Health inspection·May 9, 2025

F580 §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 Patient representative(s) when there is: (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);

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 3/25/2025, the California Department of Health (CDPH) made an unannounced visit to the facility to conduct an Annual Recertification Survey. During the survey, it was determined that the facility failed to provide the necessary respiratory care for Resident 1 in accordance with the resident’s respiratory care needs, care plan, professional standards of practice, the physician’s order and facility’s policy and procedure to Resident 1 who was diagnosed of acute respiratory failure with hypoxia (a life-threatening condition where the lungs fail to deliver enough oxygen to the blood, leading to dangerously low oxygen levels in the body), chronic obstructive pulmonary disease (COPD) exacerbation (worsened COPD, sudden severe symptoms of a lung disease characterized by poor airflow to the lungs that results in shortness of breath, difficulty breathing and respiratory distress) and pulmonary hypertension [a condition characterized by high blood pressure (BP, the measurement of the pressure or force of blood inside the blood vessels) in the arteries of the lungs which makes the heart work harder to pump blood through the narrowed or damaged blood vessels in the lungs that causes shortness of breath and difficulty breathing]. The facility failed to: 1. Monitor Resident 1 for respiratory distress (life-threatening condition that causes severe difficulty breathing. It occurs when the lungs become inflamed and damaged, making it difficult for oxygen to reach the bloodstream) and change in respiratory condition, in accordance with the resident’s care plan for COPD and physician orders, when Certified Nurse Assistant (CNA) 1 found Resident 1 with weakness, labored breathing, and an oxygen saturation (blood oxygen level) of 88% (normal range 90-100%) while receiving oxygen via nasal cannula (NC- a plastic flexible tubing used to deliver oxygen into the nose) at 2 LPM [Liters (unit of volume) Per Minute (unit of time)] and reported his findings to Licensed Vocational Nurse (LVN) 1. 2. Follow physician orders to titrate (adjust) Resident 1’s oxygen therapy to 10-15 LPM via mask to maintain oxygen blood levels of 94% and above, when Resident 1’s oxygen saturation decreased to 70% on 2/13/2024 at 5:50 AM, while receiving 2 LPM of oxygen via NC. 3. Ensure LVN 1 monitored and documented Resident 1’s vital signs (measurements of the body's most basic functions, including temperature, pulse rate, breathing rate, and BP, used to assess a person's overall health), treatments rendered, and reported to the physician, in accordance with the physician orders. 4. Ensure LVN 1 immediately notified the physician and called 911 (an emergency number) emergency services, when CNA 1 reported to LVN 1 that Resident 1 was experiencing labored breathing with his oxygen saturation decreased to 88% on 2/13/2025 at around 5:30 AM, and when LVN 1 assessed Resident 1 with findings of weakness and oxygen saturation continued to decrease to 70% on 2/13/2025 at 5:50 AM. 5. Ensure LVN 1 implemented Resident 1’s Physician Orders for Life-Sustaining Treatment (POLST, a portable medical order that communicates a patient's wishes for end-of-life care and treatment interventions) according to the resident’s preferences. These deficient practices resulted in delays in diagnosis, care, and respiratory services for Resident 1’s change in respiratory condition. Resident 1 expired at the facility on 2/13/2025 with the cause of death as cardiac dysrhythmia (abnormal or irregular heartbeat), acute respiratory distress, and pulmonary hypertension. A review of Resident 1's “Admission Record (AR),” the AR indicated the facility admitted Resident 1 on 2/7/2025 with diagnoses that included acute respiratory failure with hypoxia, COPD exacerbation (worsened respiratory symptoms), pulmonary hypertension, type 2 diabetes mellitus with hyperglycemia (DM, a chronic condition that happens when the body has persistently high blood sugar levels), and atrial fibrillation (“afib”-an irregular heart beat). A review of Resident 1’s “Order Summary Report (OSR),” indicated on 2/7/2025, Resident 1 had a physician order to monitor temperature and oxygen saturation every shift for suspected/confirmed Covid-19 (Coronavirus disease, an infectious disease caused by the SARS-CoV-2 virus), and to call the physician if oxygen saturation is newly below 91%, or if the resident’s usual oxygen saturation is lower or is 3% or more lower than their baseline. A review of Resident 1’s Care Plan (CP), dated 2/8/2025, indicated Resident 1 had COPD exacerbation. The goal included Resident 1 would display optimal breathing patterns (a respiratory rate of 12 to 20 breaths per minute with regular, rhythmic inhalations and exhalations) daily with the interventions that included monitoring for signs and symptoms of acute respiratory insufficiency (not enough oxygen or too much carbon dioxide in your body) such as shortness of breath at rest, cyanosis (a bluish or purplish discoloration of the skin, typically caused by a lack of oxygen in the blood), and somnolence (lethargy, weakness, and difficulty thinking), and to administer oxygen via NC at 2-3 LPM continuously, may titrate oxygen to 10-15 LPM via mask to maintain oxygen saturation greater or equal to 94%. A review of Resident 1’s CP, dated 2/8/2025, indicated Resident 1 was at risk for Covid-19 (Corona Virus 19- a severe lung infection) related to diagnosis of COPD exacerbation, DM, and afib. The interventions included following Resident 1’s POLST, monitor temperature and pulse oximetry (a test used to measure oxygen levels of the blood) per physician’s order and report abnormal findings to the physician. A review of Resident 1’s CP, dated 2/8/2025, indicated Resident 1 had altered cardiovascular (related to heart and blood vessels) status related to afib, hypertension (high BP), and hyperlipidemia (high level of fats in the bloodstream). The interventions included monitoring Resident 1’s vital signs and notifying the physician of significant abnormalities, monitor/document/report to the physician for changes in capillary refill (a quick test to assess blood flow to tissues by observing how quickly color returns to the nail bed after pressure is applied) and color/warmth of extremities. A review of Resident 1’s “History and Physical,” dated 2/9/2025, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1’s OSR, indicated on 2/9/2025, for Resident 1 to receive oxygen via NC at 2-3 LPM continuously, may titrate oxygen to 10-15 LPM via mask to maintain oxygen saturation greater or equal to 94%. A review of Resident 1’s OSR, indicated on 2/10/2025, the physician ordered to follow the instructions in Resident 1’s POLST. A review of Resident 1’s “POLST,” dated 2/10/2025, indicated if Resident 1 was found with a pulse and/or is breathing, the healthcare provider may, in addition to oxygen treatment, use a non-invasive positive airway pressure (a method of breathing support that delivers pressurized air or oxygen through a mask without inserting a tube into the windpipe) which included continuous positive airway pressure (CPAP, a machine that uses mild air pressure to keep breathing airways open), bi-level positive airway pressure (BiPAP, a type of device that helps with breathing), and bag valve mask (a handheld device used to provide emergency breaths to someone who is not breathing or not breathing adequately) assisted respirations. A review of Resident 1’s “Minimal Data Set (MDS-a federally mandated resident assessment),” dated 2/12/2025, indicated Resident 1’s cognition (ability to think, remember, and reason) was moderately impaired and needed moderate assistance (helper does less than half the effort) in eating and oral hygiene. A review of Resident 1’s “Weights and Vitals Summary,” indicated Resident 1’s last vital signs was taken on 2/13/2025 at 1:09 AM with the resident’s BP at 128/85 mmHg (millimeters of mercury, a unit of measurement for blood pressure), oxygen saturation of 93% while the resident was on room air, heart rate at 100 beats per minute, and temperature of 98.7 degrees Fahrenheit (a scale for measuring temperature). There was also no documented evidence in the resident’s clinical record that indicated Resident 1 was monitored for vital signs on 2/13/2025 at 5:50 AM when Resident 1 responded to touch only by opening his eyes and had “slow breathing.” A review of Resident 1’s “Progress Notes,” dated 2/13/2025, indicated at 5:50 AM during CNA morning care, Resident 1 responded only by opening his eyes, breathing slowing down with oxygen saturation at 70% via NC until the resident passed away. There was no documented evidence in the report that Resident 1 was provided with respiratory care to assist the resident to increased oxygen blood level to oxygen saturation at or above 94% as ordered by the physician. There was also no documented evidence that Resident 1 was monitored for vital signs or provided with 10-15 LPM oxygen via mask per physician's order on 2/13/2025 at 5:50 AM, when Resident 1 responded to touch only by opening his eyes, had “slow breathing,” and oxygen saturation at 70 % while on 3 LPM oxygen via NC. A review of Resident 1’s SBAR Communication Form (Situation, Background, Assessment, and Recommendation is a structured approach to healthcare communication to ensure clear and concise information exchange, especially in critical situations) and Resident 1’s clinical records indicated on 2/13/2025, there was no documented evidence that the physician was notified when Resident 1’s mental condition changed to responding only by opening his eyes, breathing slowing down with oxygen saturation at 70% via NC on 2/13/2025 at 5:50 AM until the resident expired on 2/13/2025 at 5:59 AM. A review of Resident 1’s “Record of Death,” dated 2/13/2025, indicated Resident 1 expired on 2/13/2025 at 5:59 AM with the final diagnosis that included COPD, hypoxia and respiratory failure. A review of Resident 1’s “Physician’s Discharge Summary,” dated 3/11/2025, indicated Resident 1 was admitted on 2/7/2025 and was discharged from the facility due to resident “expired” on 2/13/2025 at 5:59 AM. A review of Resident 1’s “Death Certificate” dated 2/13/2025, indicated Resident 1 expired on 2/13/2025 with the primary cause of death as cardiac dysrhythmia and secondary cause of death that included acute respiratory distress and pulmonary hypertension. During an interview on 3/26/2025 at 6:38 AM with CNA 1, CNA 1 stated, he took care of Resident 1 from 11 PM on 2/12/2025 until the resident expired on the morning of 2/13/2025. CNA 1 stated, when he was caring for Resident 1 at the beginning of his shift on 2/12/2025, Resident 1 was alert and oriented, with the vital signs that included BP and oxygen saturation was within normal limits. CNA 1 stated, he could not recall the results of the vital signs and time they were taken. CNA 1 stated, around 5-5:30 AM during his rounds in the facility, he noticed that Resident 1 did not respond when he called Resident 1’s name and observed the resident breathing “very slow but his skin was warm when touched.” LVN 1 stated Resident 1 was “very weak with his oxygen level at around 88%.” CNA 1 stated, he immediately reported to LVN 1 that Resident 1’s oxygen blood level was low and then LVN 1 went to assess Resident 1. CNA 1 stated, they (LVN 1 and CNA 1) checked Resident 1's vital sign about four times, but he could not recall the results and time the vital signs were taken. CNA 1 stated, he could only recall Resident 1’s oxygen level was at 88% when he found the resident at around 5-5:30 AM on 2/13/2025, which he notified LVN 1. CNA 1 then stated Resident 1 “slowly died” in about 1 hour while receiving oxygen via NC. During a concurrent record review and interview on 3/26/2025 at 6:52 AM with LVN 1, Resident 1’s “Weights and Vitals Summary,” “SBAR Communication Form,” and clinical records on 2/12/2025 and 2/13/2025 were reviewed. LVN 1 stated, there was no records indicating Resident 1 was assessed and monitored for vital signs, Resident 1’s physician was notified, or interventions were provided related to Resident 1’s slow breathing with oxygen saturation at 70% on 2/13/2025 at 5:50 AM. During an interview on 3/26/2025 at 7 AM with LVN 1, LVN 1 stated, he was the charge nurse that took care of Resident 1 from 11 PM on 2/12/2025 until the resident expired on 2/13/2025 at 5:59 AM. LVN 1 stated, Resident 1 was alert, oriented and responsive at the beginning of his shift on 2/12/2025, with oxygen saturation above 90% while receiving oxygen supplement at 3 LPM via NC. LVN 1 started on 2/12/25 at 4 AM, Resident 1 was able to make his needs known and was provided with his scheduled breathing treatment (treatment to prevent difficulty breathing and shortness of breath) with oxygen saturation at about 93% and Resident 1 was placed back on 2-3 LPM oxygen via NC after the breathing treatment. During an interview on 3/26/2025 at 7:05 AM, LVN 1 started around 5:30 AM, CNA 1 told him Resident 1 had a change in condition and breathing very slowly and was very weak. LVN 1 stated he went to Resident 1’s room, and Resident 1 opened his eyes but was very weak. LVN 1 stated he checked Resident 1's vital sign a few times but could not recall the results of the VS and he did not document the vital signs in Resident 1’s clinical record. LVN 1 stated, he did not report Resident 1’s change of condition to the Registered Nurse (RN) who was working during his shift on 2/12/25. LVN 1 stated, he did not increase Resident 1’s oxygen level as per physician’s order because the resident had diagnosis of COPD. LVN 1 stated, he did not inform the physician when Resident 1’s condition changed with oxygen saturation down to 88% and 70%. LVN 1 stated he