Health inspection·April 13, 2026

§483.10(c) Planning and Implementing Care The resident has the right to be informed of, and participate in, his or her treatment, including: §483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. §483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care. §483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. §72523(a) 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. §72527(a) Patients’ Rights (a)Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and public upon request. Patients shall have the right: (3) To be fully informed by a physician of his or her total health status and to be afforded the opportunity to participate on an immediate and ongoing basis in the total plan of care including the identification of medical, nursing and psychosocial needs and the planning of related services. On 3/4/2026, the California Department of Public Health (CDPH) received a complaint alleging a resident’s (Resident 1) Responsible Party (RP) was not aware of Resident 1’s dental issues leading to the extraction of Resident 1’s tooth. Resident 1’s tooth was extracted without the RP’s knowledge or authorization. The complaint allegation indicated Resident 1 was overheard screaming indicating she was in pain and they believed this was done in retaliation for a complaint they previously filed. On 3/13/2026, CDPH conducted an unannounced visit to the facility to investigate the complaint allegations. Upon investigation, the CPDH determined Resident 1, who did not have the capacity to make decisions, tooth was extracted without the RP’s knowledge or authorization. The facility failed to: 1. Ensure Resident 1’s RP was notified of Resident 1’s dental needs and/or proposed procedure and a consent was obtained from the RP prior to Resident 1’s tooth extraction. 2. Ensure the facility followed its Policy and Procedure (P/P) titled “Notification of Changes” revised 12/19/2022, that indicated “the facility shall inform the residents’ representatives for any decisions that have to be made when the residents are incapable of making decisions.” 3. Ensure the facility followed its P/P titled “Informed Consent” revised 12/19/2022, that indicated “the facility must uphold the right of the residents to participate in the planning and decision-making process concerning their care and treatment. When a complex situation arises; the facility shall verify the informed consent obtained from the residents and/or their representative prior to any medical intervention or treatment is initiated.” 4. Ensure the facility followed its P/P titled “Resident Rights” revised 12/19/2022, that indicated “the residents’ representatives have the right to be informed, in advance, of any changes to the plan of care of the resident. The residents’ representatives have the right to be informed by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option that he or she prefers.” 5. Ensure the facility followed its P/P titled “Dental Services” revised 12/19/2022, that indicated “the resident and/or resident representative shall be kept informed of all dental arrangements.” As a result, Resident 1 and/or the RP’s right to decide to remove or not remove Resident 1’s tooth was taken away. These deficient practices had the potential to subject Resident 1 to an unnecessary procedure, discomfort/pain, bleeding, and infection. Resident 1, a 95 year -old female, was admitted to the facility on 7/13/2025. Resident 1 had diagnoses including metabolic encephalopathy (a disease that affects the brain causing confusion) and dementia (a progressive state of decline in mental abilities). A review of Resident 1’s Minimum Data Set ([MDS] a resident assessment tool) dated 1/15/2026, indicated Resident 1 was not able to make decisions that were reasonable and consistent. Resident 1 required a one-person assist to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). A review of Resident 1’s History and Physical (H&P) dated 7/14/2025, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1’s Dental Medical Order form, dated 12/6/2025, indicated a proposal to extract Resident 1’s number 12 tooth (a tooth located on the left side of the upper jaw used for crushing food) and tooth number 29 (a tooth located on the lower part of the mouth used for chewing and grinding food). Resident 1’s Attending Physician signed the form on 2/4/2026 authorizing and/or providing clearance for Resident 1 to undergo the dental procedures with instructions for the dentist to call Resident 1’s RP to explain the procedure. A review of the Dental Procedure Consent dated 3/3/2026, indicated Resident 1’s signature authorizing the tooth extraction after she read the consent in its entirety, and her questions were answered to her satisfaction. The Dental Procedure Consent indicated Licensed Vocational Nurse (LVN) 1’s signature as a witness to Resident 1’s consent for the procedure. A review of Resident 1’s Dental Progress Note dated 3/3/2026, indicated the following: 1. Resident 1’s number 12 tooth was unrestorable and was extracted with the use of dental forceps (specialized stainless-steel instrument used to grasp and remove teeth from the bone socket). Resident 1 was medicated with two doses of 1:100,000 epinephrine (an anesthetic used to provide numbness and reduce bleeding). A review of Resident 1’s Change of Condition (COC) Evaluation dated 3/3/2026 and timed at 10:50 a.m., indicated Resident 1 underwent a tooth extraction of the number 12 tooth. A review of Resident 1’s Social Service Progress Notes dated 3/5/2026 and timed at 6:10 p.m., indicated Resident 1’s RP complained that Resident 1’s tooth extraction on 3/3/3026 was completed without the RP’s knowledge or consent. During a telephone interview on 3/13/2026 at 11:45 a.m., Resident 1’s RP stated she was not aware of Resident 1’s dental concerns, or that Resident 1’s tooth needed to be extracted. The RP stated the facility’s dentist, or licensed nurses never called to provide information about Resident 1’s dental needs or to obtain consent prior to extracting Resident 1’s tooth. Resident 1 was subjected to unsafe conditions and pain, and she (RP) was disrespected when she was not informed of Resident 1’s dental needs and the extraction of her tooth. During a telephone interview on 3/13/2026 at 1:10 p.m., LVN 1 stated on 3/3/2026 before lunch (exact time unknown), she was called by the facility’s dentist to act as a translator between him (dentist) and Resident 1 during the extraction of Resident 1’s tooth. LVN 1 stated the dentist informed Resident 1 that her tooth would be removed and had Resident 1 sign a dental consent before extracting Resident 1’s tooth.  LVN 1 stated she was asked by the dentist to sign the dental consent following the procedure as a witness that Resident 1 consented to the procedure. LVN 1 stated she did not call Resident 1’s RP before the procedure to verify the RP’s knowledge of the procedure and she did not check Resident 1’s medical record to verify if Resident 1 had the capacity to consent for a medical and/or dental procedure because she thought this had already been done prior to the procedure. During a telephone interview on 3/13/2026 at 1:13 p.m., the Registered Nurse Supervisor (RNS) stated he was informed by the dentist on 3/3/2026 during the 7 a.m. to 3 p.m. shift that Resident 1’s tooth had been extracted. The RNS stated the dentist asked him to witness Resident 1’s consent after the procedure was completed, but he (RNS) declined because he knew Resident 1 had no capacity to consent and her family was responsible for Resident 1’s healthcare decisions. During an interview on 3/13/2026 at 2:23 p.m., the Social Services Director (SSD) stated she was responsible for coordinating/arranging residents’ ancillary services, but she does not call residents’ families to explain dental care concerns or to obtain a consent for procedures. The SSD stated she faxed the Dental Medical Order to the dental office after Resident 1’s attending physician signed the order and cleared Resident 1 for the procedure on 2/4/2026. The dental office and their dentists were supposed to inform the family of the residents’ dental concerns and obtain the family’s consent for the procedure. The SSD stated the dental assistant normally checks with her before seeing residents’ but on 3/3/2026, the day of Resident 1’s procedure, she was not approached by any of the dental staff. The SSD stated on 3/4/2026, the day after the RP filed the grievance, she followed up with the dental office and was informed by the dental staff, Resident 1’s RP was not informed of the dental procedure, and her consent was not obtained. During a telephone interview on 3/16/2026 at 12:01 p.m., the Dentist stated on 3/3/2026 he explained the dental procedure to Resident 1 through LVN 1, who acted as a translator, he then had Resident 1 sign the dental consent to have her tooth extracted because Resident 1 was agreeable to the procedure. The Dentist stated he did not call Resident 1’s RP prior to extracting Resident 1’s tooth because Resident 1’s face sheet did not indicate there was a RP designated and he assumed the dental office, where he was employed, called Resident 1’s family before scheduling Resident 1’s tooth extraction. The Dentist stated he did not verify Resident 1’s cognition or capacity to make decisions prior to extracting her tooth and he should have done so prior to the procedure as well as verify with Resident 1’s RP. During a telephone interview on 3/16/2026 at 1:10 p.m., Resident 1’s Attending Physician stated it was the responsibility of the dentist to ensure any dental concerns were discussed with Resident 1 and/or her RP and to inform them of any recommended procedures and to obtain permission to proceed with those recommended services prior to the procedure.  During an interview on 3/16/2026 at 3:07 p.m., the Director of Nursing (DON) stated LVN 1 should have checked Resident 1’s medical records (H&P and Face Sheet) then referred this to the RNS and/or to her (DON) so they could determine if Resident 1 could give consent for the procedure. The DON stated they would have contacted Resident 1’s RP to determine if the RP agreed to have the procedure done. The DON stated Resident 1 should not have undergone a tooth extraction because the consent was invalid.  During an interview on 3/16/2026 at 3:30 p.m., the Administrator (ADM) stated the dentist should have communicated with Resident 1’s RP with any pertinent medical information and obtained the RP’s permission to extract Resident 1’s tooth. A review of the Dental Facilities Services Agreement dated 11/1/2022, indicated the dentist shall at all times maintain a legal and binding informed consent for dental care signed by the residents/and or their responsible parties and should coordinate with the licensed nurses of the facility to check on the residents. A review of the facility’s Policy and Procedure (P/P) titled “Notification of Changes” revised 12/19/2022, indicated “the facility shall inform the residents’ representatives for any decisions that have to be made when the residents are incapable of making decisions.” A review of the facility’s P/P titled, “Informed Consent” revised 12/19/2022, indicated “the facility must uphold the right of the residents to participate in the planning and decision-making process concerning their care and treatment.  When a complex situation arises; the facility shall verify the informed consent obtained from the residents and/or their representative prior to any medical intervention or treatment is initiated.” A review of the facility’s P/P titled, “Resident Rights” revised 12/19/2022, indicated “the residents’ representatives have the right to be informed, in advance, of any changes to the plan of care of the resident.  The residents’ representatives have the right to be informed by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option that he or she prefers.” A review of the facility’s P/P titled “Dental Services” revised 12/19/2022, indicated “the resident and/or resident representative shall be kept informed of all dental arrangements.” The facility failed to: 1. Ensure Resident 1’s RP was notified of Resident 1’s dental needs and/or proposed procedure and a consent was obtained from the RP prior to Resident 1’s tooth extraction. 2. Ensure the facility followed its P/P titled “Notification of Changes” revised 12/19/2022, that indicated “the facility shall inform the residents’ representatives for any decisions that have to be made when the residents are incapable of making decisions.” 3. Ensure the facility followed its P/P titled “Informed Consent” revised 12/19/2022, that indicated “the facility must uphold the right of the residents to participate in the planning and decision-making process concerning their care and treatment. When a complex situation arises; the facility shall verify the informed consent obtained from the residents and/or their representative prior to any medical intervention or treatment is initiated.” 4. Ensure the facility followed its P/P titled “Resident Rights” revised 12/19/2022, that indicated “the residents’ representatives have the right to be informed, in advance, of any changes to the plan of care of the resident. The residents’ representatives have the right to be informed by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option that he or she prefers.” 5. Ensure the facility followed its P/P titled “Dental Services” revised 12/19/2022, that indicated “the resident and/or resident representative shall be kept informed of all dental arrangements.” As a result, Resident 1 and/or the RP’s right to decide to remove or not remove Resident 1’s tooth was taken away. These deficient practices had the potential to subject Resident 1 to an unnecessary procedure, discomfort/pain, bleeding, and infection. These violations, jointly, separately or in any combination, had direct or immediate relationship with the health, safety or security and welfare of Resident 1.