Health inspection·November 24, 2025

California Code of Regulation Title 22, Section 72311(a)(1)(A) (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. Code of Federal Regulation Title 42, 483.25 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: On October 3 and 9, 2025, unannounced visits were conducted at the facility to investigate three complaint allegations. It was determined that the facility failed to ensure safe and appropriate transportation for Patient 1, who was wheelchair-bound and required two-person assistance for transfer. This failure resulted in missed or delayed dialysis appointments on September 23 and 24, 2025, hospital transfer for dialysis, and continued use of an unsafe transport method. The facility continued to use Uber (a personal ride-hailing service for individuals) three times a week, causing the patient to be uncomfortable during transfers in and out of the wheelchair into the Uber vehicle during each appointment. On October 2, 2025, while being transported in a standard vehicle (Uber), Patient 1 sustained a right chest-wall hematoma (localized collection of blood), soft-tissue swelling, and possible rib fractures. A review of Patient 1’s “Admission Record,” dated October 3, 2025, indicated Patient 1 was initially admitted to the facility on March 5, 2025, with diagnoses which included type 2 diabetes (high blood sugar), end stage renal disease (permanent kidney failure that requires a regular course of dialysis). A review of Patient 1’s “Physical Therapy Evaluation and Plan of Treatment,” dated September 18, 2025, indicated, “...Precautions: fall risk...heel WB (weight bearing) only during transfers...S/P (status after) amputation (removal of the body part) of L (left) 2nd and 3rd toes...” A review of Patient 1’s “Minimum Data Set (MDS – a standardized assessment tool),” dated September 22, 2025, indicated Patient 1 was cognitively intact (ability to think effectively) and required maximum assistance with sit to stand and chair/bed-to-chair transfer and dependent with wheelchair mobility. A review of Patient 1’s “Order Summary Report,” dated October 3, 2025, indicated Patient 1 received dialysis three times per week. A review of Patient 1’s “Progress Notes,” indicated the following: a. On September 23, 2025, at 6:30 a.m., Patient 1 missed her dialysis appointment due to a transportation issue; b. On September 23, 2025, at 4:58 p.m., the Social Services Director (SSD) wrote she was informed Patient 1 missed dialysis due to transportation not arriving and she reached out to the transportation who stated that they are no longer transporting Patient 1 due to non-payment from the facility. The SSD reached out to the corporate office regarding non-payment, and she was informed that Patient 1’s transportation needs to be provided by a straight Medi-cal (a type of health insurance plan) provider; c. On September 24, 2025, at 6:38 a.m., Patient 1 missed the rescheduled dialysis appointment due to transportation issues. At 9:27 a.m., the patient was transferred to the general acute care hospital, and at 11:10 p.m., the patient returned to the facility after receiving dialysis; d. On September 30, 2025, at 6:13 a.m., Patient 1 was picked up by Uber and accompanied by a (Certified Nursing Assistant) CNA; e. On September 30, 2025, at 11:59 a.m., Patient 1 returned from her dialysis appointment at 11:45 a.m., with the CNA escort, via Uber; f. On October 4, 2025, at 12:33 a.m., the Licensed Vocational Nurse (LVN) was notified that Patient 1 had large bruising on the right side of her chest and small discoloration to her left underarm. The area was assessed, and discoloration and slight inflammation were noted. Patient 1 stated she had trouble getting into the transportation vehicle for dialysis and she got hurt; and g. On October 4, 2025, at 2:39 a.m., Patient 1 was transferred out to the general acute care hospital for the discoloration on the right side of her chest. A review of Patient 1’s “IDT (Interdisciplinary Team – a group of healthcare professionals from different disciplines who collaborate to provide comprehensive and coordinated care for a patient) Care Conference,” with a review date of October 1, 2025, indicated that Patient 1’s family member (FM) expressed concerns regarding Patient 1’s dialysis transportation method. It was explained to him that Patient 1 went to dialysis via Uber because the facility paid for transportation and they had not been authorized to schedule a wheelchair van (wheelchair-accessible transportation). On October 3, 2025, at 10:14 a.m., during a concurrent observation and interview, Patient 1 was observed sitting in her wheelchair on the smoking patio and was wheeled by a staff member to the family room. Patient 1 stated she goes to dialysis three times a week and leaves the facility at 3:30 a.m. She stated the SSD “quit paying her insurance” for her van transportation, and the facility has been putting her in an Uber car which is uncomfortable and "awfully hard" for her. Patient 1 stated the facility nurses transferred her to the car, but “it’s wrong” because she should be going in a wheelchair van. She stated the last time she had dialysis, she was at the dialysis center until 7:30 a.m., because the facility had to send a larger Uber car which took more time. Patient 1 stated she does not want to take Uber anymore because she may end up breaking a bone. On October 3, 2025, at 11:37 a.m., during a telephone interview with the Unit Secretary (US) of (name of dialysis center), The US stated the issues with Patient 1’s transportation started when her insurance changed. Initially, the facility used UBER to transport Patient 1 to the dialysis center by herself, requiring the dialysis staff to transfer Patient 1 out of the car to her wheelchair. However, the US stated as per dialysis center policy, the dialysis staff cannot transfer patients from car (Uber) to wheelchair. Therefore, facility (skilled nursing facility-SNF) subsequently decided to provide a SNF staff member to accompany Patient 1 during her dialysis appointments. The US stated Patient 1 missed dialysis appointments in August and September 2025, due to transportation issues and her refusal to go to dialysis. The US stated the facility should have arranged wheelchair van transportation for the patient. On October 3, 2025, at 1:08 p.m., during an interview, the SSD stated Patient 1’s insurance was accepted by very few transportation companies. The SSD stated they were using private wheelchair van transportation for Patient 1, but the facility stopped paying for it and she does not know why. The owner of the private wheelchair van transportation informed her that because he was not getting paid, he could not take Patient 1 to dialysis anymore. The SSD stated the Case Manager (CM) arranged recurrent trips for Patient 1’s dialysis appointments via Uber which started the week of September 22, 2025, which was not discussed with Patient 1 nor her FM. The SSD stated it was the corporate office who determined to use Uber because they did not want to pay for wheelchair van transportation. The SSD stated if the patient’s insurance does not cover transportation, the patient can pay privately, and if the patient cannot pay, the facility will pay for it. On October 3, 2025, at 2:49 p.m., during an interview, the Director of Nursing (DON) stated the SSD coordinated the transportation. The DON stated non-emergent transportation should be provided by the facility to the patients including dialysis transportation. The DON stated that the corporate office told them to provide Uber transportation for Patient 1. On October 3, 2025, at 4:23 p.m., during a telephone interview with Patient 1’s FM, the FM stated the facility was sending Patient 1 to her dialysis appointments via Uber. He stated Patient 1 had an operation on her feet and was not supposed to put pressure on her feet and she needed a lifted van for a wheelchair transfer. The FM stated he had a meeting with the facility on October 1, 2025, and they (SNF) said they would take care of the transportation, but he did not hear from them. On October 3, 2025, at 5:17 p.m., during a telephone interview, Registered Nurse (RN) 1 stated that there was an occasion when transportation did not show up to take Patient 1 to her dialysis appointment. The SSD informed her (RN) - it was an “insurance thing.” She stated Patient 1 is now going to dialysis via Uber with two CNAs, but the CNAs stated they have trouble transferring her into the car. RN 1 stated Patient 1 used to have a wheelchair van pick her up, which was safer form of transportation for Patient 1. On October 6, 2025, at 2:53 p.m., during a telephone interview, RN 2 stated, on September 23, 2025, the transportation for Patient 1 did not show up and her dialysis appointment was rescheduled for the next day, September 24, 2025. On September 24, 2025, an Uber picked up Patient 1 to go to her dialysis appointment and she went by herself. When she arrived at the dialysis center, she did not get her dialysis treatment because she was in an Uber. RN 2 stated that it was the first time she had seen an Uber pick up Patient 1. RN 2 stated Uber was “absolutely not” an appropriate transportation for Patient 1 because it was hard for her (Patient 1) to transfer herself in and out of the Uber; and that she (patient) needed help. On October 9, 2025, at 10:39 a.m., during an interview, CNA 2 stated she began accompanying Patient 1 to her dialysis appointments via UBER on October 2, 2025. CNA 2 stated another CNA helped her transfer Patient 1 into the Uber vehicle. She stated Patient 1 could stand with two-person assistance, and she is basically "deadweight (a person who is physically unable to assist with their own movement) ". She stated Patient 1 disliked Uber, and she informed the SSD and the RN about it. On October 9, 2025, at 11:27 a.m., during an interview with the Director of Rehabilitation (DOR), she stated since Patient 1 had her toes amputated, they placed her on heel weight bearing status as a precaution to allow wound healing. The DOR stated whoever arranged the transportation should have asked their department to assess Patient 1 to determine the appropriate mode of transportation. She stated their department is typically asked to assess patients for appropriate transportation methods, but she did not know what happened this time. The DOR stated that car transfer training was conducted for Patient 1 by two other rehabilitation staff on October 3, 2025, using a staff member’s car. On October 9, 2025, at 12:31 p.m., during a follow-up interview, CNA 2 stated that on October 2, 2025, Patient 1 was agitated during the Uber ride because her FM could not pay for the wheelchair van transportation. On October 9, 2025, at 12:39 p.m., during an interview, the SSD stated she did not reach out to the rehabilitation or nursing prior to the use of Uber because the CM initiated the use of it (Uber). The SSD stated she reached out to the rehabilitation department on October 2, 2025, after speaking to Patient 1’s FM. The SSD stated Patient 1 is still going to her dialysis appointments via Uber because the corporate office would not pay for wheelchair van transportation. She stated the facility is responsible for providing the appropriate transportation for Patient 1. On October 9, 2025, at 12:56 p.m., during an interview, LVN 2 stated during shift change on October 3, 2025, he received a report from a CNA that Patient 1 had a bruise on the right side of her chest, and he created a change of condition (recording any major or minor change in a Patient’s health status). LVN 2 stated he found out the next day that Patient 1 was transferred out to the general acute care hospital. On October 9, 2025, at 1:33 p.m., during a telephone interview, the CM stated she booked Patient 1’s Uber trips to the dialysis center via Uber Health. The CM stated she did not reach out to the rehabilitation nor the nursing department before booking the Uber because she only did what she was asked to do. The CM stated the Administrator (ADM) told her to book the Uber for Patient 1’s dialysis appointments. On October 9, 2025, at 2:30 p.m., during an interview, Patient 1 stated she did not like Uber because the cars were either too small or too high, which were hard for her to get into. Patient 1 stated she was transferred into the car by the CNAs who put their arms under her armpits and scoot her backward into the car. On October 9, 2025, at 3:17 p.m., during an interview, the Physical Therapist Aid (PTA) stated they were asked to conduct car transfer training with Patient 1 and the CNAs, but not an assessment to determine an appropriate mode of transportation. The PTA stated Patient 1 can transfer from bed to wheelchair and vice versa with two-person physical assistance, meaning she can transfer anywhere as long as there are two people helping her. The PTA stated it was the facility who decided to use Uber for Patient 1. On October 9, 2025, at 3:57 p.m., during an interview, the DON stated Patient 1 was transferred to the hospital for evaluation because of her bruises which according to CNA 2, Patient 1 sustained when she became agitated and tried to get out of her seatbelt while they were inside the Uber. On October 9, 2025, at 4:40 p.m., during a follow up interview with the DON, the DON was asked if she knew that Patient 1 disliked Uber. The DON stated she heard about it on October 3, 2025, when they found out about the bruises. When asked why Patient 1 was still going to her dialysis appointments via Uber, she stated she did not have an answer. On October 9, 2025, at 4:56 p.m., during an interview, the ADM stated Patient 1 was going to dialysis via Uber with two CNAs for safety. The ADM stated the facility began paying for Patient 1’s Uber transportation when her insurance changed and a decision was made to stop using the prior transportation and he does not know why. He stated they were having problems getting transportation that is reliable to come to the facility at 4 a.m. The ADM stated that using Uber without first determining the appropriate mode of transportation poses a greater risk to the patient than using a wheelchair van. A review of Patient 1’s general acute care hospital records titled, “Physician Chart,” dated October 4, 2025, indicated Patient 1 arrived at the Emergency Department at 1:34 a.m., and on physical examination Patient 1 had bruising on the right and left side of her body between the lowest rib and the hip, with mild tenderness when touched. A review of Patient 1’s Computed Tomography (CT) Scan (a diagnostic imaging test that created detailed pictures of the inside of the body) of the chest dated October 4, 2025, indicated Patient 1 had a right breast and chest muscle and soft tissue swelling, right chest wall subcutaneous (under the skin) soft tissue swelling probable contusion (bruise), possible nondisplaced lateral right rib fractures (a type of bone fracture where the broken bone pieces remain in their original position). A review of the facility’s policy titled, “Transportation, Social Services,” dated January 2018, 2025, indicated “...Our facility shall help arrange transportation for residents as needed...Social services will help the resident as needed to obtain transportation...” Based on interview and record review, it was determined that the facility failed to ensure safe and approp