Other·November 18, 2025

REGULATION VIOLATION(S) F687: 483.25(b)(2)(i)(ii) 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: (b)(2) Foot care. To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must: (i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and (ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments. California Code of Regulations, Title 22: §72315(d) (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. California Code of Regulations, Title 22: § 72523(a) (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. FINDINGS: On 6/14/21, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a complaint investigation regarding Resident 1's quality of care. The facility failed to ensure Healthcare Personnel (HCP) provided the necessary foot care per the physician's orders, and nursing assessments, for one of two sampled residents (Resident 1), who had been admitted to the facility for physical therapy post-surgery of a fractured left ankle and was at risk for poor circulation (blood flow) because of comorbidities (two or more diseases), diabetes (high blood sugar) and on dialysis (a procedure to divert blood to a machine to remove waste products and excess fluid from the blood when the kidneys stop working properly). The facility failed to: 1. Prevent Resident 1 from suffering from neglect for nursing services and wound care; 2. Ensure that Resident 1 receive proper treatment and care to maintain mobility and good foot health; 3. Follow industry standard practices and its own policies and procedures regarding foot care and wound care; As a result of these failures, the facility failed to routinely assess and follow Resident 1's physician's left foot care orders, leading to infection of Resident 1 left second toe, requiring amputation of the toe. A review of Resident 1's acute hospital "Discharged Summary," dated 3/27/21, indicated Resident 1 had fallen at home and fractured her left distal tibia (larger bone on the inside of the lower leg) and fibula (smaller bone on the outside of the leg)) and left ankle. Resident 1 underwent an ORIF (Open Reduction and Internal Fixation: a type of surgery used to stabilize and heal a broken bone) of the left ankle. A review of Resident 1's "Admission Record," dated 4/6/21, indicated Resident 1 was admitted to the facility on 3/27/21 with diagnosis including Fracture of the Left Tibia and Fibula, Type 2 Diabetes Mellitus, End Stage Renal (Kidney) Failure, Dependence on Renal Dialysis, Mental Disorder, Psychosis [lose some contact with reality such as hallucinations (hearing or seeing things), and delusions (believe things that are not true)], Major Depression, Unsteadiness on Feet, amongst others. A review of Resident 1's "Nursing - Admission/Readmission Assessment," dated 3/27/21, indicated Resident 1 was admitted to the facility for Physical Therapy (PT) and Occupational Therapy (OT: treat patients who have injuries, illnesses, or disabilities through the therapeutic use of everyday activities) post ORIF of left ankle on 3/24/21. There was swelling present at Resident 1's left lower extremity, limited physical mobility, non-weight bearing (NWB) to left lower extremity, and needed assistance with bathing, dressing and toileting upon admission. A review of Resident 1's "Baseline Care Plan Person-Centered Care Planning," dated 3/28/21, indicated Resident 1 was "Developmentally Delayed," was to be NWB to LLE (left lower extremity: leg) for 8 weeks, starting 3/24/21, was to go out for dialysis Monday, Wednesday and Friday, and her left foot/ankle dressing would be changed by physician one week after admission. A review of Resident 1's "Progress Notes," dated 4/12/21, and "Doctors' Order Sheet," dated 4/12/21, indicated Resident 1 saw her orthopedic surgeon on 4/12/21 and had new care orders for Resident 1's LLE, which included: NWB for four more weeks, ok to wash foot and ankle, ok to put lotion on foot and ankle, boot on except for bathing, and follow-up appointment in four weeks. "Progress Notes" indicated Resident 1 had nine Steri-Strips intact to left outer ankle and three Steri-Strips intact to left inner ankle. Skin warm and dry. A review of Resident 1's "Medication Administration Record (MAR)," dated 4/2021 and 5/2021, indicated "Ok to wash foot and ankle every shift (Day shift, P.M. shift and Night shift) and "Ok to put lotion on foot and ankle every shift." A review of Resident 1's "Nursing - Daily Skilled Charting Form - V 3.0," dated 4/27/21, 4/28/21, 4/29/21, 4/30/21, 5/4/21, 5/5/21, 5/6/21, 5/8/21, 5/9/21, and 5/10/21, indicated: "Integumentary (external layer of skin) Status" was warm, dry and skin color normal (white to pink). Resident 1's "Nursing - Daily Skilled Charting Form - V 3.0, dated 5/1/21, 5/2/21, and 5/7/21, indicated: "Integumentary" was warm and skin color normal. Resident 1's "Nursing - Daily Skilled Charting Form - V 3.0, dated 5/3/21, indicated: "Integumentary" was warm and dry, skin color normal and wounds, but "Wound Sites and Treatments (specify wound and site)" indicated, "None." Resident 1's "Nursing - Daily Skilled Charting Form - V 3.0," dated 5/3/21 and 5/9/21, under "Musculoskeletal" per check box, were the only two assessments to indicate the nurse did a Skin/Circulation/Surgical Site Assessment of the LLE. No details of the incision or the use of Steri-strips were documented. A review of Resident 1's "Weekly Summary Notes," effective 4/17/21, 4/24/21, and 5/6/21 indicated an entry for each of these dates stating there were, "No new skin issues this week." There was no mention of the LLE. Resident 1's "Weekly Summary Notes," effective date 5/1/21, indicated, "Surgical site to LLE and no new skin issues this week." A review of Resident 1's "Bathing Record," dated 4/2021, indicated she had five out of eight scheduled showers or bed baths in the month of April: on 4/7/21, 4/14/21, 4/17/21, 4/21/21, and 4/28/21. The record indicated Resident 1 refused her shower on 4/3/31. Additional entries on 4/10/21, 4/11/21, 4/24/21 and 4/25/21 indicated NA (Not Applicable). Resident 1's Bathing Record," dated 5/2021, indicated Resident 1 had two out of three scheduled showers or bed baths from 5/1/21 through 5/10/21: 5/1/21 a bed bath and 5/7/21 a shower. The entry for 5/4/21 in the "Bathing Record" indicated NA. During an interview on 7/15/21 at 12:10 p.m., Licensed Staff A stated Resident 1 did have an attitude, describing Resident 1 as a "brat", and further stating "[Resident 1] would have temper tantrums. Refused showers and did not want her foot touched." During an interview on 7/15/21 at 1:40 p.m., the DSD (Director of Staff Development) stated a resident should receive a shower or bed bath twice per week. The DSD stated if a resident refused a shower/bed bath, the Certified Nursing Assistant (CNA) should record a refusal of a shower or bed bath as RR (Resident Refused), not NA. The DSD stated the CNA should let the nurse know if the resident refused a shower or bed bath. The DSD stated the CNA should have given the nurse a "Shower" sheet and the nurse signs the sheet indicated she reviewed the "Shower" sheet. On 1/20/22 at 4:06 p.m., the Administrator was specifically asked to provide Resident 1's "Shower" sheets filled out by her CNAs. No "Shower" sheets were provided to the Department. A review of Resident 1's "Alteration in skin integrity related to surgical wound to left ankle status post ORIF" care plan, initiated 3/31/21, indicated: "Physician will change the splint at her office appointment, monitor incision for signs and symptoms of infection such as swelling, redness, pain, drainage and report as needed to MD (medical doctor), and treatment as ordered." Resident 1's "Diabetic Mellitus" care plan, initiated 3/29/21, indicated: "Check all of body for breaks in skin and treat promptly as ordered by doctor. If infection is present, consult doctor regarding any changes in diabetic medications. Inspect feet daily for open areas, sores pressure areas, blisters, edema or redness. Monitor for dry skin and apply lotion as needed." Resident 1's "Dialysis" care plan, initiated 3/29/21, indicated: "Monitor for peripheral edema (leg swelling caused by the retention of fluid in leg tissues)." Resident 1's "At Risk for Pain/Discomfort Related to Left Ankle Fracture" care plan, initiated 3/29/21, indicated: "Assess level of pain, frequently, site and factors that trigger the pain. Consider pre-medicating for pain prn (as needed) to optimize participation. Document and notify physician of increasing and/or unrelieved pain." A review of Resident 1's "Nurse's Notes, created date 5/11/21, indicated Resident 1 went to her orthopedic surgeon appointment on 5/10/21 and the physician called the facility to indicate Resident 1 had a wound on her foot, which looked infected when her cast was removed. Resident 1 was going to be sent to the ER (Emergency Room). Note: Resident 1 had Steri-Strips per Physician B's interview on 8/3/21 and a boot, not a cast to her LLE per Physician B's orders, dated 4/12/21. During an interview on 8/3/21 at 3 p.m., Physician B stated Resident 1 saw him on 4/12/21, whereby he removed the stitches to her left ankle and applied Steri-Strips. On 5/10/21, Resident 1 went to Physician B's office for a follow-up appointment regarding Resident 1's left ankle. Physician B stated when he removed Resident 1's boot and dirty sock, he could tell no one had cleaned her left foot and ankle "for at least two weeks." Physician B stated Resident 1's Steri-Strips were still intact after a month, there was caked-on dead skin at Resident 1's left foot and her second toe (next to her big toe) looked ulcerated (sore on the skin). Physician B stated no one could have assessed and washed Resident 1's left foot and ankle for at least two weeks because there were layers of dead skin. Physician B stated if a nurse had assessed Resident 1's left foot, the nurse would have seen there was a change of condition: Resident 1's left second toe was infected. Physician B stated Resident 1's infected left second toe did not happen overnight; it took at least two weeks to become that infected. Physician B stated he sent Resident 1 to the ER, whereby Resident 1 had to have her second toe amputated. Physician B stated the facility had instructions for wound care: to wash Resident 1's left foot and ankle, and apply lotion to Resident 1's foot and ankle daily. Physician B stated if Resident 1's left foot and ankle had been cleaned daily, Resident 1's Steri-Strips should have fallen off and there would not have been caked on dead skin. Physician B said, "The dead skin was that bad." Physician B stated the skin around Resident 1's left foot and ankle looked like what Physician B would have seen after removing a cast after six weeks. The sock was dirty, and the dead skin was caked on. Physician B stated again, no one at the facility assessed and cleaned Resident 1's left foot and ankle for at least two weeks or they would have noticed her infected toe. Physician B stated Resident 1 was "vulnerable" because of her intellectual capacity and developmentally delayed along with psychological issues. Physician B stated Resident 1 did not have the intellectual capacity to take it upon herself to take off her boot and sock, assess her left foot and ankle, and let someone know her toe did not look good. Physician B stated Resident 1 was at the mercy of the facility to take care of her. Physician B stated Resident 1 was neglected. During a concurrent interview and record review on 8/19/21 at 11:55 p.m., Resident 1's "Comprehensive Skilled Review Note-V 3.0," dated 4/9/21 and 4/23/21, indicated: "II. Therapy Services: I. Resident Information: ...B. Barrier to Therapy Progress: Resident 1's Barriers: NWB eight weeks LLE, MD to remove dressing in one week ..." Nursing left lateral ankle wound ..." and Resident 1's "Comprehensive Skilled Review Note-V 3.0," dated 5/8/21, indicated: "II. Therapy Services: I. Resident Information: ... B. Barrier to Therapy Progress: Resident 1's Barriers: NWB eight weeks LLE, MD to remove dressing in one week ..." Note: Resident 1's dressing was removed by Physician B on 4/12/21 and Steri-Strips were applied. Resident 1 was to wear a boot at all times unless Resident 1's foot and ankle was being washed and lotion applied, start date, 4/12/21, which was never mentioned. The MDS Coordinator stated he did not talk to Resident 1 nor assess her left foot and ankle to complete Resident 1's Comprehensive Skilled Review Note-V 3.0 form. The MDS Coordinator stated he reviewed and relied on documentation from the nurses for information regarding Resident 1's left surgical ankle wound, and he copied the nurses' notes into the "Comprehensive Skilled Review Note-V 3.0: I. Barrier to Nursing Progress" document. The MDS Coordinator stated the "Comprehensive Skilled Review Note" was just a review to see if Resident 1 should stay on "Skilled Services (patient's need for care or treatment that can only be performed by licensed nurses). The MDS Coordinator stated it was not his fault if the nurse(s) did not document Resident 1's left foot and ankle details accurately. During an interview on 10/21/21 at 5:15 p.m., Licensed Staff C stated he did not recall any abnormalities to Resident 1's left foot and ankle. Licensed Staff C stated he could not recall if he took off Resident 1's boot, washed her foot and ankle, and applied lotion, during his 3 assigned shifts on 5/4/21-5/5/21. Licensed Staff C stated the order: "Ok to wash foot and ankle every shift" and "Ok to apply lotion to foot and ankle every shift" to him meant, he could have removed Resident 1's boot, washed her foot and ankle and applied lotion, not that he necessarily had to follow through with the order. Licensed Staff C stated there probably should have been a clarification of the order. Licensed Staff C stated any order placed on a resident's MAR and TAR (Treatment Administration Record) was the responsibility of the nurse to complete. Licensed Staff C stated he did recall Resident 1 was not being cooperative with taking her medication/insulin (controls the blood sugar levels), but Licensed Staff C could not recall specific treatment to Resident 1's left foot and ankle. Licensed Staff C was asked if Resident 1's Steri-Strips, which were applied on 4/12/21, should have fallen off by the time Resident 1 went to her follow-up appointment, on 5/10/21? Licensed Staff C stated Resident 1's Steri-Strips should have fallen off by 5/10/21, and her incision to her ankle should have healed. A review of Resident 1's MAR, dated 4/2021 and 5/2021, indicated Licensed Staff D was assigned to care for Resident 1 on 4/12/21-4/15/21, 4/19/21-4/21/21, 4/25/21, 4/27/21, and 5/8/21, Night shift. During an interview on 10/22/21 at 12:09 p.m., Licensed Staff D was asked about the order on Resident 1's 4/2021 and 5/2021 MAR with a start date, 4/12/21, indicating "OK to put lotion on foot and ankle every shift ... OK to wash foot and ankle every shift," Licensed Staff D stated, her understanding was that the order was merely "FYI" (For Your Information), and did not mean Resident 1's foot and ankle needed to be washed and lotion applied every shift.. Licensed Staff D stated if Resident 1 was asleep, she would not have woken