Health inspection·August 4, 2025

The following reflects the findings of the California Department of Public Health during the investigation of complaint numbers 952627 and 957904. The inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. A deficiency was written for complaint numbers 952627 and 957904 at F-tag 684/G. F684 § 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, including but not limited to the following: INTENT To ensure facilities identify and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. 22 CCR § 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: (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 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 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: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (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. 22 CCR § 72315 Nursing Service -Patient Care (e) Each patient shall be encouraged and/or assisted to achieve and maintain the highest level of self-care and independence. Every effort shall be made to keep patients active, and out of bed for reasonable periods of time, except when contraindicated by orders of a licensed health care practitioner acting within the scope of his or her professional licensure. (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (2) Encouraging, assisting and training in self-care and activities of daily living. (3) Maintaining proper body alignment and joint movement to prevent contractures and deformities. 22 CCR 72403 Physical Therapy Service Unit-Services (b) Physical therapy services shall include but are not limited to: (1) Assisting the physician in an evaluation of the patient's rehabilitation potential. (2) Applying muscle, nerve, joint and functional ability tests. (3) Treating patients to relieve pain and to develop or restore function. (4) Assisting patients to achieve and maintain maximum performance using physical means such as exercise, massage, heat, sound, water, light or electricity. (5) Establishing and modifying a treatment program by the physical therapist, as needed, based upon initial and continuing assessment of the patient. (6) Maintaining patient health records which contain pertinent information and signed orders for treatment. (A) Notes shall be written and entered into the patient's health record after completion of each procedure. The note shall indicate the procedure(s) and shall be signed by the physical therapist. (B) Initial and continuing assessment, development of a treatment plan and discharge summary shall be written and entered in each patient's health record. (C) Individual progress notes shall be written and signed at least weekly by the physical therapist.22 CCR §72543. Patients' Health Records. (f) Patients' health records shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each patient. On 3/26/25, an unannounced visit was conducted at the facility to investigate complaints regarding lack of provision of therapy services to the residents. Resident 1 is a 98-year-old female who was admitted to the facility on 11/10/2022 with a diagnoses including: Dementia (A brain disorder that affects thinking, movement, behavior, and mood, often causing visual hallucinations and changes in alertness), and neurocognitive disorder with Lewy bodies (a progressive brain disorder characterized by the presence of Lewy bodies[little clumps of a protein that abnormally form inside brain cells] in brain cells, leading to cognitive decline, movement issues, and behavioral changes). Based on interview and record review, the facility failed to ensure one of 11 sampled residents (Resident 1) received quality care when the facility failed to: 1. Implement their policy and procedure on a change of condition (an important change in a resident ' s baseline condition which includes physical, mental, emotional or functional changes that require a change in treatment to address) for one of 11 sampled residents (Resident 1). 2. Ensure the MDS assessment (Minimum Data Set - an assessment tool) was accurate for one of 11 sampled residents (Resident 1) when contractures (when your skin, muscles, tendons [tough, ropelike cords that connect muscles to bones, enabling movement], or ligaments [tough tissues that act like ropes or bands connecting bones to other bones providing stability and allowing for movement] get permanently stiff or shortened, making it hard to move the affected area) were not inputted into the assessment. 3. Ensure Restorative Nursing Assistant (RNA - a person that provides therapy to residents) orders reflected to one of 11 sampled residents (Resident 1) ability to complete/participate in. 4. Obtain necessary medical equipment for one of 11 sampled Residents (Resident 1). 5. Document accurately the time spent with one of 11 sampled residents (Resident 1) during therapy. These failures resulted in the worsening of Resident 1 ' s right hand contracture. Findings: During a review of Resident 1's MDS Assessment, under the section Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns] with scores ranging from 0 - 15, the higher the score the more intact the resident ' s cognition is. A score of 99 is the resident was unable to complete the interview and therefore unable to determine the resident ' s cognition), dated 1/1/25, the BIMS score indicated, Resident 1 ' s BIMS score was 99. The MDS assessment dated 1/1/25, under section "GG (assesses functional abilities and goals)," Resident 1 was documented as completely dependent on staff for all activities of daily living (ADL refers to the basic, everyday tasks needed focusing on personal care and hygiene such as eating, dressing, bathing, and using the bathroom). 1.During a review of Resident 1's "OT (Occupational Therapy - a health profession that helps people of all ages with activities of daily living and improves their ability to engage in meaningful activities) Evaluation and Plan for Treatment (OTEPT)," dated 12/22/24, the OTEPT indicated, Resident 1 had contractures of her muscles to multiple sites (no documentation to indicate what muscles) with an onset date of 12/22/24. During a concurrent interview and record review on 4/14/25 at 12:20 p.m. with Director of Nursing (DON) 2, Resident 1's Electronic Medical Record (EMR) was reviewed. DON 2 stated Resident 1 was admitted to the facility on 11/10/22 with no contractures. DON 2 stated therapy documented Resident 1 had contractures on 12/22/24. DON 2 stated a change of conditions should have been implemented but it was not. DON 2 stated the medical doctor, and family should have been notified about the change in Resident 1 ' s condition but were not. During a review of the facility's policy and procedure (P&P) titled, "Change of Condition Notification," dated 6/1/17, the P&P indicated, "To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. . . An acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. "Clinically important" means a deviation that, without intervention, may result in complications or death. The Facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not limited to . . . An injury/accident . . . A significant change in the resident 's physical, cognitive, behavioral or functional status . . . A significant change in treatment . . . The Licensed Nurse will notify the resident ' s Attending Physician when there is an . . . A significant change in the resident's physical, mental or psychosocial status, e.g., deterioration in health, mental or psychosocial status, life-threatening conditions or clinical complications . . . The Licensed Nurse will assess the resident ' s change of condition and document the observations and symptoms. . . The Attending Physician will be notified timely with a resident ' s change in condition. . . Notification to the Attending Physician will include a summary of the condition change and an assessment of the resident ' s vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required." 2.During a review of Resident 1's "Condition on Admission (CAD)," dated 11/10/22, the CAD indicated Resident 1 was admitted with no contractures. During a review of Resident 1 ' s OTEPT, dated 12/22/24, the OTEPT indicated Resident 1 had contractures of her muscles to multiple sites with an onset date of 12/22/24. During a concurrent interview and record review on 4/9/25 at 1:30 p.m. with Minimum Data Set Nurse (MDSN), Resident 1 ' s MDS assessments for 10/1/24, 1/2/25 and 4/2/25, were reviewed. MDSN stated, Resident 1 was assessed to be dependent on all aspects of care, Resident 1 was unable to communicate, was not alert and oriented, and was at increased risk for contractures to her upper extremities (arms), but there was no documentation Resident 1 had contractures on 10/1/24, 1/2/25 and 4/2/25. During a review of Resident 1's Care Plan (CP), dated 1/9/24, the CP indicated Resident 1 was at potential risk for complications related to a diagnosis of osteoarthritis (a progressive disorder of the joints [a point where two or more bones connect], caused by a gradual loss of cartilage [A tough, flexible tissue that lines joints]). The CP indicated Resident 1 would be free of complications from her osteoarthritis which included developing contractures. The CP dated 12/22/24 indicated Resident 1 was referred to therapy for contractures to her right and left hands. The CP indicated Resident 1 would have a resting hand splint (a device that positions a resident in a way that provides a stretch to improve range of motion and prevents further tightening of muscles) to her right wrist and a palmar guard splint (a device used to prevent your fingers from digging in to the palm of your hand, to prevent skin damage and prevent further deformity) to her left hand. During a concurrent observation and interview on 4/9/25 at 3:12 p.m. with MDSN, in Resident 1 ' s room, MDSN assessed Resident 1. MDSN stated Resident 1 could not move her upper extremities very well and she had a noted contracture to her right hand (did not mention her left hand). MDSN stated the MDS assessment completed on 1/2/25 and 4/2/25 was incorrect and should have mentioned Resident 1 ' s contracture to right hand (section GG of the MDS). MDSN stated the MDS (1/2/25 and 4/2/25) for Resident 1 indicated no impairment regarding her upper extremities. MDSN stated a new CP should have been created for Resident 1 that identified her contractures and the plan of care for staff (not just therapy) to follow. During a review of the facility's policy and procedure (P&P) titled, "RAI (Resident Assessment Instrument - an assessment and care planning process used to ensure residents receive the highest quality of care and quality of life) Process," dated 10/1/19, the P&P indicated, "To ensure that the Resident Assessment Instrument (RAI) is used, in accordance with specified format and timeframes, in conducting comprehensive assessments as part of an ongoing process through which the facility identifies each resident ' s preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified. . . The Facility will utilize the Resident Assessment Instrument (RAI) process as the basis for the accurate assessment of each resident's functional capacity and health status . . . The assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts. . . The quarterly MDS does not require the completion of Care Area Assessments (CAAs). However, the resident 's care plan must be reviewed and revised by the interdisciplinary team after each assessment." 3.During a review of Resident 1's Physician Orders (PO), dated 2/27/25, the PO indicated, a PO for RNA (Restorative Nursing Assistant - a nursing aide with additional training in restorative care, focusing on helping residents regain and maintain their physical abilities) to provide active range of motion (AROM - the movement of a joint that is achieved through the voluntary and unassisted contraction of surrounding muscles) and passive range of motion (PROM - the movement of a joint through its range of motion by an external force, such as a therapist or a machine, without any muscle effort from the individual) three times a week. During an interview on 4/9/25 at 2 p.m. with RNA 1, RNA 1 stated, she has been providing RNA treatment to Resident 1 since 2/2025. RNA 1 stated she provided PROM to Resident 1 but not AROM because Resident 1 was dependent in all areas of care and the resident could not actively participate in AROM. RNA 1 stated Resident 1 had been on the RNA program since 2/2025 and had not been able to participate in AROM. RNA 1 stated she meets with leadership (not specific who) every Monday to discuss the RNA program but had not brought up the need to clarify Resident 1 's AROM physician ' s order (during the one-day remainder of February, the 31 days in March, and nine days in April). During a concurrent observation and interview on 4/9/25 at 3:12 p.m. with MDSN in Resident 1 ' s room, MDSN assessed Resident 1. MDSN stated Resident 1 could not move her upper extremities on her own for AROM and she could not move her upper extremities past her shoulders when being provided with PROM. During a review of the facility's policy and procedure (P&P) titled, "Specialized Rehabilitative Services," dated 6/1/17, the P&P indicated, "The Facility shall meet the assessed needs of any resident admitted to assist them in obtaining or maintaining their highest practicable level of functional well-being. . . Skilled therapies will be provided to any resident based on physician order, validation of assessed needs . . ." 4. During a review of Resident 1's OTEPT dated 12/22/24, the OTEPT i