Studebaker Healthcare Center: Breathing Crisis Ignored - CA
That is what a September inspection of Studebaker Healthcare Center on Studebaker Road documented.
The resident, identified in inspection records only as Resident 1, had been admitted to the facility on August 21, 2025, with diagnoses that included pneumonia from COVID-19 and hypoxia, a condition in which the body's tissues are starved of oxygen. Shortly after midnight on August 20, he told the nurse on duty that he was short of breath and scared to lie flat. He spent most of the 11 p.m. to 7 a.m. shift either perched on the edge of his bed or sitting in a wheelchair because it was the only way he could breathe.
The nurse, identified as LVN 1, gave him pain medicine for his headache and cough drops for his throat.
When inspectors interviewed Resident 1 on September 8, he said the cough drops really didn't help. He said he felt increasingly anxious and nervous, and believed the nursing staff did not think his breathing trouble was real. His family called 911. He was transferred to the hospital at approximately 7 a.m.
LVN 1, reached by phone on September 9, told inspectors she had contacted the resident's physician twice that night, at around 12:30 a.m. and again at 3:30 a.m., by texting through the nurse supervisor's cell phone. She said she reported that Resident 1 had a cough and congestion. She acknowledged she did not tell the physician that the resident felt like he was choking.
The physician never responded during her shift.
LVN 1 did not call him. She did not contact the medical director. She did not call the Director of Nursing. When her shift ended at 7 a.m., she handed off Resident 1's care to the next nurse and went home.
The physician told inspectors on September 10 that he received the texts, couldn't explain why he hadn't responded until nearly 9 a.m., and said directly that if he had known the resident felt like he was going to choke, he would have ordered an X-ray or transferred him to the hospital himself. The information he was given, cough and congestion, did not prompt that response. The information he was not given, a man sitting upright in the dark because lying down felt like dying, would have.
LVN 1, when pressed, told inspectors she knew she should have followed up when the doctor didn't respond. She said she should have called the medical director. She said she should have called the Director of Nursing.
The Director of Nursing, interviewed on September 10, said the same thing. Physicians are supposed to be reachable around the clock. When one doesn't respond, the nurse escalates. That is the expectation.
It did not happen.
The facility's own written policy on change-of-condition notification, dated October 2023, describes exactly this situation. Unexpected shortness of breath is listed as an emergency requiring an immediate phone call to the attending physician, not a text. If the physician cannot be reached, the policy says to call the medical director. The policy also requires documenting the time of contact, the method, how long the physician took to respond, and whether any orders were received.
What LVN 1 did instead was text twice, receive no response, and wait for morning.
Resident 1 spent those hours in a wheelchair, breathing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Studebaker Healthcare Center from 2025-09-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
STUDEBAKER HEALTHCARE CENTER in NORWALK, CA was cited for violations during a health inspection on September 10, 2025.
That is what a September inspection of Studebaker Healthcare Center on Studebaker Road documented.
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.