A valid POLST Form on a resident with dementia living in a memory unit (licensed as a Residential Care Facility for the Elderly {RCFE}), called for DNR, comfort-focused treatment, meaning generally do not transfer to the hospital. Yet when he developed acute altered mental status (AMS), his wife was surprised and dismayed that the facility could not provide comfort-focused care and needed to send him to the ER. To those working in the PALTC space, this is not a surprise, since most ALFs (Assisted Living Facilities) do not have the expertise or quick access to palliative care meds. By Title 22 regulations, they must transfer their residents to the ER for potentially serious changes of condition. In addition, AMS has many potential causes, some of which are potentially reversible like a systemic infection or electrolyte abnormality. Of course, in the case above, the resident was not suffering any significant symptoms that were bothering him; he was just more lethargic. With comfort-focused treatment preferences, no workup or changes in therapy would typically be warranted. 

Building on the energy and enthusiasm generated at this past weekend's Leadership and Management in Geriatrics (LMG) course, we are thrilled to shift our focus to the next major event on CALTCM’s calendar—the 2026 CALTCM Summit for Excellence.

Senate Bill 1088, sponsored by the Coalition for Compassionate Care of California (CCCC) and authored by Sen. Catherine Blakespear of Encinitas (D-38), is working its way through the Senate with very little opposition.  This bill will improve processes around POLST in several ways.

We are living in a post-pandemic respiratory landscape where seasonality is less predictable than in years past. After COVID-19 began to recede in 2022, many facilities experienced the so-called “tripledemic” winter with influenza and RSV surging again. Since then, respiratory viruses have continued to circulate in less predictable patterns, with norovirus adding further complexity in many long-term care settings.

The recent release of CDPH AFL 26-12 served as an important reminder to skilled nursing facilities and medical directors across California that the deadline to become a Certified Medical Director is approaching. For many physicians, the reminder sparked questions about timelines, eligibility, and the certification process.

The 2025-2026 winter season in the USA is coming to an end.  The subclade K of Influenza A (H3N2) became the predominant strain, with the highest severity in the pediatric (0-17 y/o) population, resulting in 25 million cases, 330,000 hospitalizations, and 20,000 deaths. COVID-19 peaked in late summer with a 9.2% positivity rate and is currently below 3% nationwide, with low levels. RSV had a lower level of activity this year with onset later than usual, and hospitalizations have remained elevated through April. Respiratory virus panels have expanded revealing more hospital cases of Human Metapneumovirus (hMPV), Parainfluenza virus. and Rhinovirus. 

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.

I recently received a call from a financial advisor concerned about the cost of supportive care for a client with early-stage dementia who was still ambulatory with a cane and did not have problem behaviors. The base price of this ALU (Assisted Living Unit) was $10,500, but with “à la carte” Care, the monthly bill was $19,500/month. 

The ability to access specialty support services for my post-acute rehab patients has become more difficult over the last 10 years as the specialists in my community have moved from private practice to working for either the Sutter or Providence HealthCare Systems. Many offices have moved to off-site appointment scheduling systems focused on elective care appointments, often with first available appointments months out. Even when an office has a live receptionist, it seems like the default triage of the receptionist is to preserve the specialist’s elective appointment schedule and defer urgent appointments to an urgent care center or the ER. I suspect this default triage system is often implemented without the knowledge of the specialist. 

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. 

I just saw my internist for a preoperative exam for upcoming cataract surgery. This is my third encounter over the last year and a half. The care was medically sound and efficient. However, I later thought, “My physician doesn’t know me.” I know there have been many changes in the delivery of healthcare since I left my office internal medicine practice in 2005 to work exclusively in long-term care settings. However, I really enjoyed getting to know my patients as persons, which allowed me to contextualize the care I provided. 

In the 1990s, our USA immigration policy allowed skilled nursing facilities (SNFs) to sponsor healthcare workers from the Philippines and other countries. Many of these additions to our SNF team in Sonoma County rapidly advanced to leadership positions. Coming from countries whose cultures highly value older adults, the caring part of their work in SNFs enhanced our care. 

Dementia is one of the most common hospice diagnoses in long-term care, yet hospice referral is frequently delayed. Unlike cancer or heart failure, dementia follows a prolonged and variable trajectory, making prognosis difficult. Understanding how functional decline—not cognitive decline—determines hospice eligibility is essential for physicians and interdisciplinary teams caring for these patients.

The 2024 requirements for 24/7 RN coverage and minimum hours per resident day for RNs and nurse aides were officially rescinded as of February 2, 2026. Currently, thirty-six states have some type of minimum staffing requirements. Attorneys general from eighteen states are asking CMS to consider a new staffing rule for certain for-profit nursing homes (NHs)  demonstrating high-risk financial and ownership practices. 1

At recent Sutter meetings with SNF partners, potential transfers of patients with a first episode of Clostridioides difficile (C. diff.) with orders for the expensive antimicrobial fidaxomicin (Dificid), were sometimes slow to place for fear that insurers might only approve Vancomycin. 

PALTMed is pleased to announce the launch of a free e-learning module for medical directors and leaders of nursing homes covering the clinical trial evidence and protocols for adopting universal decolonization as a Quality Assurance and Performance Improvement (QAPI) program.

In December 2025 Issue 1 Wave, I introduced the subject of Ambient AI. This is a technology that has rapidly expanded across over 200 hospital systems in the USA that use EPIC as their electronic health records (EHR) platform and the Abridge Ambient AI app (see link). Those using this technology for their providers and staff report more focused time with patients and less time documenting encounters. The improved efficiency also translates into greater productivity for healthcare teams.