Dreier's Nursing: Immediate Jeopardy Death Case - CA
Resident 53 had been readmitted to Dreier's Nursing Care Center in May after a fall at the facility led to hospitalization for altered mental status. Hospital records showed she had suffered a small stroke in her brain, likely due to atrial fibrillation, and a heart attack caused by low blood pressure that triggered her fall.
Her vital signs told a story of steady decline that no one acted upon.
On her final day, her blood pressure dropped from a reading taken that morning to dangerously low levels by evening. Her heart rate simultaneously spiked from 82 beats per minute to 106. Licensed Vocational Nurse 1 documented the concerning readings but never notified the resident's physician.
The resident's family had requested pain medication that evening because she was crying, moaning, and fidgeting. LVN 1 assessed her pain at 7 out of 10 on a standard pain scale. The resident had no physician orders for pain medication stronger than Tylenol for that level of pain, but LVN 1 administered Tylenol anyway and never called the doctor.
"I should have documented the resident's behavior of moaning, but I did not," LVN 1 told inspectors later.
At midnight, Licensed Vocational Nurse 2 found the resident staring at the ceiling, unresponsive to touch or voice. Her breathing had slowed to eight breaths per minute. The blood pressure cuff registered no reading at all.
LVN 2 tried multiple blood pressure devices, both electronic and manual. Nothing registered. She elevated the resident's legs, applied oxygen, and called for help from another nurse. The pulse oximeter showed 100% oxygen saturation and a heart rate of 70, but the resident's breathing remained dangerously slow.
For 13 minutes, LVN 2 continued interventions without calling the physician or paramedics.
"The biggest thing was how I could not get her blood pressure and after 13 minutes, Resident 53's respirations ceased and went full on cardiac arrest," LVN 2 told inspectors. "I did not immediately notify Physician 1 of Resident 53's change in condition because I was doing my nursing interventions."
When the resident stopped breathing entirely, LVN 2 finally called for the crash cart and began CPR. The resident's do-not-resuscitate order had not been properly signed by the physician, making her a "full code" despite the family's wishes for comfort care only.
Paramedics pronounced her dead at 12:43 AM. LVN 2 did not notify the physician of the death until more than six hours later.
The physician told inspectors he expected to be called when a resident's blood pressure continued decreasing and when pain was not controlled. "If there were other things happening while Resident 53 was observed with pain like if resident's heart was going up from 60 bpm to 100 bpm, Physician 1 stated he would expect to be notified."
The facility's Director of Nursing confirmed the nurses had failed to follow basic protocols. When a resident's blood pressure drops to dangerous levels while the heart rate spikes, "the nurse should have called Physician 1 because the pulse was high and the diastolic was low and that Resident 53 was in distress," she told inspectors.
She said LVN 1 should have called the registered nurse to perform a full body assessment when the vital signs became abnormal. When the resident's pain reached 7 out of 10, it was "considered moderate to severe pain, and the licensed nurse should have notified Physician 1 because there was no medication ordered for the pain level of 7."
Federal inspectors found no evidence that nurses had developed a care plan to monitor the resident for stroke symptoms, despite her recent hospitalization for brain injury. Her medical record contained no documentation of change-of-condition assessments from the time of her readmission until her death.
The facility's own policies required nurses to notify physicians of significant changes in residents' vital signs and pain levels. The pain management policy mandated comprehensive assessments when residents experienced new or worsening pain, and adjustments to treatment when pain was not adequately controlled.
The violations triggered an immediate jeopardy citation from federal regulators, who determined the facility's failures created a situation likely to cause serious injury or death. The citation was removed only after the facility implemented an extensive retraining program for all licensed nurses.
The resident's death certificate listed cerebrovascular disease, atrial fibrillation, and hypertension as the primary causes of death.
In separate violations, inspectors found the facility routinely threw residents' personal information into kitchen trash cans where it could be seen by unauthorized people. Name cards containing residents' medical record numbers were "always thrown in the trash because they are soiled with food after a meal," the dietary supervisor told inspectors, despite facility policy requiring such information to be shredded.
The facility also failed to properly handle resident grievances. When Resident 32 complained that staff had removed his personal extension cord from his room, the Social Service Director promised to follow up but never filed a formal grievance or returned the resident's property. Three days later, the resident was still waiting for his extension cord or an explanation of what happened to it.
Additional violations included late submission of federally required resident assessments. Three residents had their mandatory assessments completed and transmitted to Medicare systems weeks or months after deadlines, with one assessment submitted 51 days late.
The facility failed to develop comprehensive care plans for residents taking psychiatric medications and blood thinners. Inspectors found no care plans detailing how to monitor residents for side effects of antidepressants, antipsychotic drugs, or anticoagulation medications, despite physician orders for these high-risk treatments.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dreier's Nursing Care Center from 2024-06-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
DREIER'S NURSING CARE CENTER in GLENDALE, CA was cited for immediate jeopardy violations during a health inspection on June 11, 2024.
Resident 53 had been readmitted to Dreier's Nursing Care Center in May after a fall at the facility led to hospitalization for altered mental status.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.