Other·December 11, 2018

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 STANDARD SURVEY for COMPLAINT: CA 00519197. Inspection was limited to the Abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Health Facilities Evaluator Nurse 31572. ONE DEFICIENCY WAS ISSUED FOR COMPLAINT: CA 00519197 at F 314. Representing the California Department of Public Health: Health Facilities Evaluator Nurse 31572.

F314 SS=G TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES CFR(s): 483.25(b)(1)

F314 02/28/2018 (b) Skin Integrity (1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure thatLABORATORY 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: T2VD11 Facility ID: CA220000772 If continuation sheet 1 of 6 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: _______________ 555595 (X3) DATE SURVEY COMPLETED 04/19/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SMITH RANCH SKILLED NURSING & REHABILITATION CENTER 1550 Silveira 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 (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, interview and record review, the facility failed to provide active interventions like turning and how often it should be done for Resident 2 who was admitted to the facility without a pressure ulcer, P.U. (injury to skin and underlying tissue resulting from prolonged pressure on the skin. P.U. most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips and tailbone.) which resulted in Resident 2 developing an unstageable (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (a dry, dark scab or falling away of dead skin) pressure ulcer. This failure resulted in pain and delayed healing. Findings: Review of the facility Order Summary Report indicated, Resident 2 was admitted to the facility on 11/13/16 with diagnoses of difficulty walking, generalized muscle weakness, history of falling, nondisplaced fracture (the bone FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T2VD11 Facility ID: CA220000772 If continuation sheet 2 of 6 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: _______________ 555595 (X3) DATE SURVEY COMPLETED 04/19/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SMITH RANCH SKILLED NURSING & REHABILITATION CENTER 1550 Silveira 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 cracks either part or all of the way through, but does not move and maintains its proper alignment) of left neck femur (thigh bone) and dementia (an overall term that describes a wide range of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). Review of the MDS (Minimum Data Set) an Admission Assessment tool dated 11/19/16 indicated Resident 2 had severely impaired cognition (understanding, comprehension); required two plus persons physical assist for bed mobility, transfer, toilet use and personal hygiene; incontinent of bladder and bowel and without pressure sore. Review of the Braden Scale (assessment tool used for predicting pressure sore risk) indicated Resident 2 "At Risk" with a score of 16. Interventions linked to the "At Risk Braden Scores" of 15 to 18 are: frequent repositioning/turning; maximize patient's mobility; off-load (to get rid of something unpleasant or burdensome) patient heels for protection; use a pressure-distribution support surface (a support surface takes the weight of the patient when lying or sitting, and is intended to spread out (redistribute) the pressure exerted on the tissues in contact with that surface. The term support surface can apply to specialist beds, mattresses and mattress overlays, and also to chair and wheelchair cushions.) if patient is bed bound or chair bound. During a concurrent (occurring at the same time) observation and interview Resident 2 was sitted on a wheelchair in the dining room on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T2VD11 Facility ID: CA220000772 If continuation sheet 3 of 6 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: _______________ 555595 (X3) DATE SURVEY COMPLETED 04/19/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SMITH RANCH SKILLED NURSING & REHABILITATION CENTER 1550 Silveira 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 1/27/17 at 1:10 p.m., Family Member 3 stated that except on weekends, she visits from four to five hours everyday and that Resident 2 was seated in the wheelchair from 9 a.m. to 2 p.m. and repositioning every two hours while in bed was not done. Review of the facility's "Weekly Pressure Ulcer BWAT(Bates Wound Assessment Tool) Report" indicated on 12/14/16 at 2:12 p.m., Resident 2 had an unstageable pressure ulcer on the sacrum (a large, triangular bone at the base of the spine) measuring 0.8 cm in length and 0.6 cm in width. On 12/21/16 and 12/28/16 at 1:36 p.m., the unstageable pressure ulcer measured 0.9 cm long x 0.5 cm wide and a depth of 0.1 cm. On 1/4/17 at 1:36 p.m., the unstageable pressure ulcer measured 1.6 cm long x 0.6 cm wide and 0.1 cm deep. On 1/11/17 at 1:36 p.m., the unstageable pressure ulcer measured 1.6 cm long x 0.8 cm wide and 0.1 cm deep. On 1/18/17 at 1:36 p.m., the unstageable pressure ulcer measured 2 cm long x 1.0 cm wide and 0.1 cm deep. Review of Resident 2's undated "Care Plan" indicated stage 2 pressure ulcer (the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) related to immobility. New interventions (action taken to improve a situation) listed indicated to document location of wound, amount of drainage, peri-wound area (is the tissue surrounding the wound itself), pain, edema (medical term for swelling), and circumference measurements. Evaluate wound for: Size, Depth, Margins: peri-wound skin (the area of skin surrounding a wound), erythema (skin condition characterized by redness or rash), FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T2VD11 Facility ID: CA220000772 If continuation sheet 4 of 6 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: _______________ 555595 (X3) DATE SURVEY COMPLETED 04/19/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SMITH RANCH SKILLED NURSING & REHABILITATION CENTER 1550 Silveira 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 scars, edema, skin temperature, sensation, and pain, sinuses (a hollow, air-filled cavity) undermining (erode, wear away, eat away at), exudates (any fluid that filters from the circulatory system into lesions or areas of inflammation. It can be a pus-like or clear fluid.), edema, granulation (the healing surface of a wound), infection, necrosis (the death of most or all of the cells in an organ or tissue due to disease, injury, or failure of the blood supply), eschar, gangrene (part of your body tissue dies because the tissue is not getting enough blood from your circulatory system.) Document progress in wound healing on an ongoing basis. Notify physician as indicated. During an interview on 3/3/17, at 1:58 p.m., Licensed Staff D stated the interventions listed in the care plan were mainly to document, it was not an active intervention of turning and how often it was to be done. It was just to document and evaluate. The facility failed to develop a care plan to prevent and care for Resident 2's pressure ulcer when no regular repositioning/turning was done. During an interview on 4/17/17, at 10:31 a.m., Unlicensed Staff E stated she looked after Resident 2. When asked what are the possible causes why a resident would get a pressure sore, Unlicensed Staff E stated, "too much time in the wheelchair, dressing change not attended promptly when diaper is wet or soiled, no repositioning, the aide is too busy and cannot do the work right." Review of the facility manual "NCD (Nursing Center Division)-19 Pressure Ulcer" indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T2VD11 Facility ID: CA220000772 If continuation sheet 5 of 6 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: _______________ 555595 (X3) DATE SURVEY COMPLETED 04/19/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SMITH RANCH SKILLED NURSING & REHABILITATION CENTER 1550 Silveira 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 patients are at risk of developing pressure sores if they have difficulty moving and are unable to easily change position while seated or in bed. Immobility may be due to: Those who have sustained a hip fracture, injury or illness that requires bed rest or wheelchair use. Other factors that increase the risk of pressure sores include: Age. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: T2VD11 Facility ID: CA220000772 If continuation sheet 6 of 6