Critical CPR Knowledge Gap Discovered
During the February 9, 2025 inspection, investigators found that CNA 6, despite holding what appeared to be a current Basic Life Support (BLS) certification card, demonstrated dangerous gaps in CPR knowledge. When asked to describe the procedure, the staff member incorrectly stated the compression-to-breath ratio as "10 compressions immediately followed by 10 breaths per cycle."
The correct ratio for adult CPR is 30 compressions to 2 breaths - a fundamental difference that could mean the difference between life and death during cardiac arrest. The facility's own Director of Staff Development confirmed the proper ratio and acknowledged that "performing proper CPR was important to ensure oxygen circulated in the blood because this saved lives."
The facility's emergency procedures specifically require all staff to be prepared to initiate CPR in response to sudden cardiac arrest. The policy states that trained rescuers should provide chest compressions and ventilations with the correct 30:2 ratio. This discovery revealed that despite having written protocols, the facility had not ensured all direct care staff possessed the practical knowledge needed for emergency situations.
Infection Control Failures Endanger Vulnerable Resident
Inspectors documented particularly concerning infection control violations involving Resident 11, who had been admitted with endometrial cancer and diabetes. The resident had a wound vacuum system attached to their abdomen for wound healing - a critical medical device that requires strict sterile technique to prevent potentially fatal infections.
On February 7, 2025, surveyors observed the wound vacuum's drainage tubing in direct contact with the floor while the pump rested on the resident's bed. This violation of basic infection control principles created a direct pathway for dangerous pathogens to travel from the contaminated floor surface to the resident's surgical wound site.
The facility's Infection Preventionist later acknowledged that "any part of the system that touched the floor could potentially break the sterile field, putting the wound at greater risk of becoming infected." For a diabetic patient with cancer and already compromised healing abilities, such contamination could lead to severe complications including sepsis, delayed healing, or wound breakdown requiring additional surgery.
Wheelchair Safety Hazard Left Unaddressed
The same cancer patient, Resident 11, had been using a wheelchair with a non-functional right-side brake for more than a week, despite reporting the problem to staff multiple times. The resident expressed fear that "the wheelchair could have rolled on her unexpectedly when transferring in and out of the wheelchair, becoming a safety issue."
This resident's medical record indicated a history of falls and moderate cognitive impairment, requiring substantial assistance with daily activities. The combination of these risk factors with faulty equipment created an extremely dangerous situation. The facility's Director of Maintenance confirmed no maintenance request had been documented for the wheelchair repair, indicating a complete breakdown in the reporting and repair system.
Properly functioning wheelchair brakes are essential for safe transfers. When brakes fail, wheelchairs can roll backward or sideways during transfers, causing residents to fall between the wheelchair and bed, toilet, or chair. Such falls frequently result in hip fractures, head injuries, and other serious trauma that can be life-altering or fatal for elderly residents.
Food Safety Violations Risk Foodborne Illness
Kitchen inspections revealed multiple food safety violations that could expose all residents to foodborne pathogens. Inspectors found:
- A cook preparing food without a hairnet covering his beard, allowing potential contamination of food with hair and bacteria - An opened banana cream pie in the freezer without any date marking - A tray of green beans in the refrigerator that was both uncovered and undated
The facility's own policies require all opened food items to be labeled, dated, and covered. Food items are only safe for consumption for three days after opening. Without proper dating, staff cannot determine whether food has exceeded safe consumption periods, potentially serving spoiled or contaminated food to residents.
The Culinary Director confirmed these violations, stating it was "not healthy for residents to eat food that was too old" and that proper coverage and dating prevented contamination and foodborne illness.
Additional Documentation and Medication Errors
Inspectors also uncovered concerning documentation errors that could impact resident care. The facility failed to follow through with physician-approved recommendations from the consultant pharmacist for critical blood tests. Resident 21, who had diabetes and had experienced a stroke, required TSH (thyroid) and A1C (blood sugar) testing as recommended by the pharmacist and approved by the physician. However, these tests were never performed, potentially missing important changes in the resident's condition.
Additionally, staff incorrectly documented administering Vagisil medication to Resident 11 on February 4, 2025, when the medication had not yet arrived from the pharmacy. The Director of Nursing emphasized that accurate documentation "allowed for clear communication between healthcare providers" and reduced risks of medication errors.
Pattern of Systemic Failures
These violations reveal systemic problems with staff training, equipment maintenance, infection control practices, and basic safety protocols at Brookdale San Dimas. The facility's own policies and procedures addressed each area of violation, indicating leadership understood the requirements but failed to ensure implementation.
The CPR training failure is particularly troubling as cardiac emergencies can occur at any moment in a nursing home population. The three-minute window for initiating effective CPR means there is no time to look up procedures or wait for properly trained staff to arrive. Every direct care staff member must be prepared to act immediately and correctly.
Similarly, the infection control and equipment maintenance failures demonstrate a pattern of neglecting basic safety measures that protect vulnerable residents from preventable harm. When multiple staff members and departments fail to address or even document safety issues like broken wheelchair brakes and contaminated medical equipment, it suggests inadequate supervision and quality assurance systems.
The facility must now submit a plan of correction to federal regulators detailing how they will address each violation and prevent recurrence. This includes ensuring all staff maintain current, valid CPR certifications and can demonstrate proper technique, implementing systems to track and promptly repair faulty equipment, retraining all staff on infection control protocols, and establishing oversight mechanisms to ensure food safety procedures are consistently followed.
Families with loved ones at Brookdale San Dimas should inquire about what immediate steps the facility has taken to address these violations, particularly regarding emergency preparedness and infection control measures. The full inspection report provides additional details about these violations and the facility's response.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brookdale San Dimas from 2025-02-09 including all violations, facility responses, and corrective action plans.
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