As skilled nursing facilities care for increasingly complex patients, consistency in clinical workflows is essential. Differences in admission orders, laboratory notification parameters, medication holding instructions, and sliding-scale insulin protocols can create confusion for nursing staff and generate unnecessary calls to providers.

This year’s 2026 CALTCM Annual Conference is just around the corner.  Last year, I was impressed by the large number of submissions that had a significant impact on clinical practice.  I wanted to highlight one of these posters through the Wave.    

Recalling the history of the initial requirement, is helpful in appreciating why it is worthwhile to take a second look at the August 8, 2024, changes to the regulation.  Originally, the requirement for a facility assessment was included in the 2016 revisions to the Requirements of Participation, rather than nurse staff ratios, at §483.70(e). 

Are you surprised when receiving a text, call or fax that a resident on your SNF, ALF, or Memory unit has fallen Unfortunately, most of the time, I am not surprised since most of those I care for have chronic or varying risk due to modifiable and non-modifiable factors. Falls are a common problem, with 1/3 of adults > 65 and ½ of NH (nursing home) residents falling each year. Falls are the leading cause of death from injury in people aged > 65, and this rate increases with age. Falls are associated with a decline in functional status, fear of falling, civil and regulatory litigation, and increased use of medical services. 

This spring, as we recognized both Long-Term Care Physician Day and National Physicians Day, we take a moment to celebrate a remarkable group of leaders in our field—California physicians who have achieved Certified Medical Director (CMD) status.

Very few new regulations in nursing homes have anything to do with physicians or medical directors.  The new written informed consent regulation for California facilities is an exception.  On January 1, 2024, AB 48 became law at Health & Safety Code (HSC) §1599.1 and 1599.15 and raises the requirements prior to clinicians prescribing and facilities administering psychoactive medications. 

In recent years, medical directors and other physicians practicing in post-acute care settings have recognized the benefits of aligning with advanced practice nurses working in these settings. Physicians benefit by having a clinical partner participating in the medical management of their patients. Academic nursing has hailed this partnership in hopes that advanced practice nurses will help to elevate the nursing practices of nursing services offered in these settings.

October was the month for employee physicals for skilled nursing facilities (SNFs) and for a Home Health Aide (HHA) and Certified Nursing Assistant (CNA) Training Academy that prepares students for certification exams. In both these situations, my job is to ensure employees are fit to perform their work and ensure they are free of serious contagious illnesses like TB. 

“For it may safely be said, not that the habit of ready and correct observation will by itself make us useful nurses, but that without it we shall be useless with all our devotion” (Florence Nightingale, 1859/2012, p. 112)1

Turning on the Light podcast (Anyone Can Choose Leadership with Dennis Wagner and John Scanlon - Turn on the Lights Podcast | Podcast on Spotify) highlighted the key healthcare leadership themes in a just completed book by Dennis Wagner and John Scanlon. Leadership is distinct from management, administration, and observation. The book presents twelve essential leadership mindsets and methods drawn from years of experience and insights from respected figures. I agree with their assertion that Leadership is a choice and can be taught. Leaders view problems as a temporary setback to be overcome and usually do so by a team approach.

It is understandable that there is confusion about which members of nursing services have sufficient authority and education to assess residents in California nursing homes (NHs). The confusion is a consequence of issues related to the discipline of nursing itself, California RN and LVN scopes of practice, the nature of the nursing skill mix used in NHs, and language used in the October 2024 (version 1.19.1) Resident Assessment Instrument/Minimum Data Set guidelines.¹

Our state's QIO (Quality Improvement Organization) is HSAG (Health Services Advisory Group).  They have developed a series of 30-minute Webinars called Quickinars that are focused on Improving Care Transitions.  As a part of this series, they have developed a free QIIP (Quality Improvement Innovation Portal) which allows a facility and their hospital partners to share patient protected standardized readmission data that permits hospitals and their SNF partners to identify opportunities for improving care transitions. 

Last year, cases of RSV in children and adults accelerated over the summer into the fall, raising a concern about a “Triple-demic” (COVID, Flu, & RSV).  Fortunately, for unclear reasons, RSV cases declined as winter set in. 

CALTCM is proud to announce that it has received an award from CDPH's Healthcare-Associated Infections (HAI) Program. Our project, the Leadership and Management in Geriatrics Infection Prevention and Control Leadership Program (LMG-IPC Strike Team) combines the methodology from two established CALTCM programs, CALTCM SNF 2.0® and CALTCM’s Leadership and Management in Geriatrics course (LMG)®.

On November 11, 2022, the OIG (Office of Inspector General) released a report on the Long-Term Trends of Psychotropic Drug Use in NH.  From the years 2011-2019, the use of antipsychotic medications declined from 31% to 22%, while the use of anticonvulsants increased from 28% to 40%.  In 2015, CMS began using the long-stay quality measure that tracks MDS reported antipsychotic use in the NH in its Nursing Home Five-Star Quality Rating System calculations.  Between 2015-2019, the number of NH residents reported as having schizophrenia increased 35%.  Additionally over this time, the number of residents reported as having schizophrenia but lacking a corresponding diagnosis in the Medicare claims and encounter data increased by 194%.  A small fraction of US nursing homes (99) had particularly high levels of MDS reporting of Schizophrenia (> 20% of their residents) w/o corresponding preceding diagnosis in Medicare’s database.

At a recent town hall meeting for a local Continuing Care Retirement Community (CCRC), I updated our residents on the state of the COVID pandemic in our community.  Compared to the prior 2 years, we are experiencing much less serious medical illness and the deaths in 2022 were about one-tenth of what we experienced in the prior 2 years.  However, the risk of dying from COVID is still about 10 times higher than that for influenza and nearly 9 in 10 COVID deaths have occurred in those over 65 years of age.   The uptake of the new bivalent booster has been disappointingly slow with only 15.4% of the eligible USA population vaccinated.  As of January 9, this booster uptake in CA has been 22.7%, which is higher in elders, but is still low.  In Sonoma County, of those over 65,  53% are boosted, but this drops to 29% of the 50-64 y/o and further drops to 8-11% for those in the 6-34 y/o age ranges.  

This law requires specified types of health care facilities (including SNF and ALF) to allow a terminally ill patient’s use of medicinal cannabis, within the health care facility, subject to certain restrictions.

Purpose: To evaluate the effects of evidence-based transitional care intervention and self-efficacy training for skilled nursing facility (SNF) patients and caregivers. 

I was so honored to present a summary of the work that my organization, Los Angeles Jewish Health is doing in Telehealth at the recent CALTCM Summit for Excellence.   Los Angeles Jewish Health is the lead program that works in partnership with the California Technology Fund in a statewide coalition. We received FCC funding to demonstrate the value of telehealth in PALTC facilities. Our purpose is to inform those who are seeking to adopt or expand telehealth in facilities, and to educate policy makers, to better understand the potential benefits and challenges of implementing telehealth in facility-based care.  

I recently saw a woman for a colleague who had been one of my patients in the remote past.  Since that time, her persistent low back pain despite multiple prior back surgeries has persisted and been complicated by depression, malnutrition, frailty, polypharmacy, and recent functional decline requiring SNF care.  Fortunately for her, my colleague had begun deprescribing medicines which were potentially more burdensome than beneficial.  Though this patient didn’t recognize it, her husband said her appetite had greatly improved.  When I saw her I observed she was easily moving about the facility in her wheelchair.  When I asked if her pain was keeping her from getting about the facility, she confirmed my observation that this was a good day.