Health inspection·December 24, 2025

Title 22 Article 6 Physical Plant 72601. Alterations to Existing Buildings or New Construction. (a) Alterations to existing buildings licensed as skilled nursing facilities or new construction shall be in conformance with Chapter I, Division 17. Part 6. Title 24, California Administrative Code [Reference: 2022 California Building Code Section 1225.2 – New buildings and additions, alterations, or repairs to existing buildings subject to licensure shall comply with applicable provisions of the California Electrical Code, California Mechanical Code, California Plumbing Code and California Fire Code (Parts 3,4, 5 and 9 of Title 24)] and requirements of the State Fire Marshal. 72649. Gases for Medical Use. (a) Gases for medical use covered by this section are: carbon dioxide, cyclopropane, ethylene, helium, nitrous oxide, oxygen, helium-oxygen mixtures and carbon dioxide-oxygen mixtures. (b) Provision shall be made for safe handling and storage of medical gas cylinders. (c) Transfer of gas by facility personnel from one cylinder to another shall not be permitted. (d) The piped oxygen or nitrous oxide system(s) shall be tested in accordance with the “NFPA 99: Health Care Facilities Code” (2012) by the National Fire Protection Association, hereby incorporated by reference, and a written report shall be maintained in each of the following instances: (1) Upon completion of initial installation. (2) Whenever changes are made to a system. (3) Whenever the integrity of a system has been breached. On 12/11/2025 at 1:20 PM, CDPH made an unannounced visit to the facility to investigate a FRI regarding the physical environment. The facility failed to obtain the required written emergency authorization, building permit, construction approval, and attain substantial compliance from the California Department of Healthcare Access and Information (HCAI, previously known as the Office of Statewide Health Planning and Development [OSHPD], the State agency that reviews and approves plans for construction, repairs, renovations and remodeling made to healthcare facilities to comply with state Building Codes) prior to repairing the oxygen medical gas line of the medical gas system (network of pipelines, valves, outlets, and monitoring equipment in healthcare facilities that delivers essential gases, such as oxygen, medical air, nitrous oxide, and vacuum, to patient care areas for life-supporting and therapeutic use) connected to the Subacute (a level of medical care that is less intensive than acute care [an active, short-term treatment for an episode of illness or severe injury] but more specialized than typical skilled nursing care) unit. Additionally, the facility did not submit the required inspection, testing, and verification report from a certified medical gas verifier (individual who verifies medical gas systems have been installed per National Fire Protection Association [NFPA, an organization that develops and publishes fire, electrical, and life safety codes and standards] 99, Health Care Facilities Code [a safety standard that outlines requirements for healthcare facility systems, including medical gas, to minimize risks to patients, staff, and visitors] standards) to HCAI prior to reactivating the system once the repairs were complete. As a result, 43 residents in the Subacute unit, all of which could potentially rely on the oxygen medical gas system for life-sustaining treatment, were placed at risk of contaminated oxygen inhalation, increased fire risk from oxygen leakage, and/or failure during resident care, from the unauthorized repair of the oxygen medical gas system. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents. During an interview on 12/11/2025 at 1:47 PM with the Director of Nursing (DON), the DON stated, “At 10:02 AM of 12/9/2025, the PSI [pounds per square inch, measure of pressure] alarm of Subacute went off. We contacted Facilities to investigate. By 12:25 PM, we were on H tanks [a large, high-capacity, high-pressure steel cylinders used for storing compressed oxygen gas] and cut out from the main [oxygen] line, and using the H tanks.” During an interview on 12/11/2025 at 1:54 PM with the Facility Director (FD), the FD stated that the oxygen medical gas line for the Subacute unit has been, “In the ground since 1958.” During an interview on 12/11/2025 at 1:57 PM with the FD, the FD stated that on 12/9/2025, they discovered a problem with the oxygen medical gas line going from the main oxygen tank to the Subacute section. During an interview on 12/11/2025 at 2:12 PM with the FD, the FD stated that the oxygen medical gas line for the Subacute unit was closed, and residents were receiving oxygen via back feeding from six vertical gas liquid (VGL, specialized, vacuum-insulated containers used to safely store and transport super-cold liquids, like liquid oxygen, at very low temperatures) tanks. During an observation on 12/11/2025 at 2:56 PM with the Charge Nurse (CN) by the southwest side of the Subacute building, one of six VGL tanks was connected to the Subacute building. During a concurrent observation and interview on 12/11/2025 at 3:11 PM with the CN by the southwest side of the Subacute building, there was a construction crew present with digging equipment, and the walkway pavement had been removed. The CN stated that the facility was trying to find out where the leak was coming from. During an interview on 12/12/2025 at 11 AM with the Facility Services (FS), the FS stated that they had determined the leak to be somewhere along the pipe that goes from the main oxygen tank to the Subacute unit. During a concurrent observation and interview on 12/12/2025 at 11:28 AM with the FS in the Subacute parking area, there was an open pipe in the ground vault, with construction crew present nearby. The FS stated that the facility found and removed the section of pipe where the leak was coming from, and that the leak was due to corrosion over the years. During an interview on 12/12/2025 at 12:34 PM with the FD, the FD stated that the leaking oxygen medical gas line had been repaired, and the oxygen medical gas line from the main oxygen tank was turned back on to the Subacute unit. The FD stated that the plumbing company took pictures of the repair, which included brazing (method to join metal pipes using a filler metal and intense heat from a torch) the pipe. The FD stated they sent documentation to the Inspector of Record (IOR, an independent inspector certified by HCAI that is responsible for verifying that all construction work complies with approved plans and applicable codes), who will, in turn, notify the HCAI Regional Compliance Officer (RCO). During an interview on 12/12/2025 at 1:35 PM with the RCO, the RCO stated that the facility did not perform the proper inspection and verification for the repair of the oxygen medical gas line. The RCO stated the facility had not officially opened a project or received approval from HCAI for the oxygen medical gas line repair. The RCO stated that the process, including shutting off the oxygen, performing the brazing procedure, cutting off the valve, and capping the valve, needs to be inspected by a, “6020 med gas inspector [a certified professional who inspects medical gas systems to ensure compliance with safety codes and standards],” or a, “6030 med gas verifier [a certified expert who tests and verifies the proper installation and operation of medical gas systems before they are used].” The RCO stated once the repairs are complete, the 6030 med gas verifier must perform the medical gas verification process before the medical gas system may be turned on and used for patients. The RCO stated that if the system is not verified to be clean, there is concern that patients may inhale contaminated gas. The RCO stated that it is better for the facility to continue using temporary oxygen tanks until the medical gas system is properly verified. During a review of an e-mail from RCO to the facility, dated 12/12/2025, the e-mail indicated, “I express the following concerns based on the information provided. The leak was found to be a ‘future’ valve [capped-off connection point to allow for the easy addition of a valve or new plumbing fixture at a later date] that was corroded. It was cut off and capped. A 6020 medgas or a 6030 medgas verified needs to be inspecting this work. Once complete the 6030 needs to complete the medical gas verification process.” The e-mail indicated that, if the medical gas verification was not completed, “I recommend that these temporary tanks or a trailer is reconnected to the Emergency Oxygen Supply Connection (EOSC) once again. The concern is that verification the medical gas line is safe, pure and functional in accordance with NFPA 99 Chapter 5.” During an interview on 12/12/2025 at 2:25 PM with the FD, inspection and verification of the medical gas system for the repaired oxygen medical gas line was requested. The facility was unable to provide the requested documents. The FD stated that the medical gas inspection and testing verification would be done either that day (12/12/2025), or Monday (12/15/2025), at the latest. During an interview on 12/12/2025 at 2:35 PM with the FD, the FD stated that the main medical gas line was connected to the Subacute unit after the oxygen medical gas line repair was completed at approximately 12:30 PM on 12/12/2025. The FD stated that the Subacute unit was currently receiving oxygen from the bulk oxygen storage, which is part of the facility’s medical gas system. During a concurrent observation and interview on 12/12/2025 at 2:45 PM with the FD in the Subacute nursing station, the main oxygen medical gas line valve at nursing station was turned on. The FD stated, “Right now, the Subacute is getting oxygen from the main tank.” During an interview on 12/12/2025 at 2:47 PM with the FD, the FD stated that the decision to reactivate the medical gas system to the Subacute unit was made collaboratively by respiratory therapy, nursing supervision, Facilities, and the Chief Executive Officer. During a concurrent interview and record review on 12/12/2025 at 3 PM with the CN, the facility’s census for 12/12/2025 was reviewed. The facility’s census indicated that there was a total of 43 residents in the Subacute unit. The CN stated 24 residents are on oxygen ventilator machines (a life-support device that helps a person breathe when they are unable to do so on their own, by delivering oxygen-rich air to the lungs through a mask or a tube), and 16 residents are on oxygen concentrators (medical device that takes in air from the surrounding environment and provides concentrated supplemental oxygen through a nasal cannula or mask). During a concurrent observation and interview on 12/12/2025 at 4:42 PM with the CN in Room A, there was a resident that was connected to an oxygen ventilator machine, which was in turn connected to a green wall outlet labeled “Oxygen, Use No Oil”. The CN stated, “They’re currently receiving oxygen. We know because of the hissing noise it makes if we loosen the flowmeter, and also the ventilator machine alarms when the oxygen is low.” During a concurrent observation and interview on 12/12/2025 at 4:47 PM with the CN in Room B, there was a resident that was connected to a ventilator machine, which was in turn connected to a green wall-outlet labeled “Oxygen, Use No Oil”. The CN stated the resident is currently receiving oxygen. During a concurrent observation and interview on 12/12/2025 at 4:49 PM with the CN in Room C, there was a resident that was connected to a ventilator machine, which was in turn connected to a green wall-outlet labeled “Oxygen, Use No Oil”. The CN stated the resident is currently receiving oxygen. During a concurrent observation and interview on 12/13/2025 at 12 PM with the Maintenance Personnel (MP) and FD (who was on the phone) in the parking lot of the Subacute building, the MP opened the manhole and showed the oxygen medical gas line that was capped off. The end point of the repaired copper pipe was capped off. The FD stated over the phone that the repair of the oxygen medical gas line involved the removal of the failed shut-off valve and the capping of the copper oxygen supply line located in the manhole in the parking lot of the Subacute building. The facility failed to obtain the required written emergency authorization, building permit, construction approval, and attain substantial compliance from HCAI prior to repairing the oxygen medical gas line of the medical gas system connected to the Subacute unit. Additionally, the facility did not submit the required inspection, testing, and verification report from a certified medical gas to HCAI prior to reactivating the system once the repairs were complete. As a result, 43 residents in the Subacute unit, all of which could potentially rely on the oxygen medical gas system for life-sustaining treatment, were placed at risk of contaminated oxygen inhalation, increased fire risk from oxygen leakage, and/or failure during resident care, from the unauthorized repair of the oxygen medical gas system. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.