Other·October 10, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for a complaint. Complaint number: CA00638989 Representing the California Department of Public Health: Health Facilities Evaluator Nurse # 41283 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for CA00638989.

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 08/22/2019 SS=G CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(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 and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interviews, and record LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QCZQ11 Facility ID: CA220000065 If continuation sheet 1 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555214 (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROFESSIONAL POST ACUTE CENTER 81 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE reviews, the facility failed to implement its policies and procedures for the prevention of pressure injuries (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical device or other device as a result of intense and/or prolonged pressure) for one of three sampled residents, Resident 1. This failure resulted in the development of a DTPI (Deep Tissue Pressure Injury- a pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise. These lesions may signal the subsequent development of a Stage III-IV pressure injury even with optimal treatment.) on the left heel of Resident 1. Findings: During the review of the clinical record for Resident 1, the Discharge Summary from the acute care hospital dated 4/15/19, indicated that Resident 1 had a mechanical fall and sustained a left hip fracture. He was hospitalized from 4/12/19-4/15/19. Resident 1 had a surgery done on 4/13/19 to repair the fracture and he was stable upon discharge to a skilled nursing facility on 4/15/19. During a review of the admission record for Resident 1, it indicated that he was admitted to this SNF (Skilled Nursing Facility - is a special facility that provides medically necessary professional services from nurses, physical and occupational therapists, speech pathologists and audiologists) on 4/15/19, at 1:30 p.m. During a review of the clinical record for Resident 1, an entry on the care plan initiated on 4/16/19, indicated that Resident 1 had declined in bed mobility, transfer, gait, balance, safety, postural alignment, skin integrity, and range of motion of the lower extremities. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QCZQ11 Facility ID: CA220000065 If continuation sheet 2 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555214 (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROFESSIONAL POST ACUTE CENTER 81 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a review of the clinical record for Resident 1, the Braden Scale for Predicting Pressure Sore Risk, an admission assessment tool, dated 4/15/19, at 2:53 p.m., indicated a score of 15. A score of 15 to 18 places the resident at risk for developing a pressure injury. During a review of the clinical record for Resident 1, the Comprehensive Care Plans initiated on 4/15/19, did not indicate interventions defined to address the risk for skin impairment and did not indicate interventions defined to promote the prevention of pressure injury development. Resident 1 was assessed as an at risk (for pressure injury)resident based on the Braden Scale for Predicting Pressure Sore Risk. During an interview with the DON (Director of Nursing) on 5/29/2019, at 3:43 p.m., she stated that if a newly admitted resident was assessed to be at risk for pressure ulcer injuries, there must be interventions in place in the plan of care to address the concern such as, pressure relieving measures to the heel and elbow, and a repositioning schedule to turn the resident from side to side every two hours. After the DON provided the comprehensive care plans for Resident 1, she was asked to review this record and verify that this care plan did not include interventions to prevent the development of pressure injury for Resident 1, the DON stated, "Correct". During a review of the clinical record for Resident 1, the MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QCZQ11 Facility ID: CA220000065 If continuation sheet 3 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555214 (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROFESSIONAL POST ACUTE CENTER 81 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE problems.) dated 4/22/19, indicated on Section M (assessment for skin conditions), that Resident 1 was at risk for developing pressure injuries. The MDS also indicated that Resident 1 had two unhealed Stage 1 (intact skin with non-blanchable redness of a localized area usually over a bony prominence) pressure injuries. During the review of the clinical record for Resident 1, the comprehensive care plans initiated at the time of his admission on 4/15/19, did not indicate that there were interventions to address these unhealed Stage 1 pressure injuries. During an interview with the DON on 5/29/19, at 3:43 p.m., after she provided a copy the Section M of the MDS, she was asked if the identified unhealed Stage 1 pressure injuries were healed and what were their locations, she stated that she was unsure and will have to ask the MDS coordinator about these identified pressure injuries. The DON also stated that the MDS coordinator who did the assessment was on leave. During a concurrent interview and review of the clinical record for Resident 1 with the DON on 5/29/2019, at 3:43 p.m., an entry on the care plan which was initiated on 4/15/19, indicated that Resident 1 had a mild blanchable (color of skin returns to normal immediately when pressure is released) redness on his coccyx (tailbone). The intervention for this assessed skin issue was to monitor as ordered. After the review of the intervention defined for the blanchable redness on coccyx, the DON was asked if it was acceptable to her that the only intervention on the care plan for this identified skin integrity concern was to monitor as ordered, she stated, "No." She further stated and stressed the importance of pressure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QCZQ11 Facility ID: CA220000065 If continuation sheet 4 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555214 (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROFESSIONAL POST ACUTE CENTER 81 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE relieving measures and repositioning as preventive measures. During a review of the clinical record for Resident 1, the Skin/Wound Note entry dated 4/24/19, at 5:26 p.m., indicated that Resident 1 developed a blister with black fluid on the left heel. The wound was manually measured at 5 centimeters by 4.5 centimeters. During the review of the clinical record for Resident 1, the skin integrity care plan initiated on 4/24/19, indicated a DTI (Deep Tissue Injury) was discovered on Resident 1's left heel and was assessed to be an unavoidable pressure injury. During an interview with the DON on 7/19/19, at 8:10 a.m., she was asked to clarify the entry on Resident 1's care plan on 4/24/19, the day that the pressure injury was discovered and indicating that the pressure injury was "unavoidable," (Unavoidable means the resident developed a pressure injury even though the facility had evaluated the resident's clinical condition and risk factors, defined and implemented interventions that are consistent with the resident's needs, goals, and professional standards of practice; monitor and evaluated the impact of the interventions; and revised the approaches as appropriate), she stated that the pressure injury of Resident 1 was "avoidable", (Avoidable means that the resident developed a pressure injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors, defined and implemented interventions that are consistent with the resident's needs, goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate). She further stated that a simple intervention of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QCZQ11 Facility ID: CA220000065 If continuation sheet 5 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555214 (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROFESSIONAL POST ACUTE CENTER 81 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE floating the heels by placing pillows under the lower legs to elevate the feet could have been enough to prevent pressure injuries on the heels. During a review of the clinical record for Resident 1, the acute care hospital's Discharge Summary and Last Progress Notes dated 5/25/19, at 1:27 p.m., indicated that Resident 1 was admitted to the hospital from 5/19/195/26/2019 with dignoses that included UTI and pressure ulcer (pressure injury) of left heel. The discharge summary also indicated that the pressure ulcer of the left heel was acquired in the skilled nursing facility. This document also indicated that during this hospital stay, Resident 1 was seen by a podiatrist (A podiatrist is a doctor who specializes in treating the foot, ankle, and lower leg.) for left heel pressure wound care. During an interview with Licensed Staff A on 5/29/19, at 12:45 p.m., she stated that the CNAs (Certified Nursing Assistants) usually had about nine to ten residents assigned to them, and as the charge nurse, she usually had about 28-30 residents assigned to her. She further stated that she had about seven residents who were being treated with pressure injury wounds. She also stated that they had a wound nurse who did the dressing changes, but if the wound nurse was unavailable, she did the dressing changes herself. When asked if the number of staff was sufficient to provide the care needed by the residents, she stated, "I don't think so." She also stated that six to seven residents per CNA will be more realistic because sometimes they were assigned to give showers to two to three residents in their shift but they were unable to do it during the shift, and so they passed them on to the next shift. She further stated that the repositioning schedule of every 2 hours will be hard for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QCZQ11 Facility ID: CA220000065 If continuation sheet 6 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555214 (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROFESSIONAL POST ACUTE CENTER 81 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE CNAs to implement if they were assigned nine to ten residents for patient care. During an interview and concurrent observation with Resident 1 on 5/29/19, at 1 p.m., in his room, he was in bed lying on his back. Resident 1 stated that he felt some pain on the left heel prior to the discovery of the pressure injury. Licensed Staff B removed the dressing and the left heel injury was visibly covered with thick brown eschar (Eschar is an area of dead tissue on the skin. Often called a black wound, the scab may appear black with a thick collection of dry tissue. This tissue is often necrotic, or created as a result of the early death of otherwise healthy skin cells). A new dressing was reapplied using a clean technique. During an interview with Licensed Staff B on 5/29/2019, at 1:45 p.m., she stated that the pressure injury on Resident 1's left heel was discovered by CNA C on 4/24/19. Licensed Staff B also stated that she reported the discovery of the pressure injury to Licensed Staff D, the nurse in charge for Resident 1. Licensed Staff B stated that she was surprised that Resident 1 developed a pressure injury because he wore heel protectors. When Licensed Nurse B was asked if there were documentations that would show that there were interventions in place prior to the development of the left heel pressure injury on Resident 1, she stated "No." She further stated that not all of the nursing staff were able to consistently adhere to the turning and repositioning schedule to prevent pressure injuries. The facility policy and procedure titled," Pressure Injury Risk Assessment," last revised in July 2016, indicated that the purpose of this procedure was to provide guidelines for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QCZQ11 Facility ID: CA220000065 If continuation sheet 7 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555214 (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROFESSIONAL POST ACUTE CENTER 81 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE assessment and identification of residents at risk of developing pressure injuries. Under "General Guidelines", guideline number two indicated that the most common pressure injury was where the bone was near the surface of the body including the back of the head, around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes. Under "Assessment", item number four indicated that because a resident at risk can develop a pressure injury within two to six hours of the onset of pressure, the at risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure injuries. The admission evaluation helps define those initial care approaches. The facility policy and procedure titled, "Repositioning," last revised on May 2013, and still a current facility policy, indicated that the purpose this procedure was to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to provide comfort for all bed or chair bound residents, and to prevent skin breakdown, promote circulation, and provide pressure relief for residents. Under, "Steps in the procedure, repositioning the resident in bed", step one was to "Check the care plan, assignment sheet, or the communication system to determine resident's specific positioning needs, including special equipments, resident's level of participation, and the number of staff required to complete the procedure. Under "Interventions", item number one indicated that a turning/repositioning program includes a continuous consistent program for changing the resident's positions and realigning the body. A program was defined as a specific approach that was organized, planned, documented, monitored, and evaluated. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QCZQ11 Facility ID: CA220000065 If continuation sheet 8 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555214 (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PROFESSIONAL POST ACUTE CENTER 81 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: QCZQ11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA220000065 (X5) COMPLETE DATE If continuation sheet 9 of 9