Health inspection·October 7, 2025

The following reflects the findings of the California Department of Public Health during the investigation of a complaint. Complaint Number: 2591377 A Class A citation was issued. REGULATORY VIOLATIONS: Code of Federal Regulations, Title 42, Section 483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician Code of Federal Regulations, Title 42, Section 483.21(b) Comprehensive Care Plans (b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being 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 resident's choices, including but not limited to the following: Code of Federal Regulations, Title 42, Section 483.25(b) Skin Integrity (b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment sand services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Code of Federal Regulations, Title 42, Section 483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required at § 483.71. (a)(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. (a)(4) Providing care includes but is not limited to assessing, evaluating, planning, and implementing resident care plans and responding to resident's needs. California Code of Regulations, Title 22, Section 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: (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. (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. (b) All attempts to notify licensed healthcare practitioners acting within the scope of his or her professional licensure shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending licensed healthcare practitioner acting within the scope of his or her professional licensure or his or her designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g). California Code of Regulations, Title 22, Section 72315. Nursing Service-Patient Care. (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (4) Using pressure-reducing devices where indicated. (5) Providing care to maintain clean, dry skin free from feces and urine. (7) Carrying out of physician's orders for treatment of decubitus ulcers. The facility shall notify the physician when a decubitus ulcer first occurs, as well as when treatment is not effective, and shall document such notification as required in Section 72311(b). California Code of Regulations, Title 22, Section 72517. Staff Development. (a) Each facility shall have an ongoing educational program planned and conducted for the development and improvement of necessary skills and knowledge for all facility personnel. Each program shall include, but not be limited to: 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. On 8/16/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident's neglect and death. The facility failed to prevent the development of pressure injuries (PI - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) and provide care and services consistent with professional standards of practice for Resident 1. The facility failed to: 1. Implement and document care plan interventions to prevent PI development for Resident 1 who was admitted without a pressure injury by not repositioning Resident 1 according to the Care Plan (CP- a document that details an individual's health conditions, treatments, needs, and goals, serving as a blueprint for their healthcare and support services) for quadriplegia (paralysis [can't move] of all four limbs) dated 6/27/25. 2. Accurately assess the pressure injury risk for Resident 1 during the comprehensive risk assessment completed on 6/30/2025. The assessment incorrectly identified the resident as having "no risk" for pressure injury development, despite the presence of documented high-risk factors, including a diagnosis of quadriplegia, hip fracture, bedbound and was totally dependent on staff for positioning. 3. Provide pressure-relieving mattresses as indicated in the CP for quadriplegia dated 6/27/25 for Resident 1. 4. Implement the recommendation from the wound care specialist for Low Air loss Mattress on 8/4/2025 upon discovery of the PI for Resident 1. 5. Ensure that facility staff (licensed nurses in general) demonstrated the necessary competencies to identify, assess, document, and appropriately manage pressure injuries and report a critical laboratory finding indicative of potential infection. As a result, on 8/4/2025, Resident 1 developed pressure induced deep tissue damage (is damage to the skin and underlying soft tissues from sustained pressure or pressure and shear) of the sacral region (refers to the area at the base of the spine, where the sacrum bone is located), ulceration (an open sore or wound that develops on the skin), moderate sanguineous drainage (a bright, red, and fresh-bleeding discharge from a wound, indicating damage to blood vessels and occurring normally in the early stages of wound healing), slough (the shedding of the outer layer of the skin), and epithelialization (the regeneration and migration of epithelial cells across the surface of a wound) that could led to a systemic infection (sepsis- a life-threatening organ dysfunction caused by a disorganized response to an infection), unnecessary hospitalization, organ failure, and death. On 8/11/2025, Resident 1 was found unresponsive, requiring transfer to a General Acute Care Hospital (GACH) where he was admitted for sepsis. Resident 1 expired on 8/14/2025. A review of Resident 1's "Record of Admission" (undated), indicated, Resident 1, a 78 year-old male was initially admitted to the facility on 1/19/2024 and readmitted on 6/30/25 with diagnoses including fracture (a break in the bone) of right femur (the thigh bone), chronic atrial fibrillation (a type of long-lasting, irregular heartbeat where the heart's top chambers quiver instead of beating in a coordinated, regular way), and dysphagia (difficulty swallowing) oropharyngeal phase (second stage of swallowing when the food goes from the back of the mouth to into the esophagus [tube that connects the throat to the stomach]). A review of the CP created 6/27/2025 with a focus on the quadriplegia diagnosis, indicated interventions which included: "Perform skin assessments every shift. Reposition every two hours using pressure-relieving mattresses or cushions (e.g., ROHO cushions- a soft, squishy seat made of air-filled bubbles that adjust to your body. It's used mostly by people who can't move around much, like those in wheelchairs, to help protect their skin and keep them comfortable). Use moisture-barrier creams and keep skin clean and dry." A review of Resident 1's Admission assessment dated 6/30/25, indicated Resident 1 was able to move in bed and chair independently with no apparent problems with friction and shear. The same assessment indicated Resident 1's skin was good/intact with no skin breakdown. The same assessment indicated the Braden scale (a widely used, evidence-based assessment tool in healthcare used to predict a patient's risk of developing pressure injuries) score was "0" (zero score would be invalid, as the lowest possible total score is 6, score ranges between 6 and 23 where the lower the score, the higher the risk). A review of Resident 1's CP created 7/7/2025 with a focus on the quadriplegia diagnosis, indicated interventions which included: "Reposition is necessary to prevent skin breakdown. Prevent 90-degree flexion (bending a part of your body to create a right angle) to prevent circulation problems." A review of Resident 1's "History and Physical" (H&P, a comprehensive medical assessment that includes a patient's medical history, a physical examination, and an assessment/plan), dated 7/9/2025 indicated, Resident 1 was having memory loss and had fluctuating capacity to make decisions. The same H&P indicated advance directives, and/or goals were discussed in detail with Resident 1's (next of kin) and designated decision maker, Family Member (FM) 1. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/25/2025, indicated that Resident 1 had moderate cognitive (ability to think, understand and make daily decisions) impairment. The MDS further indicated Resident 1 was mostly dependent on staff for his activities of daily living (ADLs-toileting, shower/bathe self, lower body dressing, and putting on/taking off footwear). The MDS indicated Resident 1 required substantial/maximal assistance (describe the level of help a patient requires to perform a task, the resident is highly dependent and requires extensive physical support to complete the task) for rolling left and right, sitting to lying, and lying to sit on side of the bed. A review of Resident 1's wound care specialist notes dated 8/4/2025, indicated Resident 1 had pressure induced deep tissue damage of the sacral region measuring 15 centimeter (cm, is a unit of length measurement), 3 x 5 cm ulceration, moderate sanguineous drainage, 26-50% slough, and 26-50% epithelialization. The notes indicated, "recommend low air mattress. Spoke with nurse (unidentified) who will facilitate." A review of Resident 1's physician order dated 8/4/2025 indicated, "Sacrum (is a large, triangular bone at the base of the spine, formed by the fusion of five vertebrae) DTI [deep tissue injury]: Cleanse wound with normal saline [NS, sterile mixture of salt and water that closely matches the salt concentration of human blood], pat dry, paint with betadine, cover with foam dressing every day shift." A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers when there is a change of condition among the residents) dated 8/4/25 indicated that the resident presented with a DTI on the sacrum. Resident 1 was informed of the recommendation [from the wound specialist] to initiate use of a low air loss (LAL) mattress (a specialized medical air mattress designed to promote skin integrity by providing continuous airflow to reduce moisture and heat, preventing bedsores and enhancing comfort for people with limited mobility). However, the resident, who had a designated Responsible Party (RP), declined the use of the LAL mattress. "The facility initiated the appropriate treatment protocol for the DTI, and Resident 1 to be repositioned every two hours." A review of Resident 1's CP created on 8/4/2025 with focus on, "The resident has DTI pressure ulcer in sacrum or potential for pressure ulcer development r/t (related to) immobility," indicated interventions which included: "Assess/record/monitor wound healing, measure length, width depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the medical doctor (MD). Educated the resident/family/caregivers as to the causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulation/mobility, good nutrition and frequent repositioning." A review of Resident 1's Laboratory Results report dated 8/7/2025 and reported at 4:14 pm, indicated a white blood cell count (WBC - measure the total number of white blood cells in the blood, which are a crucial part of the immune system that fight infection and disease, and may indicate infection or inflammation if level is elevated) of 15.81 cells per microliter (cells/µL, unit of measurement) (WBC normal level range is 4-11 cells/µL). A review of Resident 1's nursing notes dated 8/