Health inspection·May 1, 2025

F636 §483.20 Resident Assessment The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident’s functional capacity. §483.20(b) Comprehensive Assessments §483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident’s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychological well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnosis and health conditions. (xi) Dental and nutritional status. (xii) Skin Conditions. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

F655 §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(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. (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. §483.21(a)(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). §483.21(a)(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.

F684- Quality of Care § 483.25 Quality of care- Quality of care is a fundamental principle that applies to all treatment and care CVA patients receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the patients’ choices[.]

F835 §483.70 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. On 3/12/2025 at 7:35 AM, the California Department of Public Health [CDPH] conducted an unannounced visit to the facility, to investigate a complaint regarding quality of care and death of Resident 1. Resident 1 was hospitalized at general acute care hospital (GACH 1) on 12/26/2023. Resident 1 was hospitalized at GACH 1 for an acute cerebrovascular accident (CVA – a type of stroke [occurred when blood flow to the brain was interrupted], loss of blood flow to a part of the brain), right internal carotid artery stenosis (Rica stenosis – a condition that happened when the carotid artery, which was the large artery on either side of the neck, becomes blocked), and PAD. On 03/10/2022, GACH 1 transferred Resident 1 to the facility, providing written recommendations for care and treatment based on Resident 1’s diagnoses and condition. As a result of the investigation, CDPH determined the facility failed to: 1. Ensure the facility’s licensed staff and the attending physician, identified Resident 1’s diagnoses of PAD and Atherosclerosis (the buildup of fats, cholesterol and other substances in and on the artery walls. This buildup is called plaque) and include in the resident’s cumulative diagnoses list (a compilation of all diagnoses a patient has received, including past and present conditions, to provide a comprehensive overview of their medical history) upon readmission to the facility on 3/10/2022, to establish the resident’s diagnoses while in the facility. 2. Ensure the facility’s licensed staff and administration followed through Resident 1’s elective (a procedure that was chosen [elected] by the patient or physician that was advantageous to the patient) bilateral lower extremity (legs) arteriogram (a medical imaging procedure to visualize and assess blood flow in the arteries [blood vessels] and detect blockages to plan for surgical interventions) and endovascular intervention (a surgical procedure used to treat a wide range of vascular conditions including PAD and stenosis [narrowing of a passageway in the body]), in accordance with the GACH 1 Discharge (DC) Summary orders made by the GACH 1 Physician on 3/10/2022. GACH 1 DC Summary on 3/10/2022 indicated GACH 1 physician recommendations for an elective bilateral lower extremity arteriogram and endovascular intervention when Resident 1 is stable. 3. Ensure the facility followed its policies and procedures. As an example, but not limited to, licensed staff develop a PAD/PVD and Atherosclerosis comprehensive and individualized care plans, in accordance with the facility’s policy & procedures titled “Care Area Assessments.” 4. Ensure the facility’s licensed staff monitor Resident 1’s bilateral (both) pedal pulses (palpable pulse wave in the arteries of the foot). It is a clinical sign used to assess the circulation in the lower extremities) as indicated in the resident’s Physician’s Order dated 3/10/2022. The licensed nurses documented monitoring and assessment of Resident 1’s left pedal pulses from 3/11/2022 to 3/21/2022 and did not have documentation of monitoring and assessment of Resident 1’s right pedal pulses from 3/11/2022 to 3/21/2022. The order for bilateral pedal pulses monitoring was discontinued without a reason on 3/21/2022. Subsequent to these failures, Resident 1’s condition deteriorated. Resident 1 developed right knee and right lateral knee extending to posterior aspect open scratch vascular wounds on 12/22/2023. On 12/26/2023 Resident 1 experienced a change in condition, developing symptoms of altered level of consciousness (ALOC), and fluctuating oxygen saturation (indicated how much oxygen the blood was carrying, [normal ranges from 95% to 100%) of 86 to 90% secondary to sepsis from known wounds to the right knee, requiring 911 emergency services to transfer Resident 1 to GACH 2. Resident 1’s GACH 2 physician notes indicated Resident 1 had a suspected right lower extremity superficial femoral artery occlusion (refers to a partial or complete blockage of the femoral artery [a large blood vessel located in the upper thigh], which can lead to reduced blood flow and oxygen supply to the lower leg and foot). Resident 1 died at GACH 2, two days after the GACH 2 admission, on 12/28/2023, with diagnoses that included but not limited to cellulitis of the leg (a bacterial infection of the skin and the tissues beneath the skin), right lower extremity gangrenous (when lack of blood flow causes tissues in the body to die) changes, PAD and septic shock (a subset of sepsis [a serious condition in which the body responds improperly to an infection] in which particularly profound circulatory (the system that contains the heart and the blood vessels and moves blood throughout the body) and metabolic abnormalities [disruptions in the body's chemical processes that convert food into energy and building blocks] substantially increase death). A review of Resident 1’s GACH 1 record, the resident’s Duplex Ultrasound ([US] a test to see how blood moves/flows through the arteries and vein) dated 2/28/2022 was reviewed. The US indicated that Resident 1’s Right Lower Extremity Arterial (a blood vessel that carried blood from the heart to the tissues and organs in the body) US indicated “50 to 75% stenosis (narrowing of a passageway in the body), in the mid superficial (on the surface) femoral artery (the main blood vessel that delivered oxygen-rich blood from the heart to your lower body, specifically the thigh and leg), 30 to 49% stenosis in the right external iliac artery (a major blood vessel that carried oxygenated blood from the pelvis [bone that connects spine to the legs] to the legs)...” A review of Resident 1’s GACH 1 Left Lower Extremity Arterial Duplex (sound waves used to create images of blood vessels and assess blood flow) dated 3/1/2022, the Ultrasound indicated “Severe diffuse calcific (buildup of calcium deposits that could lead to hardening of tissues, blood vessels, or organs) atherosclerotic disease identified throughout the left lower extremity with at least moderate stenosis left external iliac (brings blood to the legs) and common femoral arteries with severe stenosis within the proximal (center of the body) and mid superficial (located on or near the surface of the body) femoral artery of at least 50 to 75% narrowing...” A review of Resident 1’s GACH 1 Interventional Radiologist’s (IR, a medical specialty that used imaging techniques to guide tiny instruments through the body to diagnose and treat diseases) Consultation dated 3/1/2022, the IR Consultation indicated Resident 1 would benefit from an elective bilateral lower extremity arteriogram and endovascular intervention when the resident is stable... A review of Resident 1’s GACH 1 DC Summary dated 3/10/2022, authored by the GACH 1 physician, the DC Summary indicated one of Resident 1’s “problems” included PAD. The DC Summary indicated Resident 1’s reason for admission to GACH 1 was Left Upper Extremity and Left Lower Extremity (LLE) numbness and weakness. The DC Summary indicated Resident 1 was deemed stable for discharge back to the facility. The DC Summary included the following problems for Resident 1: “1. Acute CVA. “2. RICA. “3. PAD – Doppler Ultrasound (used sound waves to visualize and measure blood flow in vessels, arteries, and veins, helping doctors assess blood flow speed and direction, and detect conditions like clots or blockages) showed LLE arterial stenosis and bilateral AT/PT stenosis. IR consulted for further recommendation indicated elective bilateral lower extremity arteriogram and endovascular intervention when resident was stable. Any dual antiplatelet (medications that prevent platelets from clumping together and forming blood clots) therapy would be beneficial for the resident’s PAD.” “4. Diabetes ...” A review of Resident 1’s Admission Record (AR), the AR indicated a 77-year-old, male resident was readmitted to the facility on 3/10/2022, with diagnoses that included but not limited to the following: 1. Atherosclerosis of native arteries (a natural, un-altered blood vessel that carried oxygen-rich blood from the heart to the body’s tissues and organs) of extremities with intermittent claudication (most common symptom of PAD which is pain and numbness in the lower extremities made worse with exertion of affected extremity) of bilateral legs. 2. Type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and