Health inspection·July 25, 2025

REGULATORY VIOLATIONS: Cal. Code Regs., Tit. 22, § 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. § 72507. Smoking. (a) Patients shall not be permitted to smoke in or on the bed except when a facility staff member or responsible adult is present in the room to ensure safety against fire hazards. (b) The facility shall provide designated areas for smoking. Patients shall be permitted to smoke only in designated areas. The designated area shall be under the periodic observation of facility personnel or responsible adults. This does not preclude the designation of the patient rooms as smoking areas. (c) The facility shall provide a designated area for nonsmoking patients. Such a designated area shall be identified by prominently posted “No Smoking” signs. (d) Smoking or open flames shall not be permitted in any rooms or spaces where oxygen cylinders are stored or where oxygen is in use. Such rooms or spaces shall be identified by prominently posted “No Smoking” or “No Open Flame” signs. § 483.21 Comprehensive person-centered care planning. (a) Baseline care plans. (1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must— (i) Be developed within 48 hours of a resident's admission.d (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: (A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. (2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan— (i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). (3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary. (b) Comprehensive care plans. (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at § 483.10(c)(2) and § 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under § 483.24, § 483.25, or § 483.40; and (ii) Any services that would otherwise be required under § 483.24, § 483.25, or § 483.40 but are not provided due to the resident's exercise of rights under § 483.10, including the right to refuse treatment under § 483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv) In consultation with the resident and the resident's representative(s)— (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. (2) A comprehensive care plan must be— (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to— (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. (3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must— (i) Meet professional standards of quality. (ii) Be provided by qualified persons in accordance with each resident's written plan of care. (iii) Be culturally-competent and trauma-informed. F689 § 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 resident's choices, including but not limited to the following: (d) Accidents.The facility must ensure that— (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 6/6/2025 at 11 AM, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility, to investigate a complaint regarding resident neglect and quality of care. As a result of the investigation, CDPH determined that the facility failed to: 1. Identify, assess, and develop interventions to provide additional monitoring and ensure the safety of Resident 1, who tested positive for amphetamine (a man made, highly addictive drug stimulant and is illegal without prescription) on 4/24/2024, for potential to continued drug use and intoxication from meth use, in accordance with the facility’s P&P titled “Care Planning- Interdisciplinary Team,” and “Smoking Policy - Residents.” 2. Develop a comprehensive care plan for Resident 1 that included voluntary inspection of personal belongings, staff training, monitoring/recognizing for signs and symptoms of repeated substance use, such as amphetamines/methamphetamine [meth] (similar substances [highly addictive drug stimulants] but not identical], after testing positive for amphetamines on 4/24/2024 at GACH 1, in accordance with the facility’s P&P titled "Care Planning - Interdisciplinary Team" and “Smoking Policy - Residents.” 3. Secure and prevent Resident 1 from keeping smoking items (cigarettes, glass pipe, and lighters) in his possession, when Resident 1 was assessed by the facility and documented as a non-smoker on 10/8/2024, in accordance with the facility’s policy and procedures (P&P) titled “Smoking Policy - Residents” and "Personal Property." 4. Develop and implement interventions to ensure the safety of Resident 1 and other residents when lighters were found present in Resident 1's room on 6/4/2025, who had orders to receive continuous oxygen daily, in accordance with the facility’s P&P titled "Hazardous Areas, Devices and Equipment," and “Smoking Policy - Residents.” 5. Identify all hazards in Resident 1’s environment when facility staff failed to identify Resident 1’s risk of smoking meth inside his room and while oxygen was in use and addressed appropriately to ensure Resident 1’s and other residents’ safety and mitigate accident hazards to the extent possible, after Resident 1 tested positive for meth on 4/24/2024, in accordance with facility’s P&P titled "Hazardous Areas, Devices and Equipment," and “Smoking Policy – Residents” and "Personal Property." 6. Ensure Resident 1 was placed on supervised visitation for possible individuals that may bring illegal substances into the facility which place the resident’s health and safety at risk, after Resident 1 tested positive for amphetamine use on 4/24/2024, in accordance with the facility’s P&P titled, "Visitation." 7. Follow and implement the facility’s P&P titled “Smoking Policy- Residents,” to reevaluate Resident 1’s smoking safety/supervision and/or restrict any smoking related privileges, confiscate smoking items if found in violation with the smoking policy and alert all facility staff, after Resident 1 tested positive for amphetamine use on 4/24/2024. As a result of these deficient practices, Resident 1 experienced tachycardia (rapid heart rate, defined as a heart rate exceeding 100 beats per minute [bpm]), oxygen (O2) desaturation (oxygen levels in the blood drop below normal for an extended period, normal blood oxygen level is 95 percent [%] to 100% ), shortness of breath (SOB) on 6/4/2025. Resident 1 was transported by Emergency Medical Services (EMS or 911) to General Acute Care Hospital (GACH) 2 on 6/4/2025 at 5:54 p.m. GACH 2 Toxicology Report dated 6/4/2025, indicated Resident 1 tested positive for amphetamines and methamphetamines upon arrival to GACH 2, requiring intubation (a way to secure the airway and support breathing) and admission to the GACH 2 Intensive Care Unit (ICU- a special area in a hospital or healthcare facility for people who have a life-threatening illness or injury). On 6/5/2025, after Resident 1 was transferred to GACH 2 on 6/4/2025, the police were dispatched to the facility due to facility staff finding narcotics (a drug or other substance that affects mood or behavior and is consumed for nonmedical purposes, especially one sold illegally) in Resident 1’s property. The Police Report dated 6/5/2025, indicated narcotics and a meth pipe (a thin glass tube with a round bulb at one end where the meth crystals are placed. The bulb has a small opening through which the user inhales the vaporized drug) were found in Resident 1’s room. A review of Resident 1's Admission Record (AR), indicated the facility originally admitted Resident 1 to the facility on 7/12/2021 and readmitted on 6/30/2024 with diagnoses that include paraplegia (the inability to voluntarily move the lower parts of the body), incomplete (some degree of movement and sensation may be retained below the injury site), emphysema (a type of chronic obstructive pulmonary disease [COPD, a lung disease characterized by long-term poor airflow]), atrial fibrillation (irregular heart beat), hypertensive heart disease (a group of heart conditions that develop as a result of prolonged high blood pressure) with heart failure (when the heart cannot pump enough blood and oxygen), and depression. A review of Resident 1's GACH 1 Physician History & Physical (H&P) dated 4/24/2024, indicated Resident 1 was transferred to GACH 1 due to on and off fever. Resident 1 was admitted to the Intensive Care Unit (ICU) due to low blood pressure and sepsis (a life-threatening condition where the body's response to an infection damages its own tissues and organs). GACH 1 performed a toxicology test (tests performed to detect the presence of drugs, or other chemicals in a person's body) to Resident 1 on 4/24/2024. The Toxicology Report, performed for a “Drug Screen, Urine” dated 4/24/2024, timed at 3:01 PM, indicated Resident 1 was “Positive” for Amphetamines. The Toxicology Report indicated the normal level for “Amphetamine Level, Urine” should be “Negative.” A review of Resident 1’s Order Summary Report indicated Resident 1 was readmitted to the facility from GACH 1, on 4/30/2024 under the service of primary care physician (MD) 1 with the following diagnosis: Amphetamine abuse, septic shock (a life-threatening condition that occurs when a severe infection leads to dangerously low blood pressure and organ damage), acute renal failure, multiple infected wounds and pressure sore. A review of Resident 1's facility H&P, dated 5/1/2024, indicated Resident 1 has the capacity to understand and make decisions. A review of Resident 1's facility Interdisciplinary Team (IDT- a group of professionals from different fields in the nursing facility that work together to address a patient's needs) Note, dated 5/2/2024, at 11:15 a.m., indicated, "IDT spoke to resident [Resident 1] regarding result of his urine drug screen that was completed while he was in [GACH 1] [on 4/24/2024]. Urine drug screen read that he was positive for amphetamine ... Explained to resident that taking recreational drugs is not tolerated in the facility. Provided education on risks and effects of taking recreational drugs, while taking other prescribed medications and resident's current health status. Informed resident that further investigation will be conducted regarding this matter ...IDT met to discuss resident urine drug screen result of positive for amphetamine. IDT recommends continuing to educate resident on the effect of recreational drug use while on prescribed medications, continue to provide education on the effects of recreational drug use based on his health status, remind resident that recreational drug use is not tolerated in the facility." There was no documented evidence to indicate that the facility had performed assessments, monitored, and developed care plan interventions for Resident 1 for illegal substance use, after Resident 1's urine tested positive for amphetamine in GACH 1 on 4/24/2024. A review of another GACH 1 Infectious Disease Consultation for Resident 1, with date of service on 6/28/2024, indicated under Social History, the GACH 1 record indicated “The patient (Resident 1) resides at a skilled nursing facility. He currently denies tobacco, alcohol, and drugs. He does have a history of methamphetamine use.” A review of Resident 1's facility "Smoking Assessment," dated 10/8/2024, indicated Resident 1 does not smoke. A review of Resident 1's facility record titled, "Minimum Data Set (MDS, a federally mandated resident assessment tool)," dated 3/19/2025, indicated Resident 1's cognition (ability to think, remember, and reason) was intact. The MDS indicated Resident 1 needed supervision for eating and oral hygiene, partial assistance for personal hygiene, and substantial/maximal assistance to dependent on physical assistance by staff for toileting, bathing, dressing, and transfer from bed to wheelchair. A review of Resident 1's facility record titled, “Change of Condition [COC] Evaluation,” dated 4/16/2025, at 1 p.m., indicated, "Resident [1] noted with tachycardia and desaturation.