Other·April 14, 2026

Code of Federal Regulations, Title 42, Section 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Code of Federal Regulations, Title 42, Section 483.30 Physician Services A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs. (a) Physician Supervision. The facility must ensure that- (1) The medical care of each resident is supervised by a physician; and California Code of Regulations, Title 22, Section 72301. Required Services (a) Skilled nursing facilities shall provide, but shall not be limited to, the following required services: physician, skilled nursing, dietary, pharmaceutical and an activity program. (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. California Code of Regulations, Title 22, Section 72303. Physician Services-General Requirements (a) All persons admitted or accepted for care by the skilled nursing facility shall be under the care of a physician selected by the patient or patient's authorized representative. (b) Physician services shall mean those services provided by physicians responsible for the care of individual patients in the facility. Physician services shall include but are not limited to: (4) Advice, treatment and determination of appropriate level of care needed for each patient. California Code of Regulations, Title 22, Section 72307. Physician Services-Supervision of Care (a) Each patient admitted to the skilled nursing facility shall be under the continuing supervision of a physician who evaluates the patient as needed and at least every 30 days unless there is an alternate schedule, and who documents the visits in the patient health record. California Code of Regulations., Title 22, Section 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the patient. (b) All attempts to notify licensed healthcare practitioners acting within the scope of his or her professional licensure shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending licensed healthcare practitioner acting within the scope of his or her professional licensure or his or her designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g). California Code of Regulations, Title 22, Section 72313. Nursing Service - Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. (3) Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, shall be performed as required and the results recorded. California Code of Regulations, Title 22, Section 72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 3/10/26 at 10:32 am, the Department conducted an unannounced visit to the facility to investigate two complaints regarding patient care. The facility failed to provide quality of care (each resident must receive the necessary care and services to attain or maintain the highest practicable physical well-being) in accordance with professional standards of practice for one of three sampled residents (Resident 1) when, 1. The facility staff did not implement in a timely manner the Wound (tissue injury) Doctor's (WD) verbal recommendation on 2/25/26 to transfer Resident 1 to an acute care hospital for a higher level of care to treat a worsening venous ulcer wound (shallow, slow-healing, or chronic [long term] wounds) on Resident 1's right leg. The expectation of the WD was the recommendation would have been initiated on 2/25/26. The verbal order was not initiated prior to Resident 1's transfer to the hospital on 3/3/26. 2. The facility staff did not initiate Physician 1's verbal order, dated 2/25/26, to arrange a consultation for Resident 1 with a vascular surgeon (a highly trained specialist who diagnoses and manages diseases affecting arteries and veins), prior to Resident 1's transfer to the hospital on 3/3/26. Physician 1's expectation was that the verbal order would be initiated within 24 hours. 3. The facility did not monitor Resident 1's vital signs (measurement of the body's most basic functions such as body temperature, heart rate per minute, respiration rate per minute, and blood pressure) and pain level score (numerical pain scale 0-10; 0=no pain, 1 through 4 = mild pain, 5 through 6 = moderate pain, 7 through 10 = severe pain) from 2/25/26 through 3/3/26, every shift for 72 hours, after a deterioration of Resident 1's right leg venous ulcer wound was identified on 2/25/26. 4. The facility failed to provide wound treatment for Resident 1's right leg venous ulcer as directed by the physician. The cumulative effects of these failures resulted in Resident 1 experiencing poor quality of care (medical care that falls below the reasonable level of competence) and a delay in a higher level of care from 2/25/26 through 3/3/26 (6 days). This resulted in Resident 1's wound worsening until Resident 1 was transferred to an Emergency Department (ED) on 3/3/26 with confusion, increased heart rate, and low blood pressure due to septic shock (a life-threatening medical emergency caused by the body's extreme, dysfunctional response to an infection) related to cellulitis (potentially serious bacterial skin infection) of the right lower extremity. Resident 1 died on 3/7/26 due to cardio-pulmonary arrest (heart and lungs stop working), septic shock, and necrotizing fasciitis of the right leg (a serious infection that kills the body's tissue). A review of Resident 1's clinical record titled, "Admission Record," (a document that contains the resident's demographic information) indicated Resident 1 was admitted to the facility on 8/30/22 and Resident 1's diagnosis included a non-pressure chronic ulcer of the right lower leg, cellulitis, and type 2 diabetes (the body cannot regulate blood sugar and places the resident at a higher risk for infection). The record further indicated Resident 1 did not have the capacity to make her own decisions and had a Responsible Party ([RP]- usually a family member who assists with decision making when a resident cannot make decisions for oneself). The record indicated Resident 1's code status was full code (the resident/representative requests that all lifesaving measures be implemented in the case of extreme illness). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool), dated 2/7/26, indicated Resident 1 had a Brief Interview for Mental Status (BIMS is a 0 through 15-point standardized assessment used to evaluate cognitive function; 0 through 15 = [intact cognition], 8 through 12 [moderate impairment], and 0 through 4 [severe impairment]) score of 4 reflecting severe cognition impairment. A review of Resident 1's clinical record titled, "Order Summary," dated 3/11/24, indicated, "Wound evaluation and treatment by [Wound Care Company Name]". The order did not indicate the frequency of the evaluation. A review of Resident 1's clinical record titled, "Weekly Skin Integrity Assessment for Non-Pressure Sore," date of observation was 2/11/26, signed by the facility's Wound Nurse (WN)on 2/12/26, indicated, "... right lower leg (front), Venous Ulcer - Wound is larger with significant drainage [fluid leaks out of the wound]; measures about 15cm [centimeters, unit of measurement (L=length)] x [by] 5cm [W=width] x 0.4cm [D=depth] post debridement [the medical removal of dead tissue to promote the growth a healthy tissue]. Wound bed [surface of the wound] 50% [percent, amount for every hundred] S [Slough (a yellow, tan, or white, stringy layer of dead tissue)], 50% G [granulation tissue, new vascular tissue - healing surface of the wound], significant drainage, no odor, no s/sx [signs and symptoms] of infection... wound showing improvement ...". The clinical record does not describe the type of drainage. A review of Resident 1's clinical record titled, "Weekly Skin Integrity Assessment for Non-Pressure Sore," date of observation was 2/18/26, signed by the WN on 2/19/26, indicated, "...Right lower leg (front) Venous Ulcer - wound shows slow improvement and appears healthier; measures about 15cm[L] x5cm[W] x 0.4cm[D] post debridement. Wound bed 30% S,70% G, significant drainage, no odor, no s/sx of infection... wound showing improvement...". The clinical record does not describe the type of drainage. A review of Resident 1's clinical record titled, "Weekly Skin Integrity Assessment for Non-Pressure Sore," date of observation was 2/25/26, signed by the WN on 2/27/26, indicated, "... Right lower leg (front) Venous Ulcer - wound is worse. measures about 15cm[L]x 5cm[W] x 0.4cm[D] post debridement. 100% slough/necrotic [dead, non-viable tissue resulting in lack of blood flow and/or infection] tissue. heavy [sic], drainage, no odor, no s/sx of infection... WOUND MD recommends hospital admission for operative debridement above and below leg amputation [the surgical removal of a limb (arms) or extremity (legs)] ...". The clinical record does not describe the type of drainage. 1. During an interview on 3/10/26 at 12:47 PM, the WN stated as the facility's Registered Nurse (RN) and Wound Care Nurse, her job duties included weekly rounds (a structured process where a medical team [doctors and nurses] assesses the residents' condition, care plans [a document that indicates the resident's problems, goals, and interventions] are updated on the day the condition or event occurred, and the team coordinates their care with other providers) with the WD. The WN stated before rounds, the WN updated the WD with any changes to Resident 1's wound. The WN stated after rounds were conducted with the WD, the facility process included the WN updating Physician 1 about Resident 1's current health status. The WN stated if the WD suggested a new treatment or provided recommendations, the facility process included the WN carried out the order (to execute, fulfill, or perform a command, instruction, or task) given by the WD. During a follow-up concurrent interview and record review on 3/10/16 at 12:53 PM with the WN, Resident 1's clinical record titled, "Progress Notes," dated 2/27/26, by the WN, was reviewed for the condition of Resident 1's right lower leg wound. The WN stated although Resident 1's "Progress Note" was entered on 2/27/26, it was written to reflect the rounds made by the WD and the WN on 2/25/26. The "Progress Notes," dated 2/27/26, indicated, "Resident was seen and evaluated by... [WD]... for R [right] lower leg ulcer this week. Wound is Worsening. Wound has 100% slough/necrotic tissue ...Wound has heavy drainage...Noted resident in excruciating pain...Pain medication was given prior...Resident still appears in very much pain. ... [WD] recommends hospital admission for operative debridement above and below R leg amputation ....". The WN stated the WD assessed Resident 1's wound on 2/25/26 and recommended Resident 1 to be admitted to the hospital for an operative debridement because her wound was getting worse. The WN stated the "Progress Note," dated 2/27/25 was a note that should have been documented on 2/25/26. The WN stated she had not added the phrase, late entry note, because she did not want the documentation to be flagged as a late entry. During an interview on 3/11/26 at 12:48 PM, the WD stated he treated Resident 1's right lower leg wound once a week, and he noticed there was little to no improvement, and eventually the wound worsened. The WD stated he spoke with Physician 1 and the WN on 2/25/26 and the WD informed Physician 1 that the bedside treatment (wound care) was not effective, Resident 1 was getting worse, and needed to go to the hospital to have a surgical wound debridement or amputation of the right leg. The WD stated he expressed urgency and serious concern for Resident 1 with Physician 1 and Physician 1 stated he agreed with his recommendation and Physician 1 would take care of it and he (Physician 1) walked into Resident 1's room. The WD stated after he spoke with Physician 1 and the WN about his concerns he expected Resident 1 would be transferred to the hospital no later than the end of that day on 2/25/26. The WD stated he knew if Resident 1 was not sent out to the hospital for a higher level of care, she would develop sepsis. During a follow-up phone interview on 3/20/26 at 3:02 PM, the WD stated on 2/25/26 he spoke with Physician 1 regarding Resident 1's decline in wound healing of the right leg venous ulcer and the need for transfer to a higher level of care. The WD stated his recommendation for Resident 1's transfer to a higher level of care was proactive because he saw the negative direction the wound was heading toward. The WD stated Physician 1 was overall in charge of Resident 1's care, and he provided recommendations regarding the wound. The WD stated his recommendation was strong and clear and Physician 1 agreed with his recommendation. The WD stated Resident 1's chances of survival would have been better if she had been transferred to the hospital when recommended on 2/25/26. A review of Resident 1's clinical record titled, "Care Plan Report," for Resident 1's skin integrity, initiated on 2/27/26, indicated, "... Recommends hospital admission for operative debridement above/lower leg amputation..." During an interview on 3/11/26 at 3:46 PM, Physician 1 stated, on 2/25/26, the WD notified him of the serious concern he had for the condition of Resident 1's right lower leg venous stasis ulcer (a shallow, slow-healing open sore that develops from long term insufficient blood supply). Physician 1 stated the WD informed him Resident 1's wound was not healing and that he was concerned that the right lower leg might need to be amputated. Physician 1 stated the WD relayed to him that Resident 1's wound had significant vascular compromise (lack of blood flow), Resident 1 needed to be seen by a vascular surgeon and required hospitalization. Physician 1 stated after