Health inspection·July 8, 2025

State citation A was written. Code of Federal Regulations, Title 42, Section 483.25(b) Skin Integrity (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. California Code of Regulations, Title 22, Section 72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. California Code of Regulations, Title 22, Section 72311. Nursing Service--General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. California Code of Regulations, Title 22, Section § 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. Code of Federal Regulations, Title 42, Section § 483.10(g) - Resident rights (14) Notification of changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s), when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment); On 5/13/25, at 9:30 a.m., the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding quality of care. The Department determined the facility failed to ensure Resident 1 and Resident 2 received care to prevent the development of pressure ulcers/injuries (PU/PI - areas of damaged skin caused by staying in one position for too long, usually over an area on the body where a bone is close to the skin's surface (bony prominence)) when: 1. Resident 1 was at risk for developing pressure ulcers and worsening of a shearing wound (a force that causes the skin and underlying tissues to move in opposite directions, often due to pressure and friction) on the coccyx (tailbone) and Resident 1's skin assessments and wound documentation were incomplete contrary to the facility's policies and procedures (P&P). 2. The physician was not informed about the worsening of Resident 1's wound. 3. PU preventative measures were not correctly identified and implemented for Resident 1 upon admission. 4. Resident 2 was at risk of developing pressure ulcers and worsening of a shearing wound on the coccyx and blanchable redness (a temporary reddening of the skin that disappears when pressure is applied) to both heels and Resident 2's skin assessments and wound documentation were incomplete contrary to the facility's P&Ps. 5. Measures to prevent PU development were not implemented for Resident 2. These failures resulted in Resident 1 having wound pain and required surgical intervention at a hospital with the placement of a wound vacuum (VAC -a medical treatment that uses negative pressure to help severe wounds heal). In addition, these failures resulted in Resident 2 developing a deep tissue injury (DTI - deep skin and tissue loss where the extent of the damage cannot be determined because it is covered by eschar (black dead tissue)) to the left heel and had the potential to result in increased pain, infection (the invasion and growth of germs in the body), and muscle or bone loss. 1. A review of Resident 1's "ADMISSION RECORD," indicated Resident 1 was admitted to the facility on 4/18/25 with diagnoses which included but were not limited to: sepsis (a life-threatening infection), arthritis (swelling and tenderness where two or more bones meet, causing joint pain and/or stiffness) due to other bacteria (an infection in the joint fluid and tissues caused by bacteria), chronic obstructive pulmonary disease (COPD -a chronic lung disease causing difficulty breathing), and muscle weakness. A review of Resident 1's Minimum Data Set (MDS -an assessment tool), dated 4/22/25, in the section, "M -Skin Conditions," indicated, Resident 1 was at risk of developing pressure ulcers. A review of Resident 1's, "Care Plan Report," dated 4/19/25, indicated, " ... [Resident 1] has skin sheering to her coccyx upon admit ...Goal [Resident 1's] skin will show signs of improvement ...Interventions/Tasks ...Monitor for s/sx [signs and symptoms] of infection ...Notify MD [medical doctor] of s/sx of infection ..." A review of Resident 1's "Order Details," order date 4/18/25, indicated, " ...Cleanse shearing wounds to coccyx with NS [normal saline -salt water], pat dry ...every day shift for skin shearing ... Monitor shearing wounds to coccyx for s/s [signs/symptoms] of infection until resolved ..."; and order date 4/19/25, indicated, " ...Cleanse shearing wounds to coccyx with NS, pat dry ...cover with foam dressing [an absorbent wound covering to promote wound healing] ...every day shift for skin shearing AND as needed for soiled, lifting or missing [dressing] ..." A review of Resident 1's, "Nursing Progress Note," dated 4/24/25 (late documentation on 5/7/25), indicated, " ...LATE ENTRY ...Provided wound care for resident with shearing wound to coccyx, increase in size r/t [related to] persistent watery stools. Wound size went from 3.5x1.3x0.1 on admission to 6.2x3x0.1. Wound bed is 100% [percent] granulation [pink or red, fleshy skin growth] with discolored sheared skin. Periwound is macerated. Resident complains of discomforting wound pain 6/10 with wound care ..." A review of Resident 1's "Nursing Progress Note," dated 4/26/25, indicated, " ... [Resident 1] transferred to ER [Emergency Room] ... [Resident 1] was having hallucinations [sensing things such as visions, sounds, or smells that seem real but are not] and thinking people were in bed with her, nurse noted grayish appearance ..." During a concurrent interview and record review on 5/13/25, at 1:19 PM, Resident 1's electronic health record (EHR) was reviewed with Licensed Nurse (LN) 1. LN 1 stated Resident 1 was admitted with two wounds, one on the left hand, and a shearing wound on the coccyx. Resident 1's "Admission -Readmission Nursing Evaluation ..." dated 4/18/25, indicated, " ...Indicate Pressure Ulcers and/or other wound types ...Sacrum [triangular shaped bone in the lower back located between the hip bones] ...Type: Pressure [injury to skin and underlying tissue resulting from prolonged pressure on the skin] ...Length 1.8 [cm- centimeter -a metric unit of length], Width 0.8 [cm], Depth 0.1 [cm], Stage II [2 -partial-thickness skin loss, presenting as a shallow open wound; wounds are classified into stages to indicate the depth of tissue damage and includes stages 1 through 4 and unstageable (when dead tissue is covering the wound making it unable to determine the depth of the wound)] ..." LN 1 stated the nurse who completed Resident 1's Admission-Readmission Nursing Evaluation was not a wound nurse. LN 1 stated he updated the description of the wound on the order he entered after he assessed Resident 1's wounds. LN 1 confirmed he entered " ...Cleanse [clean] shearing wounds to coccyx ..." to Resident 1's order on 4/18/25 which changed the type of wound listed on the order from "pressure ulcer" to "shearing wound." LN 1 stated he did not document in a progress note (a written record that documents a resident's health status, treatment progress, and any changes in their condition over time) the measurements, location, and description of what the wound looked like after his initial assessment. LN 1 further stated he needed to get better at documentation, and he tried to make weekly progress notes but stated he "missed the charting." LN 1 confirmed Resident 1's "BRADEN SCALE [a widely used tool in healthcare to assess and predict a patient's risk for developing pressure ulcers] FOR PREDICTING PRESSURE SORE RISK," dated 4/18/25, indicated, " ...MOISTURE ...Rarely Moist [the degree to which skin is exposed to moisture ranging from rarely moist to constantly moist], ...MOBILITY [the ability to move or be moved freely and easily] ...Very Limited: Makes occasional slight changes in body or extremity [arms and/or legs] position but unable to make frequent or significant changes independently ...[Resident 1 was] AT RISK [risk levels for pressure ulcer development range from at risk, moderate risk, high risk, or very high risk based off of the score obtained from the Braden scale assessment tool] ..." for pressure ulcers. LN 1 stated he disagreed with Resident 1's initial Braden scale assessment risk level since Resident 1 was fully incontinent of bowel and bladder (involuntary loss of urine or feces), had a high moisture risk, was immobile (not capable of movement), and required assistance to turn or reposition in bed. LN 1 stated Resident 1's Braden Scale assessment should have been assessed as a high risk for pressure ulcer development. LN 1 further stated it was his expectation for Resident 1 to be turned and repositioned every two hours to prevent the wound from worsening. LN 1 explained he completed Resident 1's wound care based on the treatment listed on the treatment administration record (TAR - a document used to track the administration of various treatments, including medications, therapies, and procedures). LN 1 stated he noted on 4/24/25 Resident 1's wound to the coccyx worsened and the wound size increased. LN 1 reviewed Resident 1's "Progress Notes," dated 4/24/25, written by LN 1, which indicated, " ...LATE ENTRY ...Provided wound care for resident with shearing wound to coccyx ...Wound size went from 3.5x1.5x0.1 [length, width, depth in cm] on admission to 6.2x3x0.1 ...discolored sheared skin. Periwound [around the wound] is macerated [softening and breaking down of the skin resulting from prolonged exposure to moisture] ...Resident complains of discomfort wound pain 6/10 [pain scale 0-no pain to 10-worst pain] with wound care ..." LN 1 confirmed that the late entry for the worsening of Resident 1's wound was written in Resident 1's EHR on 5/7/25. LN 1 stated he forgot to document Resident 1 had a worsening condition of the wound on 4/24/25 and confirmed he did not notify the doctor. LN 1 further stated it was facility policy to notify the doctor and to document worsened conditions immediately to obtain new physician orders for wound treatment. Resident 1's EHR was reviewed by LN 1, and he was unable to locate any further documentation regarding Resident 1's worsening wounds. During a follow up interview on 5/13/25 at 2:49 PM, LN 1 stated documentation in a resident's medical record was important because it provided accurate and efficient documentation on what was happening with the resident. LN 1 further explained it was important to document timely and notify the doctor of a change in a resident's medical condition to keep the doctor and care team up to date, and the doctor could give new orders to prevent wounds from getting worse. LN 1 stated the risk to a resident not being turned every two hours (q2h -a patient care practice where a patient is repositioned every two hours) was it increased skin breakdown, decreased circulation (inadequate blood flow through the body's blood vessels), was not good for anyone to stay in one position too long, and for comfort of the resident. LN 1 reviewed Resident 1's medical record but could not find evidence Resident 1 was turned every 2 hours, or where Resident 1 refused to be turned. During a concurrent telephone interview and record review on 5/14/25, at 1:16 PM, LN 4 (a nurse from the hospital Resident 1 was discharged from and later returned), confirmed she wrote Resident 1's "Progress Note," dated 4/18/25 (day Resident 1 discharged from the hospital and was admitted to the facility) and took photos of the wound to Resident 1's coccyx during her stay at the hospital. LN 4 further stated Resident 1's "Progress Note," indicated, " ...Coccyx continues to have an area of friction [force of rubbing between two surfaces] to left coccyx, wound bed is pink with red frayed [ragged] edges, blanchable erythema [a reddening of the skin that disappears when pressure is applied and returns to normal color when pressure is released], hyperpigmentation [areas of skin that appear darker than the surrounding areas] is noted at gluteal cleft [the deep groove or crease that separates the two buttocks] ...skin intact ...goals are to ...reduce friction and pressure ...turn q2hours ..." LN 4 further stated when Resident 1 returned to the hospital on 4/27/25, Resident 1's wound was re-evaluated and confirmed Resident 1's coccyx had worsened. LN 4 stated the wound covered both sides of Resident 1's buttocks creating an unstageable pressure ulcer with a foul odor (likely indicating infection). LN 4 confirmed Resident 1 required surgical debridement (removal of damaged tissue from a wound) on 5/3/25 and Resident 1 had to have a wound vacuum placed on the coccyx to help close the wound. 2. A review of Resident 2's "ADMISSION RECORD" indicated Resident 2 was admitted to the facility in the Summer of 2022 with diagnoses which included but not limited to: Cerebral Infarction (otherwise known as Ischemic Stroke -the death of brain tissue due to a lack of blood supply), difficulty in walking, muscle weakness, and heart failure (when the heart is unable to pump enough blood to meet the body's needs). A review of Resident 2's Minimum Data Set (MDS -an assessment tool), dated 3/02/25, in the section, "M -Skin Conditions", indicated, Resident 2 was at risk of developing pressure ulcers. A review of Resident 2's care plan dated 8/25/22, indicated, " ...[Resident 2] is at risk for skin breakdown/pressure injury development related to malnutrition [lack of sufficient nutrients in the body], incontinence and requires staff assistance with ADL's ...Goal ...[Resident 2 will have intact skin, free of redness, blisters or discoloration ...Interventions ...[Resident 2] needs assistance to turn/reposition at least every 2 hours, more often as needed or requested ...Monitor/document/report PRN [as needed] any changes in skin status: appearan