Health inspection·February 19, 2026

42 CFR §483.25(c) Mobility (1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident’s clinical condition demonstrates that a reduction in range of motion is unavoidable; and (2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. (3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. 22 CCR §22 72315 Nursing Services – Patient Care (e) Each patient shall be encouraged and/or assisted to achieve and maintain the highest level of self-care and independence. Every effort shall be made to keep patients active, and out of bed for reasonable periods of time, except when contraindicated by orders of a licensed health care practitioner acting within the scope of his or her professional licensure. (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (3) Maintaining proper body alignment and joint movement to prevent contractures and deformities 22 CCR § 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. 22 CCR § 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: (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: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the patient. On 1/5/2026, the California Department of Public Health (CDPH) conducted an unannounced annual recertification survey at the facility. The facility failed to: 1. Measure Resident 37’s range of motion (ROM, full movement potential of a joint) in the joints of both arms during the Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation, dated 9/17/2025. 2. Measure Resident 37’s ROM in the joints of both legs during the Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation, dated 9/17/2025. 3. Provide passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) exercises to both hands in accordance with Resident 37’s physician orders and care plan, dated 11/11/2025. 4. Provide pressure relief ankle foot orthoses ([PRAFO] device worn on the calf and foot to suspend the heel and hold the ankle in neutral [90 degree] position) to both of Resident 37’s legs from 11/12/2025 to 1/8/2026 in accordance with Resident 37’s physician orders and care plan, dated 11/11/2025. These failures resulted in Resident 37’s further ROM limitations of both ankles into plantarflexion (ankle bent with toes pointing away from the body) from 12-22 degrees (normal 0-45 degrees) on the left ankle and 10-12 degrees on the right ankle upon discharge from PT on 11/11/2025, to 39-58 degrees on the left ankle and 40-59 degrees on the right ankle on 1/8/2026, placing Resident 37 at increased risk of developing pressure injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) due to the inability to apply the PRAFOs to both legs. These failures also placed Resident 37 at increased risk for further undetected ROM loss in both hands. Resident 37 was a 77 year-old male, admitted to the facility on 10/5/2024. Resident 37’s diagnoses included paralytic syndrome (broad term for conditions causing rapid muscle weakness) following cerebral infarction (brain damage due to a loss of oxygen to the area), paraplegia (loss of movement and/or sensation, to some degree, of the legs), muscle weakness, and contractures to both hands and the right thigh. A review of Resident 37’s Minimum Data Set ([MDS] a resident assessment tool), dated 12/11/2025, indicated Resident 37 had clear speech, expressed ideas and wants, understood verbal content, and had intact cognition (clear ability to think, understand, learn, and remember). The MDS indicated Resident 37 was independent with eating. The MDS indicated Resident 37 required setup or clean-up assistance for oral hygiene. The MDS indicated Resident 37 required substantial/maximal assistance (helper does more than half the effort) for upper body dressing and rolling to both sides while lying in bed, and was dependent for toileting, lower body dressing, bathing, transferring from lying in the bed to sitting at the side of the body, and chair/bed-to-chair transfers. The MDS indicated Resident 37 had ROM limitations in both arms and legs. A review of Resident 37’s Joint Mobility Screen ([JMS] brief assessment of a resident's range of motion in each joint of both arms and legs), signed on 8/1/2025 by Physical Therapist 1 (PT 1), indicated Resident 37 had minimal ROM loss (less than 25 percent [%] of full ROM) in both elbows and moderate ROM loss (26 to 50% of full ROM) in both shoulders, both wrists and fingers, and both hips. The JMS also indicated Resident 37 had severe ROM loss (more than 50% of full ROM) in both knees and ankles. The JMS findings indicated Resident 37 had a diagnosis or condition placing the resident at risk for contracture development and indicated Resident 37 maintained joint mobility. The JMS Recommendations indicated to provide a Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) maintenance program. A review of Resident 37’s OT Evaluation and Plan of Treatment, dated 9/17/2025, indicated Resident 37 was referred to OT due to reduced participation in activities of daily living ([ADLs] basic tasks that individuals perform to maintain their daily lives and independence), decreased functional mobility, decreased strength, and reduced balance. The OT Evaluation indicated Resident 37’s past medical history included paraplegia, contractures of both hands, and contracture of the right thigh. The OT Evaluation did not include an assessment of Resident 37’s ROM in both arms. A review of Resident 37’s PT Evaluation and Plan of Treatment, dated 9/17/2025, indicated the ROM in both of Resident 37’s legs were impaired (unspecified joints), the active range of motion ([AROM] performance of an exercise to move a joint without any assistance or effort of another person) of the right knee into flexion (bending the knee) measured 0-40 degrees (normal 0-135 degrees) and both knee extension (straightening out the knee) was within normal limits ([WNL] normal joint movement). The PT Evaluation did not include ROM measurements of both hips, the left knee flexion, and both ankles. The PT Evaluation indicated a goal to improve Resident 37’s ROM on both knees and ankles to prevent further rigidity (state of increased, constant muscle tone causing stiffness). A review of Resident 37’s PT Treatment Encounter Note, dated 10/17/2025, indicated the treatment session focused on right ankle PROM due to restriction into dorsiflexion (ankle bent toward the body). The PT Treatment Encounter Note indicated Resident 37 would benefit from application of a right PRAFO to further improve ankle mobility. A review of Resident 37’s PT Treatment Encounter Note, dated 10/24/2025, indicated Resident 37 was provided with ankle foot orthoses ([AFOs] brace worn on the lower leg and foot to support, stabilize, control movement, or correct the ankle and foot’s position) to both feet due to plantarflexion contractures. The PT Treatment Encounter Note indicated Resident 37’s ROM was 10-20 degrees (normal 0-45 degrees) in the left ankle and 8-10 degrees in the right ankle. A review of Resident 37’s PT Discharge Summary, dated 11/11/2025, indicated interventions included applying both AFOs to prevent contractures, perform therapeutic exercises, and therapeutic activities for bed mobility. The PT Discharge Summary indicated Resident 37’s ROM on the left ankle was 12-22 degrees and the right ankle was 10-12 degrees. The PT Discharge Summary indicated recommendations included applying splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) and PROM. A review of Resident 37’s OT Discharge Summary, dated 11/11/2025, indicated interventions included self-care management, therapeutic activities, and therapeutic exercises. The OT Discharge Summary indicated recommendations for the RNA program to apply both hand and leg splints for two hours and PROM to both arms and legs, three times per week or as tolerated. A review of Resident 37’s care plan titled, “At risk for immobility, at risk for contracture., and at risk for decline in function,” initiated on 11/11/2025, the care plan indicated interventions included RNA to apply both leg splints for two hours, three times per week or as tolerated, RNA to apply both hand splints for two hours, three times per week or as tolerated, and RNA for PROM to both arms and legs in all planes, three times per week or as tolerated. A review of Resident 37’s physician’s orders, dated 11/11/2025, indicated for the RNA to apply both hand splints for two hours, three times per week or as tolerated. Apply both leg splints for two hours, three times per week or as tolerated. Provide PROM to both arms in all planes (planes of joint motion, including forward and backward, side to side, and rotation), three times per week or as tolerated. Another physician’s order, dated 11/12/2025, indicated for the RNA to provide Resident 37 with PROM to both legs in all planes, three times per week or as tolerated. A review of Resident 37’s RNA Flow Sheet (record of RNA tasks), dated 11/2025, indicated Resident 37 received RNA for application of both hand splints for two hours, PROM to both arms, and PROM to both legs on 11/12/2025, 11/13/2025, 11/14/2025, 11/18/2025, 11/19/2025, 11/20/2025, 11/21/2025, and 11/25/2025. The RNA Flow Sheet did not indicate the RNA applied both leg splints for two hours. A review of Resident 37’s RNA Flow Sheet, dated 12/2025, indicated Resident 37 received RNA for application of both hand splints for two hours, PROM to both arms, and PROM to both legs on 12/2/2025, 12/3/2025, 12/4/2025, 12/9/2025, 12/10/2025, 12/11/2025, 12/17/2025, 12/19/2025, 12/23/2025, 12/24/2025, 12/25/2025, and 12/30/2025. The RNA Flow Sheet did not indicate the RNA applied both leg splints for two hours. A review of Resident 37’s Physical Medicine and Rehabilitation Notes, dated 12/16/20205 and 12/30/2025 signed by the Doctor of Physical Medicine and Rehabilitation (MD 1), indicated Resident 37 was to continue with PROM and splinting to both arms and legs. A review of Resident 37’s RNA Flow Sheet, dated 1/2025, indicated Resident 37 received RNA for application of both hand splints for two hours, PROM to both arms, and PROM to both legs on 1/1/2025. The RNA Flow Sheet did not indicate the RNA applied both leg splints for two hours. During an interview on 1/5/2026 at 9:39 a.m. with the Director of Rehabilitation (DOR), the DOR stated the PT and/or OT perform the JMS on each resident (in general) upon admission, quarterly, and annually to determine if the resident experienced any changes that would impair the resident’s function. Residents who remained in the facility after discontinuation of therapy services were transitioned to the RNA program to maintain the residents’ ROM and mobility. Therapists created the physician order and the care plan for a resident’s RNA program upon discharge and would verbally notify the RNAs of a resident’s transition from therapy to the RNA program. The DOR stated the purpose of splints was to prevent contractures which could result from increased muscle tone and rigidity. Contractures could lead to skin breakdown and difficulty with self-care. During a concurrent observation and interview on 1/5/2026 at 12:22 p.m. in Resident 37’s room, Resident 37 was observed lying in bed with the head-of-bed elevated. Resident 37 had active movement in both shoulders, elbows, thumbs, index fingers, and limited movement in both middle fingers. Resident 37’s middle, ring, and small fingers of both hands were observed in bent positions. Two hand splints were observed on top of Resident 37’s nightstand. Resident 37 stated different RNAs performed exercises to both arms and legs and applied both hand splints at least twice per week. Resident 37 stated the hand splints helped straighten the fingers but RNAs did not consistently perform exercises and put on the splints, causing both of his hands to get worse. Resident 37 stated the RNAs placed boots on both feet one time a few weeks ago which helped straighten both feet but never reapplied the boots. Both of Resident 37’s ankles were observed in plantarflexion and rotated toward the left side. During a review of Resident 37’s JMS, signed on 1/6/2026 by the DOR, the JMS indicated Resident 37 had minimal ROM loss in both elbows and moderate ROM loss in both shoulders, both wrists and fingers, and both hips. The JMS also indicated Resident 37 had severe ROM loss in both knees and ankles. The JMS indicated Resident 37 remained the same percentile of ROM loss but improved with goniometer (instrument used to measure angles of joint movement) measurements due to skilled therapy services. The JMS also indicated Resident 37 was assessed for the appropriateness of the splints (unspecified). During an observation on 1/6/2026 at 2:01 p.m. in Resident 37’s room, with RNA 3, Resident 37’s RNA session was observed. RNA 3 stood next to Resident 37’s bed while the resident performed repetitions of right arm AROM exercises including elbow flexion (bending) and extension (straightening), shoulder horizontal adduction (lifting the shoulder at shoulder height and moving toward the body) with elbow flexion, wrist rotation, and finger flexion and extension. Resident 37 did not fully extend the right-hand middle, ring, and small fingers during the AROM exercises. Resident 37 then performed repetitions of left arm AROM exercises including elbow flexion and extension, shoulder horizontal adduction with elbow flexion, wrist rotation, and finger flexion and extension. Resident 37 did not fully extend the left-hand middle, ring, and small fingers during the AROM. RNA 3 did not provide PROM to both arms at the shoulder, elbow, wrist, and finger joints. RNA 3 applied the right hand-splint which was secured from Resident 37’s right forearm to the fingertips with straps. Resident 37’s right hand-splint had a cylindrical roll which was positioned in the palm to accommodate Resident 37’s fingers. RNA 3 then applied the left hand-splint which was also secured from Resident 37’s left forearm to the fingertips with straps. RNA 3 then provided ROM exercises to the right leg, including hip flexion (bending the leg at t