Health inspection·July 2, 2025

Code of Federal Regulations, Title 42, § 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. Code of Federal Regulations, Title 42, § 483.35 Nursing Services (a) Sufficient Staff (3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. (4) Providing care includes but is not limited to assessing, evaluating, planning, and implementing resident care plans and responding to resident's needs. (d) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. California Code of Regulations, Title 22, Section § 72301 Required Services. (a) Skilled nursing facilities shall provide, but shall not be limited to, the following required services: physician, skilled nursing, dietary, pharmaceutical and an activity program. (f) The facility shall ensure that all orders written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. California Code of Regulations, Title 22, Section § 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. California Code of Regulations, Title 22, Section § 72311 Nursing Service -General (a) Nursing service shall include, but not be limited to, the following: (A)Identification of care needs based upon an initial written and continuing assessment of the patient’s needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (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. California Code of Regulations, Title 22, Section §72313. Nursing Service -Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. (3) Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, shall be performed as required and the results recorded. On 5/14/2025, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding quality of care, treatment, and nursing services involving Resident 1. As a result of the investigation, the CDPH determined that the facility failed to ensure Resident 1 received wound care and treatment in accordance with the facility's Policies and Procedures (P&P) titled, "Admission Assessment and Follow Up: Role of the Nurse." The facility failed to: 1. Ensure Registered Nurse (RN) 1 conducted a complete wound assessment and documented Resident 1's left hip surgical wound upon admission to the facility on 2/18/2025. 2. Ensure RN 1 obtained a treatment order for Resident 1's left hip surgical wound upon admission on 2/18/2025. The facility did not obtain the treatment order until 2/28/2025. 3. Ensure Licensed Vocational Nurse (LVN) 3 and LVN 4 implemented the treatment order for Resident 1's left hip surgical wound on 4/13/2025, 4/14/2025, and 4/15/2025. 4. Ensure Resident 1’s wound was evaluated by a Wound Care Specialist (WCS) upon admission. A WCS assessed Resident 1’s wound for the first time on 4/16/2025. These violations resulted in Resident 1’s left hip surgical wound becoming infected, requiring transfer to General Acute Care Hospital (GACH) 2 where Resident 1 received treatment for the infected left hip surgical wound on 4/25/2025. A review of Resident 1's Admission Record (AR), indicated Resident 1, a 67-year-old male, was admitted to the facility on 2/18/2025 with diagnoses that included acute (sudden) osteomyelitis (bone infection) of the left femur (thigh bone), infection and inflammatory reaction due to internal left hip prosthesis (artificial body part), and dysphagia (difficulty swallowing foods or liquids). The AR indicated Resident 1 was transferred to GACH 2 on 4/25/2025. A review of Resident 1's History and Physical (H&P), dated 2/19/2025, indicated Resident 1 had a healing wound on the left hip. A review of Resident 1's Interdisciplinary Team Conference Record (IDT Record), dated 2/24/2025, indicated Resident 1 was admitted to the facility following "left wound care and osteomyelitis." A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 2/25/2025, indicated Resident 1 had intact cognition. The MDS indicated Resident 1 was dependent on staff for toileting hygiene and dressing. The MDS indicated Resident 1 required partial/moderate assistance from staff for oral and personal hygiene. The MDS indicated Resident 1 had a surgical wound and required surgical wound care. A review of Resident 1's Emergency Department Reports (EDR), dated 4/25/2025, indicated Resident 1 was transferred to GACH 2's Emergency Department on 4/25/2025 due to "increased swelling and drainage " on Resident 1's left hip wound for one week. The EDR indicated Resident 1's left hip wound was noted to have erythema (redness of the skin), tenderness, and drainage. The "EDR" indicated Resident 1's left hip surgical wound was infected. The EDR indicated Resident 1 was given Zosyn (antibiotic medication used to treat infections) via intravenous piggyback (IVPB, a method of administering medication through a soft flexible tube placed inside a vein). The EDR indicated Resident 1 was admitted to the telemetry unit (a unit in the hospital dedicated to patients who require monitoring of the heart) at GACH 2 on 4/25/2025. A review of Resident 1's GACH 2 Laboratory Report (LR), dated 4/25/2025, indicated a lab culture (a laboratory test to identify the presence and type of microorganisms, aiding in diagnosing infections) was collected from the wound on Resident 1's left hip on 4/25/2025. The LR indicated Resident 1's wound contained staphylococcus aureus (bacteria that can cause wound infections). A review of Resident 1's GACH 2 Progress Notes (PN), signed 4/27/2025, indicated Resident 1 had a severely infected left arthroplasty (a surgical procedure to replace part of the hip joint with a prosthetic implant). The PN indicated Resident 1 was admitted to GACH 2 with developing skin breakdown over Resident 1's left hip flap (healthy skin and tissue that is partly detached and moved to cover a nearby wound). A review of Resident 1's GACH 2 Infectious Disease Progress Note (IDPN), signed 4/28/2025, indicated Resident 1's left hip surgical wound was infected. The IDPN indicated Resident 1 was receiving Meropenem (antibiotic medication used to treat infections caused by bacteria) and Vancomycin (powerful antibiotic medication used to treat a variety of serious bacterial infections) via IV. During a telephone interview on 5/14/2025 at 12:01 p.m., Resident 1's Representative (RR) 1 stated Resident 1 fell in 2022 (did not recall exact date) and broke Resident 1's left hip at RR 1's home. Resident 1 had surgery for the broken left hip, but the surgery was not successful. Resident 1 underwent multiple surgeries and Resident 1's latest surgery was on 11/11/2024. The surgery on 11/11/2024 left Resident 1 with a "gaping" (split open) surgical wound from Resident 1's left knee to the left hip. RR 1 stated Resident 1 received wound care treatment for Resident 1's left hip surgical wound and the wound was healing while Resident 1 resided at GACH 1. RR 1 stated Resident 1's left hip surgical wound was treated and kept covered with a bandage while at GACH 1. Resident 1 was transferred from GACH 1 to the facility on 2/18/2025. Resident 1's left hip surgical wound needed daily care to continue to heal. RR 1 had to intervene and push facility staff (unable to identify) to take care of Resident1's left hip surgical wound. On one occasion, the facility staff (unable to identify) had not changed Resident 1's wound bandage for 2 days (unable to recall the dates). On 4/17/2025, Resident 1's left hip wound had drainage and a foul smell. RR 1 sent a picture of Resident 1's left hip surgical wound to Resident 1’s Physician/Medical Doctor (MD) 1 on 4/17/2025 and told MD 1 the wound looked worse (bad/poorer). RR 1 stated MD 1 replied to continue with Resident 1’s wound care. RR 1 wanted a second opinion so RR 1 went to Resident 1's Surgeon (MD 2) and showed MD 2 pictures of Resident 1's left hip surgical wound on 4/23/2025. MD 2 informed RR 1 that Resident 1's left hip surgical wound was infected. RR 1 informed MD 1 that Resident 1's left hip surgical wound was infected, and MD 1 agreed to transfer Resident 1 to GACH 2 where MD 2 could treat Resident 1's infected wound. RR 1 stated Resident 1's left hip surgical wound became infected because facility staff did not give Resident 1 the right wound care and treatment. During a concurrent interview and record review on 5/15/2025 at 9:31 a.m., the Director of Nursing (DON) reviewed Resident 1's Order Details (OD), dated 2/28/2025 and 4/16/2025. The OD dated 2/28/2025 indicated MD 1 ordered to "Change dressing to left hip with abdominal pad (ABD, pad used to absorb fluid from wounds), secure with paper tape in the evening [daily] and change as needed if becomes saturated." The treatment was to be done every evening. The OD dated 4/16/2025 indicated MD 1 ordered a wound consultation and [wound] treatment. The DON stated when residents (in general) were admitted to the facility, an assigned licensed nurse/admitting nurse assessed the resident. The DON stated when the resident had a surgical wound, the admitting nurse carried out the wound treatment orders from the sending facility. The DON stated when Resident 1 did not have wound treatment orders, the admitting nurse (RN 1) needed to obtain an order from MD 1 or the surgeon (MD 2). The DON stated when Resident 1 was admitted with a surgical wound, a wound consultation needed to be obtained to ensure assessment and treatment of the wound by the Wound Care Specialist (WCS). The DON stated Resident 1 was admitted to the facility on 2/18/2025 but the facility did not get a treatment order for Resident 1's left hip surgical wound until 2/28/2025 (10 days after Resident 1's admission). A wound consultation was not obtained for Resident 1 until 4/16/2025. On 4/16/2025, LVN 1 informed the DON that the treatment order for Resident 1's left hip surgical wound was not carried out (by LVN 3 and LVN 4) on 4/13/2025, 4/14/2025, and 4/15/2025. The DON stated the treatment orders were not carried out on those days (4/13/2025, 4/14/2025, and 4/15/2025). RN 1 possibly missed Resident 1's admission surgical wound assessment (on 2/18/2025) because the assessment was not found in Resident 1's medical record. During a concurrent interview and record review on 5/15/2025 at 12:01 p.m., LVN 2 reviewed Resident 1's Medication Administration Record (MAR) for the month of April 2025. The MAR indicated to cleanse Resident 1's wound with Normal Saline (NS, salt solution), pat dry, cover with ABD pad and secure with paper tape. The MAR dated 4/13/2025, 4/14/2025 and 4/15/2025 were left blank (no staff initial indicating wound treatment was done on these dates). LVN 2 stated on 4/16/2025 at "around" 8:20 a.m., the WCS was in Resident 1's room changing Resident 1's left hip surgical wound dressing and was there to teach RR 1 how to perform dressing changes for Resident 1. LVN 2 stated LVN 2 saw the old dressing on Resident 1's left hip surgical wound was dated 4/12/2025, indicating the dressing was last changed on 4/12/2025 (indicating staff did not change Resident 1's dressing on 4/13/2025, 4/14/2025, and 4/15/2025). During a concurrent interview and record review on 5/15/2025 at 3:25 p.m., RN 1 reviewed Resident 1's Clinical Admission (CA), dated 2/18/2025. The CA did not indicate Resident 1 had a left hip surgical wound and the area indicating surgical wounds was left blank. RN 1 stated Resident 1 was admitted to the facility with a left hip surgical wound. The left hip surgical wound was dry and did not look infected on admission. RN 1 stated when Resident 1 was admitted to the facility with a wound, RN 1 (the admitting nurse) needed to document Resident 1' s wound assessment in Resident 1’s CA. RN 1 did not measure Resident 1's left hip surgical wound. Wound assessments need to be documented so the condition of the wound could be monitored. RN 1 stated RN 1did not obtain a treatment order from MD 1 for Resident 1's left hip surgical wound upon Resident 1's admission to the facility on 2/18/2025. RN 1 did "not feel a need for it" due to Resident 1's wound bed (the base of floor of a wound) looking dry and no scab over the wound. RN 1 stated RN 1 did not think Resident 1's wound needed a dressing over the wound (to cover the wound). During a telephone interview on 5/15/2025 at 4:02 p.m., the WCS stated the first time the WCS assessed Resident 1’s wound was on 4/16/2025. On 4/16/2025, the WCS saw Resident1's left hip surgical wound dressing was not changed for several days (4/13/2025, 4/14/2025, and 4/15/2025). The WCS saw Resident 1 one more time on 4/23/2025, at which time the wound was fragile and discolored. The WCS stated facility staff (unable to identify) were not consistent in treating Resident 1's left hip surgical wound. There should have been a treatment order for Resident 1's left hip surgical wound from the first day Resident 1 arrived at the facility (on 2/18/2025). The WCS stated a wound bed needed to have some measure of moisture to promote healing. Resident 1's wound should not be left uncovered (without the ABD pad) until "it [the wound]" was fully closed and that it appeared Resident 1’s wound was left uncovered from 2/18/2025 to 2/28/2025. The WCS stated there was no treatment order for Resident 1's left hip surgical wound until 2/28/2025 (10 days after Resident 1's admission), and facility staff were inconsistent in following the treatment orders after 2/28/2025. The facility could have caused Resident 1's wound to become infected because, when Resident 1's left hip surgical wound was left uncovered, microorganisms and/or bodily fluids could have caused the wound to become infected. During an interview on 5/19/2025 at 10:49 a.m., the Infection Preventionist (IP) stated when Resident 1 was admitted to the facility with a surgical wound, the facility should ensure there was a treatment order for Resident 1's wound. When Resident 1's wound had a wound bed, the wound should be kept covered to prevent germs (bacteria) from linens and blankets from touching the wound bed (transferring bacteria from the linens and blankets to the wound bed). During a telephone interview on 5/19/2025 at 10:49 a.m., MD 1 stated Resident 1 was admitted to the facility from GACH 1 with an open surgical wound. There should have been a treatment order for Resident 1's left hip surgical wound upon Resident 1's admission to the facility (on 2/18/2025). MD 1 stated MD 1 sent Resident 1 to GACH 2 (on 4/25/2025) because Resident 1's left hip surgical wound was not healing. A review of the facility's P&P titled, "Admission Assessment and Follow Up: Role of the Nurse,” revised September 2012, indicated, "The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, ..." The P&P indicated, "Conduct an admission assessment (history and phy