Health inspection·January 6, 2026

The following reflects the findings of the California Department of Public Health (CDPH) during the investigation of complaint number 2677218. A Class A Citation was written. §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Treatment/Svcs to Prevent/Heal Pressure Ulcer Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that- (i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident- §483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. § 483.25(h) Parenteral Fluids. Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. § 483.20 Resident assessment. The facility must conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity. . . . (g) Accuracy of assessments. The assessment must accurately reflect the resident's status. . . . § 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: (A) The admission of a patient. (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (C) An unusual occurrence, as provided in Section 72541, involving a patient. . . . § 72315. Nursing Service--Patient Care. (d) Each patient shall be provided care which shows evidence of good personal hygiene, including care of the skin , shampooing and grooming of hair, oral hygiene, shaving or beard trimming, cleaning and cutting of fingernails and toenails. The patient shall be free of offensive odors. . . . (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (1) Changing position of bedfast and chairfast patients with preventive skin care in accordance with the needs of the patient. (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. (4) Using pressure-reducing devices where indicated. (5) Providing care to maintain clean, dry skin free from feces and urine. (6) Changing of linens and other items in contact with the patient, as necessary, to maintain a clean, dry skin free from feces and urine. (7) Carrying out of physician's orders for treatment of decubitus ulcers. The facility shall notify the physician when a decubitus ulcer first occurs, as well as when treatment is not effective, and shall document such notification as required in Section 72311(b). Title 22, California Code of Regulations: § 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 11/25/2025, CDPH made an unannounced visit to the facility to investigate an allegation regarding a resident's death. As a result of the investigation, CDPH determined that the facility failed to: 1. Provide skin and pressure injury (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) care consistent with professional standards of practice and per physician's orders in order to prevent the development and deterioration of pressure injuries for Resident 1 by failing to implement the recommendation of the document titled," SNF [Skilled Nursing Facility Wound Care," by the wound care specialist dated 10/21/2025 for pressure relieving devices. 2. Provide incontinence care (the involuntary loss of urine or feces) to Resident 1 to prevent Moisture-Associated Skin Damage (MASD - skin inflammation and erosion from prolonged exposure to moisture (urine, feces, sweat, saliva, wound drainage) and irritants, leading to breakdown, especially in areas like skin folds or around ostomy sites, with types including incontinence) in accordance with the facility's policy and procedures (P&P) titled, "Skin Integrity Management," reviewed 12/16/2024. 3. Implement the physician's order dated 11/5/2025 for Registered Dietician (RD) for consultation for Resident 1. 4. Implement the physician's order for Resident 1 dated 11/6/2025 at 7:02 pm to administer intravenous (IV-inside a vein) fluids for dehydration. 5. Implement the physician's order dated 11/5/2025 for laboratories ( Complete Blood Count CBC - a common blood test that measures the main components of your blood: red blood cells, white blood cells, and platelets] with diff [differential] and basic metabolic panel (a blood test that measures glucose (sugar), electrolytes, and kidney function]. Culture, urine (C&S - a lab test that checks for bacteria or other germs in a urine sample to diagnose a urinary tract infection (UTI-infection in any part of the urinary system) , Urinalysis (UA - a simple medical test of a urine sample that checks its appearance, chemical makeup, and microscopic components to help diagnose and monitor conditions like kidney disease, diabetes, and UTI) for Resident 1. 6. Notify a Medical Doctor (MD) when Resident 1 experienced a change in condition (COC - a major decline or improvement in a resident's status that will not normally resolve without intervention) by refusing to drink fluids, eat or ate less than 50% (percent) in accordance with the facility P&P titled "Change in Condition: Notification" reviewed 12/16/2024. 7. Have the IDT (Interdisciplinary Team - is a coordinated group of various healthcare professionals (nurses, doctors, therapists, social workers, dietitians, activities staff, etc.) care conference indicate measures to be implemented to prevent the development/deterioration of pressure injuries. As a result, Resident 1 was transferred and admitted to General Acute Care Hospital (GACH) on 11/7/2025 where she was diagnosed with severe sepsis (a serious illness that happens when your body has a strong reaction to an infection. This reaction can cause problems in important organs like the heart, lungs, or kidneys. It means the infection is not just in one place, it's affecting the whole body and causing organs to fail. Doctors treat it quickly because it can be life-threatening), bacteremia (the presence of bacteria in the bloodstream), osteomyelitis (an infection and inflammation of the bone, mostly caused by bacteria), and severe dehydration (is a serious and dangerous condition where the body lacks enough fluid for normal function, leading to symptoms like confusion, rapid heart rate, sunken eyes, lack of urination, extreme thirst, listlessness, and even shock or unconsciousness, requiring immediate medical attention, often with IV fluids). Resident was put to palliative care (specialized medical care providing physical, emotional and spiritual support for people living with chronic conditions or serious illness and expired on 11/15/2025. A review of Resident 1's admission record indicated the facility admitted the resident on 11/18/2015, with diagnoses that included rheumatoid arthritis (RA-is a chronic (ongoing) autoimmune disease where the immune system mistakenly attacks the body's own tissues, primarily the joints, causing inflammation, pain, swelling, stiffness, and potential joint deformity over time), anemia (a condition where the body does not have enough healthy red blood cells), RA multiple sites and hypertension (HTN-high blood pressure). The admission record did not indicate Resident 1 had diagnoses of pressure ulcers or failure to thrive. A review of Resident 1's history and physical (H&P) dated 12/12/2024, indicated that Resident 1 was able to make needs known but could not make medical decisions. The H&P indicated Resident 1's diagnoses included, "Dementia (a decline in mental ability, such as memory, thinking, and reasoning, that is severe enough to interfere with daily life) without behavioral disturbance." The H&P indicated Resident 1's family member (FM) was Resident 1's durable power of attorney (DPOA- legal authority to make Resident 1's decisions). The H&P indicated Resident 1's diagnoses included, "Dementia (a decline in mental ability, such as memory, thinking, and reasoning, that is severe enough to interfere with daily life) without behavioral disturbance." The H&P did not indicate Resident 1 had pressure injuries, had failure to thrive, and was refusing to eat and or drink. The H&P indicated Resident 1 moved all extremities spontaneously, however, Resident 1's right hand was chronically contracted. A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 8/8/2025, indicated the resident had severe cognitive impairments (a condition that involves a significant loss of abilities like memory, decision-making, and problem-solving, to the point where an individual often cannot live independently). The MDS indicated Resident 1 mostly required partial/moderate assistance for activities of daily living (ADLs) such as toileting hygiene, Shower/bathe, upper and lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1 could roll from lying on back to left side and right side and return to lying on back on the bed. The MDS indicated Resident 1 has impairment on one side of the upper extremity (shoulder, elbow, wrist, and hand). The MDS indicated Resident 1 did not attempt to sit, stand, transfer from a bed to chair, or walk, The MDS active diagnoses did not include a diagnosis for pressure ulcers or injury. a. A review of Resident 1's Skin Assessment dated 9/8/2025 indicated, "Sacro-coccyx Moisture-Associated Skin Damage (MASD- inflammation or erosion of the skin caused by prolonged exposure to a source of moisture, such as urine, stool, perspiration, or wound fluid) measuring 3 centimeters (cm - length/unit of measurement) x 1cm (width) x 0.1 (depth) cm." A review of Resident 1's Care Plan Report with focus on "Resident at risk for skin breakdown related to (left blank) and or has actual skin breakdown Type (left blank) location (left blank) Advanced age ..., decreased activity, frail fragile skin, history of pressure ulcer, incontinence, limited mobility, moisture ..., shear/friction risks: Sacro-coccyx MASD with (c) ..., initiated on 9/8/2025. The care plan goal indicated: Healing goal. The resident's wound/skin impairment will heal ..." The care plan interventions included ... provide wound treatment as ordered... Weekly wound assessment by license nurse, weekly wound assessment to include measurements and description of wound. A review of Resident 1's SNF (Skilled Nursing Facility) Wound Care document dated 10/21/2025, indicated, "Reason for visit: I was asked by the physician (attending) to evaluate and treat the patients (Resident 1's) wounds." The SNF wound care document indicated, "... Wound 1: sacrococcyx stage III (3) re-opened, pressure wound. Measurement: 3.2 x 2.8 x 0.1 cm ... Removal of devitalized necrotic subcutaneous tissue to promote healing. ... Due to the patient's mental status and orientation, it is difficult to fully educate the patient. The patient is incontinent... Please change dressing after shower/bed bath/soilage to avoid leaving on wet/moist dressings. Change position often to keep off the wound, and spread weight evenly with cushions, mattresses, pillows, foam wedges, or other pressure relieving devices ... Overall treatment goals include a decrease in wound size, preventing infection/inflammation, maceration, excessive drainage, malodor ... If the patient has any complications, please contact me (ordering physician)." A review of Resident 1's Interdisciplinary Team Care Conference (IDT) dated 10/27/2025 at 5:22 pm, indicated, Resident 1 was at risk for skin breakdown related to advanced age ..., decreased activity, frail fragile skin, history of pressure ulcer, limited mobility, moisture ..., shear/friction, and or has actual skin breakdown type: Sacro-coccyx PI (pressure injury). The IDT care conference did not indicate measures to be implemented to prevent the development/deterioration of pressure injuries. A review of Resident 1's SNF (Skilled Nursing Facility) Wound Care document dated 10/28/2025, indicated, "Reason for visit: I was asked by the physician (attending) to evaluate and treat the patients (Resident 1's) wounds." The SNF wound care document indicated, "... Wound 1: sacrococcyx stage III (3) reopened, pressure wound. Measurement: 3.6 x 2.8 x 0.1 cm ... Removal of devitalized necrotic subcutaneous tissue to promote healing. ... The patient is incontinent. Please change dressing after shower/bed-bath/soilage to