Health inspection·January 29, 2026

Code of Federal Regulations, Title 42, Section 483.25 Quality of Care. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices, including but not limited to the following: California Code of Regulations, Title 22, Section 72311. Nursing Services-General. (a) Nursing service should include, but not be limited to, the following: (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: (E) Any untoward response or reaction by a patient to a medication or treatment. California Code of Regulations, Title 22, Section 72313. Nursing Services-Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. California Code of Regulations, Title 22, Section 72315. Nursing Services-Patient Care. (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. (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. On 12/11/2025 at 9:18 am, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to investigate an anonymous complaint regarding quality of care. The facility failed to provide care and services to Resident 1 by failing to ensure: 1. Restorative Nursing Assistant (RNA) 1 correctly applied Resident 1’s right palm protector (a hand splint or supportive device designed to prevent fingers from digging into the palm) as indicated by rehabilitation staff.  2. RNA 1 informed licensed nurses on 12/11/2025 at 11 am when RNA 1 removed Resident 1’s right palm protector and observed skin breakdown and wounds to Resident 1’s right thumb and index fingers. As a result, Resident 1 developed multiple open skin wounds on Resident 1’s right thumb and index finger. Resident 1 also developed redness and an indentation on Resident 1’s index finger knuckle.    A review of Resident 1’s Admission Record (AR), indicated the facility admitted Resident 1, a 72-year-old female, on 11/19/2024 with diagnoses which included intracerebral hemorrhage, muscle atrophy, and attention to tracheostomy. A review of Resident 1’s Minimum Data Set (MDS- a resident assessment tool), dated 11/18/2025, indicated Resident 1 had severely impaired cognition and was dependent on others for all activities of daily living.  A review of Resident 1’s Joint/Mobility Assessment- Rehab (JMAR), dated 11/19/2025 and timed at 10:17 am, indicated Resident 1 had “moderate/severe (25 – 50 percent movement)” contracture of Resident 1’s right hand fingers. A review of Resident 1’s Care Plan Report (CPR), initiated on 11/25/2025 indicated Resident 1 was at risk for decline in range of motion (ROM) of upper and lower extremity related to limited mobility. The CPR goals indicated for staff to maintain and prevent decline in the resident’s ROM and to decrease the risk of skin breakdown. The CPR interventions included putting on splints per physician order, monitoring for pain and discomfort, and to monitor for any skin breakdown. A review of Resident 1’s Order Summary Report (OSR), active as of 12/10/2025, indicated Resident 1 had a physician order, dated 6/27/2025, for RNA to apply right hand palm protector to be removed only for hygiene, up to six hours every day, 5 times per week as tolerated. The OSR indicated for RNAs to monitor Resident 1’s skin integrity and to monitor for signs or behavior indicating pain/discomfort during/after splint application. The SOR indicated if skin breakdown or signs of pain were present, to notify the charge nurse and document, every dayshift on every Monday, Tuesday, Wednesday, Thursday, and Friday.    During a concurrent observation of Resident 1 inside Resident 1’s room, and interview with Registered Nurse 1 (RN 1) on 12/11/2025 at 12:57 pm, RN 1 stated the skin between Resident 1’s right hand thumb and index finger were sticking together because they were too moist and the skin was open. RN 1 stated Resident 1’s right hand was “very contracted,” and RN 1 could not open Resident 1’s right hand. RN 1 stated Resident 1’s middle fingernail on the right hand was long and had the potential to dig into Resident 1’s palm.   During an interview with RNA 1 and RNA 2 on 12/11/2025 at 1:13 pm, RNA 1 stated RNA 1 and RNA 2 worked together and would start to apply splints, hand rolls, and other devices on residents at 7 am. RNA 1 stated splints and devices were usually ordered to be in place for 4 or 6 hours. RNA 1 stated when RNA 1 went into Resident 1’s room and checked on Resident 1 on 12/11/2025 at 11 am, Resident 1 already had wounds on Resident 1’s right thumb and index finger.  RNA 2 refused to answer any questions. During an interview with Licensed Vocational Nurse 3 (LVN 3) on 12/10/2025 at 1:39 pm, LVN 3 stated LVN 3 worked as the facility’s wound/treatment nurse. LVN 3 stated LVN 3 was “never informed” of Resident 1’s wounds on Resident 1’s right hand. LVN 3 stated it was important for LVN 3 to be informed of Resident 1’s wounds so the wounds could be treated and monitored.    During an interview with Certified Nursing Assistant 3 (CNA 3) on 12/11/2025 at 1:47 pm, CNA 3 stated CNA 3 saw Resident 1 between 7:30 am and 8 am on 12/11/2025, and Resident 1 did not have any hand rolls or splint on Resident 1’s hands. CNA 3 stated CNA 3 checked on Resident 1 again at 10:30 am on 12/11/2025, and Resident 1 did not have any hand roll or splint on Resident 1’s hands.    During a subsequent interview with RNA 1 on 12/11/2025 at 2:31 pm, RNA 1 stated RNA 1 cleaned Resident 1’s hands before RNA 1 put Resident 1‘s splint on because Resident 1’s hands got sweaty and had some yellowish build up. RNA 1 stated Resident 1’s thumb was bleeding when RNA 1 removed Resident 1’s right hand palm protector at 11 am on 12/11/2025 but RNA 1 did not inform any licensed/charge nurse about the bleeding on Resident 1’s right thumb and that Resident 1’s palms were sweaty with yellowish build up. RNA 1 stated it was not the first time Resident 1’s hands became bloody.   During a concurrent observation and interview with RNA 1 on 12/12/2025 at 9:15 am, Resident 1 was lying in bed. RNA 1 stated the elastic on the palm protector in Resident 1’s right hand was supposed to go in between the thumb and the index finger. RNA 1 stated that was how RNA 1 had always put Resident 1’s palm protector on.       During a concurrent observation and interview with the Registered Occupational Therapist (OTR) on 12/12/2025 at 9:23 am, the OTR observed Resident 1’s right hand palm protector and stated the way RNA 1 placed the Resident 1’s right hand palm protector was not correct. The OTR stated the elastic band for the palm protector was not supposed to be between the fingers but supposed to be placed on the back side of the hand. The OTR stated the palm protector was supposed to protect the palm and the skin between Resident 1’s thumb and index finger from the pressure. The OTR stated having the elastic band between the thumb and the index finger could lead to skin breakdown. A review of the facility policy and procedure (P&P) titled, “Stabilization and Securement Devices” dated 2/2023, indicated, “Arm boards, splints, and other devices designed to stabilize joints…is removed regularly and the resident assessed for…skin integrity.” The facility failed to provide care and services to Resident 1 by failing to ensure: 1. RNA 1 correctly applied Resident 1’s right palm protector as indicated by rehabilitation staff. 2. RNA 1 informed licensed nurses on 12/11/2025 at 11 am when RNA 1 removed Resident 1’s right palm protector and observed skin breakdown and wounds to Resident 1’s right thumb and index fingers. As a result, Resident 1 developed multiple open skin wounds on Resident 1’s right thumb and index finger, and Resident 1 developed redness and an indentation on Resident 1’s index finger knuckle.   The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.