Health inspection·April 9, 2025

The following reflects the findings of the California Department of Public Health during the investigation of complaint # CA00947498. Event ID: FB3811 State Citation B was written §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. § 72315. Nursing Service - Patient Care. (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (1) Changing position of bedfast and chairfast patients with preventive skin care in accordance with the needs of the patient. (2) Encouraging, assisting and training in self-care and activities of daily living. (3) Maintaining proper body alignment and joint movement to prevent contractures and deformities. (4) Using pressure-reducing devices where indicated. (5) Providing care to maintain clean, dry skin free from feces and urine. (6) Changing of linens and other items in contact with the patient, as necessary, to maintain a clean, dry skin free from feces and urine. (7) Carrying out of physician's orders for treatment of decubitus ulcers. The facility shall notify the physician, when a decubitus ulcer first occurs, as well as when treatment is not effective, and shall document such notification as required in Section 72311(b). On 3/6/25 at 8:31 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding Resident 1. Resident 1 did not receive monitoring and intervention to prevent a development of unstageable pressure ulcer (skin and soft tissue injuries that develop due to prolonged pressure exerted over specific areas of the body, but not stageable due to coverage of wound bed by moist dead tissue and/or crusty, dry, and dead tissue) on the posterior of her right leg underneath a leg immobilizer (a device used to support and stabilize the leg and knee). The facility failed to ensure that Resident 1 received a care consistent with standards of practice to prevent a development of unstageable pressure ulcer on her right leg underneath the leg immobilizer. Resident 1 did not have an unstageable pressure ulcer on her right leg when she was admitted to facility on 11/11/2024, until an unstageable pressure ulcer was discovered on 12/5/2024. Resident 1 was admitted on 11/11/2024, with diagnoses that included "Periprosthetic Fracture Around Internal Prosthetic Right Hip Joint," (A broken bone around a hip replacement). Resident 1's physician "Order Recap Report" for November 2024 indicated, "right leg-knee immobilizer at all times," and "non-weight bearing tight [right] leg." Resident 1's "Braden Scale for Predicting Pressure Sore Risk," (an assessment tool used evaluate a risk for developing pressure ulcer) dated 11/11/24 indicated a score of 13 (Moderate risk score 13 - 14). Resident 1's "Body Check" dated 11/11/24, indicated there were no identified skin problem on Resident 1's right leg. During a review of Resident 1's clinical record titled "Care Plan Report" (CPR), initiated on 11/12/24, indicated Resident 1 "Has higher risk of/potential for pressure ulcer development r/t [related to] Disease process." Planned interventions in the CPR included "Assess/record/monitor wound healing (FREQ) [Frequency]. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress... Follow facility policies/protocols for the prevention/treatment of skin breakdown." Resident 1's CPR did not identify and include interventions for Resident 1's risk of skin breakdown on the right leg from the use of immobilizer. Resident 1's CPR did not indicate a refusal of care for skin check underneath the right leg immobilizer. Further, Resident 1's CPR was not updated when a pressure ulcer was identified on 12/5/24. During a review of Resident 1's Minimum Data Set (MDS - resident assessment tool) dated 11/15/24, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score of 10, (BIMS score of 08 - 12, moderate cognitive impairment). Resident 1's MDS skin assessment, indicated Resident 1 was at risk developing pressure ulcers/injuries, and had no unhealed pressure ulcer/injuries. During a review of Resident 1's clinical record titled "Change in Condition Evaluation - V5.1" (CICE) dated 12/5/24, the CICE indicated, Resident 1 was identified to have "Skin wound or ulcer." The CICE indicated, "Resident has c/o [complaint of] pain and discomfort." The CICE indicated Resident 1's skin changes were in "Site 43. Right lower leg (rear)," and "Description: wound and redness on R [right] -leg (rear)." Resident 1's skin wound or ulcer was not measured in length, width, and depth, and there was no description of the underlying tissue of the wound. During a review of Resident 1's Physician Progress Notes (PPN) dated 12/5/24, indicated "Staff reported wound on rt [right] leg at lower end of knee immobilizer... Plan- hold d/c [discharge] until wound healing... Visit Diagnoses Primary: Pressure Ulcer, Unspecified site and stage." During an interview on 3/10/25 at 2:22 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated when Resident 1's pressure ulcer was discovered on 12/5/24, there was no wound measurement done. LVN 1 stated Resident 1's physician was visiting the facility, and they took a picture of the wound. LVN 1 stated that on 12/5/24, physician ordered a treatment with Medi honey with calcium alginate (dressing used for moderate to heavy oozing wounds and to cover a shallow or fill a deep wound) indicating the pressure ulcer had slough (dead tissue usually yellow, tan, gray, or green in color, usually moist and stingy in texture). During a concurrent interview and record review on 3/6/25 at 9:49 a.m., with Director of Nursing (DON), DON stated Resident 1 was admitted with right leg immobilizer. DON reviewed Resident 1's clinical record for skin monitoring on the right leg underneath the immobilizer. DON was unable to show that Resident 1's right leg skin underneath the immobilizer was being checked. DON stated the Resident 1's skin should have been checked at least once every shift. During an interview on 3/6/25 at 12:35 p.m., with Registered Nurse (RN) 1, RN 1 stated if Resident 1's skin was checked underneath the immobilizer, it would be documented in the treatment administration record (TAR). During a concurrent interview and record review on 3/6/25 at 10:21 a.m., with DON, DON provided Resident 1's "Order Recap Report" for the month of December 2024. DON stated there was an order to check to check the skin on Resident 1's right leg. The physicians order dated 12/12/24, indicated "monitor the skin under brace to right leg daily, notify MD [Medical Doctor] if any changes of condition every day shift." During a concurrent interview and record review on 3/6/25 at 12:50 p.m., with DON, DON presented Resident 1's "Skin Monitoring Comprehensive CNA Shower Review" for the following dates 11/14/24, 11/22/24, and 11/26/24. DON stated after the CNA provided Resident 1's bed bath, CNA would provide the forms to the licensed nurse to sign acknowledging it with a counter signature. The skin monitoring form shower review forms revealed Resident 1's skin underneath the immobilizer on the right leg were not checked. During an interview on 3/6/25 at 12:18 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated only the licensed nurses would check the resident's skin under the immobilizer. During a review of Resident 1's clinical record titled "Interdisciplinary Care Conference - V 5" (IDCC) dated 12/13/24, IDCC indicated a Care Conference for Skin Alteration, for a "Trauma - device acquired injury," located at Resident 1's right shin, the measurement for length, width, and depth were blank, and the comment indicated "IHA," (In house acquired). The ordered treatment was "right lower shin posterior device related pressure injury: cleanse with NS, pat dry apply iodosorb cream and cover with border foam dressing daily," (NS - normal saline; Iodosord - medication used treat wet pressure ulcers and wounds). During a concurrent interview and record review on 3/6/25 at 10:40 a.m., with DON, DON reviewed Resident 1's "Interdisciplinary Care Conference - V 5" (IDCC) dated 12/27/24, IDCC indicated a Care Conference for Skin Alteration, a wound type was "Trauma - device acquired injury," located at Resident 1's right shin, with length in centimeter (cm) 10 cm, width 3 cm, and depth was left blank, and a comment indicated "IHA." DON stated Resident 1's pressure ulcer measurement was done on 12/27/25, and there was no measurement done when pressure ulcer was identified on 12/5/24. DON stated the pressure ulcer was "IHA." During a review of Resident 1's clinical record dated 12/11/25, the Physician Progress Notes (PPN), indicated "Add cefadroxil bid [two times a day] for 1wk [week] for possible cellulitis around wound-no fever, ...," (Cefadroxil - mediation used to treat bacterial infection). Primary visit diagnoses: "Pressure ulcer, unspecified site and stage." Resident 1's PPN dated 12/18/24 indicated "D/w [Discussed with] wound nurse, pt [patient] may need surgical debridement (medical procedure to remove the dead or infected tissue), by surgeon or ortho [orthopedic doctor] given proximity to tendon. Dtr [Daughter] was notified that wound healing may take few wks [weeks]." Resident 1's PPN dated 12/23/24, indicated, "Had lengthy discussion with dtr [Daughter] last week, dtr [Daughter] was concerned about avoidable decub [decubitus/pressure ulcer], pt's [patient's] lack of socialization and motivation etc, worry if pt [patient] giving up." ... "Size of decub [decubitus/pressure ulcer] getting smaller, slough getting softer too." During a review of Resident 1's clinical record titled "Skilled Nursing Facility Discharge Summary" SNFDS dated 1/14/25, SNFDS indicated Resident 1's Date of Discharge was 1/17/25 with diagnoses that included "rt [Right] femur fracture," and "rt [right] calf decub [decubitus/pressure ulcer]." During an interview on 3/10/25 at 1:27 p.m., with Resident 1' Responsible Party (RP), RP stated prior to Resident 1 falling, she used to live in an assisted living facility, in her own apartment. Resident 1 could inject herself insulin on her stomach after the staff prepared the insulin. Resident 1 could walk to and from the dining hall with the use of front wheeled walker. RP stated Resident 1 could have a conversation. RP stated currently, Resident 1 not very verbal and she could only respond in a "Yes or No" answer on somedays. RP stated Resident 1 was discharge on 1/17/2025, with hospice (specialized care that support a person nearing the end of life) care. During a review of the facility's policy and procedure (P&P) titled "Skin Integrity Management" with effective date of 5/26/2021, the P&P indicated "The implementation of an individual patient's skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed ... 2.1 Complete risk evaluation on admission/re-admission, weekly for the first month, quarterly, and with significant change in condition. 3. Identify patient's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information. 3.1 Perform skin inspection on admission/re-admission and weekly. Document on Treatment Administration Record (TAR) or in Point Click Care [electronic health records] (PCC). 3.2 Perform wound observations and measurements upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound." In violation of the above cited standards, the facility failed to ensure Resident 1 had monitoring and interventions in place to prevent development of unstageable pressure ulcer on the right lower leg that caused pain and extended Resident 1's stay at the facility. This violation had a direct or immediate relationship to the health, safety or security of Resident 1.