MONTEREY PARK, CA - Heritage Manor nursing home received an immediate jeopardy citation from state inspectors after staff failed to notify a physician when a resident's oxygen saturation levels dropped to dangerous levels, ultimately resulting in the resident's death.
Critical Care Failures Lead to Resident Death
The March 28, 2025 inspection revealed that Licensed Vocational Nurse (LVN) 1, who was responsible for Resident 98 during the overnight shift, failed to follow proper medical protocols when the resident experienced a significant decline in respiratory function. According to the inspection report, the resident's oxygen saturation levels dropped to 88% and then to a critically dangerous 70%.
Normal oxygen saturation levels should remain between 95-100% for healthy individuals, with levels below 90% considered concerning and requiring immediate medical attention. When oxygen saturation drops to 70%, patients face severe hypoxemia, which can cause organ damage, cardiac arrest, and death within minutes.
During interviews with inspectors, LVN 1 admitted he "did not know why he did not notify Resident 98's physician, call for help or call 911" when staff reported the resident was weak with slow breathing and decreased oxygen saturation. The nurse stated he only contacted the physician after the resident had already passed away.
Medical Protocol Violations
The resident had been receiving supplemental oxygen at 3 liters per minute (LPM) and had a physician's order allowing for oxygen level increases when medically necessary. However, LVN 1 failed to increase the oxygen flow despite the resident's deteriorating condition, citing the resident's COPD diagnosis as his reasoning.
This decision contradicted standard medical protocols for COPD patients experiencing acute respiratory distress. While COPD patients require careful oxygen monitoring, withholding increased oxygen during severe hypoxemia can be fatal. Medical standards require immediate physician notification and potential oxygen adjustment when patients experience such dramatic drops in saturation levels.
The resident's death certificate listed cardiac dysrhythmia, acute respiratory distress, and pulmonary hypertension as causes of death - all conditions that can result from severe oxygen deprivation.
Systemic Oversight Failures
The inspection revealed broader systemic problems beyond the immediate care failure. The facility's Director of Nursing (DON) admitted she did not investigate the possible cause of Resident 98's death and only began an investigation after inspectors brought the incident to her attention.
The Administrator stated he was never informed about the resident's death, despite facility policies requiring notification of all adverse events. "He should be made aware of any type of adverse event in the facility," the Administrator told inspectors, acknowledging that "due to the lack of oversight from the DON, the incident was not identified as an adverse event."
Quality Assurance Program Breakdown
Heritage Manor's own Quality Assurance and Performance Improvement (QAPI) policies require "systematic identification, reporting, investigation, analysis, and prevention of adverse events." The facility's written procedures mandate that staff "monitor residents for medical errors and adverse events" and conduct investigations to "analyze cause" while implementing "preventive actions and mechanisms."
None of these required protocols were followed in this case. The Administrator confirmed that the resident's death "should had been identified with possible causes and determine if there was a written plan that should have been created and implemented."
Additional Safety Violations
Inspectors also documented problems with food safety protocols affecting residents requiring texture-modified diets. Kitchen staff were observed failing to measure thickening powder properly when preparing pureed foods for residents with swallowing difficulties.
The facility's Cook admitted to "eyeballing the amount of thickener needed, instead of measure it" when preparing pureed food. The Dietary Manager stated staff did not maintain logs checking food textures, and she was uncertain which staff member was responsible for quality control before serving meals.
Improperly thickened foods present serious choking hazards for residents with dysphagia (swallowing difficulties). The Registered Dietitian emphasized that following recipes ensures "the food had right texture to prevent choking," yet these protocols were not being followed.
Environmental Health Concerns
Maintenance issues further compromised resident safety and quality of life. Inspectors found a "dirty and rusty commode" in a shared bathroom serving six residents in rooms 4 and 5. The Maintenance Supervisor estimated the equipment had been in this unsanitary condition "for at least a few days."
The facility's housekeeping staff admitted they had not been checking shared restrooms properly, failing to identify and report the contaminated equipment. This violated the facility's own policies requiring "preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored."
Regulatory Response and Implications
The California Department of Public Health classified the respiratory care failure as immediate jeopardy - the most serious violation category indicating that "the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident."
Immediate jeopardy citations trigger enhanced oversight and can result in monetary penalties, denial of Medicare/Medicaid payments, or facility closure if violations are not promptly corrected.
The inspection findings highlight critical gaps in clinical supervision, emergency response protocols, and quality assurance monitoring that contributed to a preventable death. Federal nursing home regulations require facilities to provide 24-hour nursing services, ensure physician notification for significant condition changes, and maintain comprehensive quality improvement programs.
Heritage Manor must now demonstrate immediate corrections to these systemic failures and implement monitoring systems to prevent future incidents. The facility's response to these citations will be crucial in determining whether residents can receive safe, appropriate care going forward.
For families evaluating nursing home options, this case underscores the importance of asking facilities about their emergency response protocols, clinical oversight procedures, and quality assurance tracking systems. These behind-the-scenes processes can mean the difference between life and death for vulnerable residents requiring skilled nursing care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heritage Manor from 2025-03-28 including all violations, facility responses, and corrective action plans.
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