Health inspection·September 18, 2025

F558 Code of Federal Regulations, Title 42, Section 483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. California Code of Regulations, Title 22 Section 72311 (a) Nursing service shall include, but not be limited to, the following: Planning of (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22 Section 72315 (d) Each patient shall be provided care which shows evidence of good personal hygiene, including care of the skin, shampooing and grooming of hair, oral hygiene, shaving or beard trimming, cleaning and cutting of fingernails and toenails. The patient shall be free of offensive odors. (m) Patient call signals shall be answered promptly. California Code of Regulations, Title 22 Section § 72527 (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 to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. On 7/30/2025, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding quality of care/treatment. As a result of this investigation, the CDPH determined the facility failed to ensure Resident 1’s call light was fully connected to the wall and within reach for Resident 1 on 7/31/2025, 8/1/2025 and 8/5/2025, and ensure Resident 1’s care was provided timely and as needed in accordance to the facility’s policy and procedure (P&P) titled, “Answering the Call Light”. As a result, the facility violated Resident 1’s rights and Resident 1 could not get assistance from staff when Resident 1 needed to be changed. Resident 1 was left soiled in Resident 1’s briefs (disposable under garment used for those who have a loss of continence [ability to hold the bladder and bowels]) with urine, feces, and/or blood. A review of Resident 1’s Admission Record indicated the facility admitted Resident 1, a 34 year-old female, on 10/4/2023 with diagnoses that included conversion disorder (CD- a mental health condition where a person experiences neurological symptoms, like paralysis [the loss of muscle function in part of the body, resulting from problems with how messages travel between the brain and muscles] or blindness [partial or full loss of vision], that cannot be explained by a medical or neurological condition due to the brain converting psychological distress into physical symptoms) with mixed symptom presentation, aphonia, and generalized anxiety. A review of an untitled Care Plan (CP) indicated Resident 1 preferred the call light to hang from above Resident 1’s head on the trapeze (a mobility aid, often used in healthcare settings, that is suspended above a bed to assist patients with repositioning, transferring in and out of bed, and performing exercises), initiated 5/12/2025. The CP indicated Resident 1 would continue to be able to use call light by tapping it. The CP interventions indicated educating staff on Resident 1’s preference of call light placement, and to ensure Resident 1 was able to reach the call light. A review of the same untitled CP indicated Resident 1 was incontinent with both bowel and bladder in relation to impaired mobility and inability to alert staff of Resident 1’s urges, and was at risk for infection, skin breakdown, and was on a check and change program, initiated on 10/14/2023 and revised on 3/7/2025. The CP goals indicated Resident 1 would be kept clean, dry, and odor free daily for three months. The CP interventions indicated that Certified Nurse Assistants (CNAs) were to check Resident 1 for bladder incontinence at least every two hours, as needed, and to increase frequency as needed, keep Resident 1’s call light within reach and answer promptly, and to monitor as indicated for redness or skin breakdown, and to report to MD (medical doctor, physician). A review of Resident 1’s Minimum Data Set (MDS- a resident assessment tool) dated 7/7/2025, indicated Resident 1 had intact cognition. The MDS indicated Resident 1 had the absence of spoken words. The MDS indicated Resident 1 was dependent with toileting hygiene and chair/bed-to-chair transfers. The MDS indicated Resident 1 required substantial/maximal with personal hygiene, showering/bathing self, and rolling left and right (in bed). During an observation on 7/31/2025 from 9:58 am to 10:09 am, inside Resident 1’s room, Resident 1 was lying in bed. Resident 1’s call light was hanging above Resident 1’s head on the trapeze. The call light was placed towards the wall on the trapeze, not above Resident 1’s head and out of Resident 1’s reach. During a concurrent observation of Resident 1 and interview on 7/31/2025 at 11 am, in Resident 1’s room, Resident 1 used the surveyor’s phone to type Resident 1’s responses to questions. Resident 1 typed, “I am really wet. I pooped and peed, and I can’t reach my call light, and I can’t communicate with anyone because the tablet they (staff in general) gave me died and no one can understand me”. Resident 1 typed that Resident 1’s sheets and brief were wet. Resident 1 typed, “I am so uncomfortable, and they (staff in general) don’t care.” During a concurrent observation and interview on 7/31/2025 at 11:27 am, inside Resident 1’s room, CNA 1 and CNA 2 were with Resident 1. Resident 1 typed on surveyor’s phone, “I’ve been wet since 2 am. The night staff wouldn’t change and neither of you asked me if I needed to be changed”. Resident 1 typed, “I need a bath, please. I pooped and peed, and I’ve been asking since you gave me breakfast this morning. I can’t reach the call light to ask you two for help,” Resident 1 typed, “You both are aware of that, and I expressed my concerns, and you don’t communicate with me.” Resident 1 attempted to reach for Resident 1’s call light but was unable to. CNA 1 stated Resident 1 liked the call light to be on the bar (trapeze) but should be within reach. During a concurrent observation and interview on 7/31/2025 at 11:46 am, inside Resident 1’s room, Resident 1 was observed with CNA 1 and CNA 2. CNA 1 stated Resident 1’s sheets and pillow under Resident 1’s left leg were wet with urine. CNA 2 stated Resident 1’s gown and bed pad were wet with urine. During a concurrent observation inside Resident 1’s room and interview with CNA 1 on 8/1/2025 at 3:15 pm, CNA 4 stated Resident 1’s call light was unplugged from the wall. CNA 4 stated, “It was not pulled out of the wall completely, just enough so that it won’t work”. CNA 4 stated, “This isn’t the first time this happened.” CNA 4 stated Resident 1’s call light was usually pushed behind Resident 1’s head so Resident 1 could not reach it and was currently positioned that way. CNA 4 stated Resident 1 did not currently have the iPad. CNA 4 stated, “It’s pretty typical that [Resident 1] is soaked through [Resident 1’s] brief with urine and/or feces when I come onto my shift.” CNA 4 stated Resident 1 was currently soaked through the brief. Resident 1 typed on surveyor’s phone, “No one has ever used the communication board with me. I don’t even know what that is.” Resident 1 stated, “I’m wet and haven’t been offered to be changed since you (points to surveyor) were in here this morning.” Resident 1 stated, “[CNA 1] and [CNA 2] were supposed to change me, they didn’t ask me if I wanted to be changed and I can’t reach the call light.” During a concurrent observation inside Resident 1’s room and interview with CNA 4 on 8/1/2025 at 4:13 pm, CNA 4 stated Resident 1’s brief was “really full and wet” all the way through. CNA 4 stated, “If [Resident 1] was changed every two hours, [Resident 1] won’t be this wet.” CNA 4 stated that Resident 1 was able to use the call light with CNA 4 to let CNA 4 know when Resident 1 needed to be changed. CNA 4 stated if Resident 1’s call light was disconnected then Resident 1 could not ask for help. CNA 4 repeated, “This isn’t the first time this happened.” CNA 4 stated the call light being disconnected was a “Real safety issue”. CNA 4 stated if something was really wrong, Resident 1 could not get help because Resident 1’s call light was pushed back and unreachable for Resident 1. During a concurrent observation inside Resident 1’s room and interview on 8/1/2025 at 4:45 pm, with the Director of Nursing (DONthe DON stated, “I see your call light is over your trapeze but not over your head.” Resident 1 typed, “They keep pushing it back so I can’t reach it.” Resident 1 attempted to reach the call light but was unable to. Resident 1 would not indicate who, “They” were. During an interview on 8/5/2025 at 1:25 pm, CNA 1 stated call lights were not supposed to be disconnected or unplugged from the walls and should be within reach. CNA 1 stated when a call light is disconnected and out of reach from a resident it became a safety issue. During an interview on 8/5/2025 at 2:13 pm, LVN 2 stated LVN 2 was familiar with Resident 1. LVN 2 stated Resident 1 could not move Resident 1’s legs or right arm. LVN 2 stated a resident’s call light should always be within reach in case they needed assistance. LVN 2 stated if Resident 1’s call light was not within reach, then Resident 1 could not ask for help. LVN 2 stated Resident 1 could not talk, so Resident 1’s needs would go unmet, which was a safety issue. During an interview on 8/5/2025 at 3:34 pm, the DON stated call lights were supposed to be within reach and always connected to the wall so residents could ask for help, otherwise they could not get help timely and their needs could go unmet or there could be a delay in their needs being met. The DON stated this was a safety issue, for example, if a resident fell. During a concurrent observation inside Resident 1’s room and interview on 8/5/2025 at 4:20 pm, with CNA 6 CNA 6 stated LVN 3 had asked CNA 6 to change Resident 1, but CNA 6 was bathing another Resident. CNA 6 checked Resident 1’s call light and CNA 6 stated Resident 1’s call light was not working. CNA 6 stated the cord was pulled out of the outlet about halfway, and the call light did not work when it was like that. CNA 6 stated this was not the first time CNA 6 had seen Resident 1’s call light cord partially disconnected from the wall. CNA 6 stated, “It happens more often than not when I come onto my shift.” CNA 6 stated Resident 1 was, “Pretty soaked through with urine and blood in [Resident 1’s] briefs.” CNA 6 stated Resident 1’s gown and sheets were wet too. A review of the facility’s undated P&P titled, “Answering the Call Light,” the P&P indicated the purpose of the procedure was to ensure timely responses to the resident’s requests and needs. The P&P indicated to be sure the call light was plugged in and functioning at all times, and to ensure the call light was accessible to the resident when in bed, from the toilet, from the shower, or bathing facility, and from the floor. As a result of this investigation, the CDPH determined the facility failed to ensure Resident 1’s call light was fully connected to the wall and within reach for Resident 1 on 7/31/2025, 8/1/2025 and 8/5/2025, and ensure Resident 1’s care was provided timely and as needed in accordance to the facility’s policy and procedure (P&P) titled, “Answering the Call Light”. As a result, the facility violated Resident 1’s rights and Resident 1 could not get assistance from staff when Resident 1 needed to be changed. Resident 1 was left soiled in Resident 1’s briefs (disposable under garment used for those who have a loss of continence [ability to hold the bladder and bowels]) with urine, feces, and/or blood. This violation jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.