oxygen at 15 liters per minute via non-rebreather mask (an oxygen delivery system used during emergencies to deliver a high concentration of oxygen) and called 911 (universal emergency number) ... paramedics called time of death at 7:59 am. A review of Resident 1's autopsy report signed 4/2/2024, indicated date of death 9/19/2023 and date of autopsy 9/21/2023, the report further indicated the cause of death as asphyxia (a condition where the body is deprived of oxygen, leading to potential loss of consciousness and even death) resulting from obstruction of airway passages by food product, and that the manner of death was accidental. During an interview with CNA 1 on 7/24/2025 at 12:33 pm, CNA 1 stated on that day (9/19/2023), she saw Resident 1 was sleeping, so she put the tray to the side of the bed and went to her other residents to feed them. She stated when she returned to Resident 1's room, she tried to wake Resident 1 up and Resident 1 opened her eyes. CNA 1 stated she gave her (Resident 1) a spoonful of the egg (pudding), and then she (Resident 1) shut her eyes again. CNA 1 further stated she tried to wake Resident 1 again and then she called the charge nurse because Resident 1 was not swallowing. CNA 1 stated she didn't know of the choking incident the day before, and that if she knew she would not have left Resident 1 alone to eat. CNA 1 stated that she was present. However, there was no documentation (Nurses Progress Note and CNA's Flowsheet) to support her report nor was there any witness that confirmed that CNA 1 was present in the room. During an interview with Licensed Vocational Nurse (LVN) 1 on 7/24/2025 at 12:47 pm, LVN 1 stated that at the beginning of the shift, huddle (a brief, structured meeting held by nurses and other healthcare professionals, usually at the start of a shift, to discuss patient care, safety concerns, and workload distribution) is completed between the oncoming and off-going shifts. After the huddle, LVN 1 then checks the communication notes (are the written or electronic records used by nurses and other healthcare professionals to document and share important information about a resident's condition, care, and progress) for events that may have occurred overnight and informs CNAs about safety instructions involving the residents they are assigned to, such as residents at high risk for falls and aspiration risks. LVN 1 stated that for residents who have a diagnosis of dysphagia or aspiration risk, nursing staff check the diet orders to ensure that they are receiving the appropriate diet and place a sign above their bed. If a resident has a history of choking, LVN 1 stated that the resident is monitored closely to ensure that they are swallowing ok because they are now at increased risk for choking and placed in a feeding program where the RNA assists or monitors them during meals. LVN 1 stated that the families of residents at risk of choking must be educated, and all food brought in is carefully screened to ensure that it is compliant with the ordered diet, otherwise notify the supervisor and schedule an Interdisciplinary Team (IDT - collaborative meeting where various healthcare professionals discuss and coordinate a resident's care plan) meeting. During a follow up interview with LVN 1 on 7/24/2025 at 2:52 pm, LVN 1 stated that Resident 1, was not on the feeding program, even though she was an aspiration risk, but the facility staff monitored her because she slept most of the time and did not like to participate in activities. LVN 1 stated that on 9/19/2023 while reviewing the communication notes, they learned that Resident 1 had a choking incident which required staff to perform a Heimlich maneuver on her. LVN 1 finished reviewing the notes and started looking for CNA 1 (who was assigned to Resident 1) to inform her about the incident and to be extra cautious. LVN 1 stated that when he walked in Resident 1's room, Resident 1 was noted to be in bed and sitting upright and appeared to be yellowing. LVN 1 stated that Resident 1 was not responsive and was not breathing so he went to look for his supervisor to assist. LVN 1 stated that many staff came to the room to assist with Resident 1 and that one of the staff (does not recall whom) swept (a first aid technique used to clear an obstructed airway in an unconscious person by using a finger to remove a visible object from the mouth or throat) her mouth. LVN 1 stated that cardiopulmonary resuscitation (CPR, a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered cardiac arrest) was not performed because Resident 1 was a Do Not Resuscitate (DNR, order is a medical order instructing healthcare professionals not to perform CPR if a person's heart stops or they stop breathing). During a concurrent telephone interview and record review of Resident 1's nursing notes with Registered Nurse (RN) 1 on 7/24/2025 at 3:57 pm, RN 1 stated that she recalled a staff member informing her that Resident 1 was unresponsive, so she rushed to the room and found that Resident 1 was unresponsive and not breathing. The breakfast tray was in the room at the bedside of Resident 1. RN 1 stated that when she checked Resident 1's mouth, she (RN 1) found about two tablespoons of food residual which appeared to be a yellow egg pudding. RN 1 confirmed that leaving food in a resident's mouth or not supervising them could result in a resident choking. RN 1 stated that when a resident chokes, that food blocks their airway depriving them of oxygen and may result in death. RN 1 confirmed that Resident 1 had an order for aspiration monitoring which must be completed at every meal or anytime anything is placed in the resident's mouth. During the same telephone interview RN 1 stated that she did not personally see the resident eat but found out from the CNA that she (CNA 1) had taken the tray to Resident 1 and fed Resident 1 a little because she appeared (Resident 1) to refuse the food. RN 1 stated she does not recall if the resident was an aspiration risk and was not aware that the resident had a choking incident the day before. RN 1 further stated staff need to make sure that they (facility staff) do not leave a resident with food in their mouth, the resident could be at risk for aspiration which may result in a blocked airway and result in death. During an interview with the ST on 7/24/2025 at 4:58 pm, ST stated that dysphagia oral pharyngeal phase required a lot of queueing and cannot clear the mouth of residual. She stated that training included reminding the residents to sweep their mouth but if they are not at that point, then supervision is required. During a concurrent interview and record review on 7/25/2025 at 11:23 am with DON (Director of Nursing), Resident 1's progress notes, physicians orders and care plans were reviewed. The DON verified there was no documentation in the resident's records indicating the CNA 1 stayed in the room to monitor the resident after passing the trays and positioning the resident to eat on 9/19/2023 at 7:20 am. DON stated a resident should be fully awake, if the resident is drowsy staff should stop the feeding. DON confirmed that Resident 1 had a choking event on 9/18/2023 during the 3pm to 11 pm shift during dinner. The DON stated that she heard FM 1 yelling so she as well as other staff went to the resident's (Resident 1) room and noted that Resident 1's lips were purple. The DON stated that she immediately did the Heimlich maneuver and a noodle which was about 2 inches came out. During an interview on 7/25/2025 at 2:19 pm, the administrator (ADM) stated that the facility talked about the post incident of choking in 9/2023 but didn't know if the facility documented it. He also stated that there is no policy specific to the outside food being brought in for the residents that is on a specialized diet for screening the food to comply with the diet ordered. During an interview on 7