Health inspection·December 30, 2025

T42 CFC, Quality of Care, Section 483.25 (b) Skin Integrity, (1) 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 injuries and does not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure injuries receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new injuries from developing. T22 CCR, Nursing Service - General, Section 72311 (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. (b) All attempts to notify licensed healthcare practitioners acting within the scope of his or her professional licensure shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending licensed healthcare practitioner acting within the scope of his or her professional licensure or his or her designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g). T22 CCR, Nursing Service - Patient Care, Section 72315 (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). T22, CCR, Patient Care Policies and Procedures, Section 72523 (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 11/6/25 at 9:30 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding the development of facility acquired (developed while a resident in the facility due to lack of assessment and treatment) pressure injuries (PI, a localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for Resident 1. The department determined the facility failed to ensure Resident 1 did not develop a pressure injury or pressure sore when they failed to follow and implement preventative interventions that included to turn and re-position frequently, monitor and assess for signs of skin breakdown, and, to use pressure relieving devices(s) for her chair and bed as outlined in their "Care Plan Report" (CP), titled "Skin integrity care plan" and "Skin assessment and prevention of pressure injuries" policy and procedures (P&P). These failures led to Resident 1 to have developed facility acquired pressure injuries and had the potential to have caused complications such as pain and sepsis (a life-threatening blood infection). During a review of Resident 1's "Admission Record," (AR), the AR indicated that Resident 1 was admitted to the facility in November 2022 with diagnoses that included Type 2 Diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and Psoriasis (skin disease, rash with itchy, scaly patches). During a review of Resident 1's Minimum Data Set (MDS a federally mandated resident assessment tool) dated 8/5/25, Section C, "Cognitive Patterns" (mental process of acquiring knowledge and understanding) showed a score of 5 out of 13 which suggested severe cognitive impairment. During a review of Resident 1's MDS, dated 8/5/25, Section GG "Functional Abilities", indicated, Resident 1 needed "Substantial/maximal assistance (resident unable to perform these activities without full help from others)," with toileting hygiene, upper and lower body dressing, roll left and right, sit to lying, lying to sitting on side of bed, chair/bed to chair transfer, toilet transfer, and tub/shower transfer. Resident 1 was completely "Dependent", with the facility staff for "Shower/bathe self, "and "Putting on/taking off footwear." During a review of Resident 1's MDS, dated 8/5/25, Section H, "Bladder and Bowel", indicated, Resident 1 was "Always incontinent (unable to control)" of bowel movements and urine. During a review Resident 1's MDS, dated 8/5/25, Section M, "Skin Condition" indicated, Resident 1 was "at risk of developing pressure ulcers/injuries," and the facility documented "B. Pressure reducing device for bed... C. Turning/repositioning program" for Resident 1 under "Skin and Ulcer/Injury Treatments. During a review of Resident 1's "Care Plan Report" (CP), dated 5/3/24, with a focus of altered skin integrity had interventions that included: "Monitor for any signs of skin breakdown (sore, tender, red, or broken areas), Pressure relieving device(s) for chair and bed, Turn and re-position frequently, and Weekly Skin Checks refer to weekly summary as indicated." During a review of Resident 1's "Braden Scale," (BS, assessment tool for predicting pressure ulcer risk) dated 8/5/25, the BS showed Resident 1's Braden Scale score was indicative of-at risk for developing a pressure ulcer. During the review of the facility's policy and procedures (P&P), titled "Skin assessment and prevention of pressure injuries," dated 2001, it indicated, "The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors... 1. ... Repeat the risk assessment weekly and upon any changes in condition... Mobility/Repositioning 1. Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team (professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological needs) ... Monitoring 1. Evaluate, report ad document potential changes in the skin..." During a review of Resident 1's "Order Summary Report," (OSR), contained current orders at time of transfer to the hospital, the OSR did not indicate a physician's order to reposition Resident 1 frequently and did not have physician's order for a pressure-relieving mattress or device for her chair as indicated in her care plan with a focus on "Altered Skin Integrity", the facilities P&Ps titled "Skin assessment and prevention of pressure injuries", and the MDS section M. During a phone interview with Resident 1's Responsible Party (RP, person in charge of decision making) on 11/5/25, at 9:43 a.m., the RP stated, Resident 1 was brought to the Emergency Department (ED, name of the hospital) on 8/17/25. She was unresponsive and had low blood pressure. The RP further stated the Emergency physician discovered Resident 1 had severe stage III (Full-thickness loss of skin. Dead and black tissue may be visible) wounds on her bottom, "We were never told about the open wounds." The RP further stated he visited Resident 1 in the facility [name of the facility] every week and stayed for a couple of hours at Resident 1's bedside. RP also stated that his sister visited Resident 1, and she was not told by the facility that Resident 1 had stage III wounds on her bottom. RP also had indicated in the complaint that, "She had been complaining about pain on her bottom for months. Additionally, when she had a doctor appointment on August 4, 2025, and was transferred to the medical transport, she was in extreme pain and distress, unable to sit up in her wheelchair, lying over the arm of her wheelchair, barely able to stay in it." During a review of Resident 1's record from [name of the hospital] ED (emergency department) titled "Wound Care Note" (WCN), dated 8/18/25, the WCN indicated the following: "... Location: Sacrum (triangular bone in the lower back between hip bones) ... Wound Category: Pressure yes...Unstageable x (when unable to determine stage of ulcer due to physician being unable to see the base of the wound) ..." "Additional wound: Location: Left ischium (above the back side of the thigh and beneath the buttocks. A pressure injury can develop here when you sit too long without shifting your weight) ... Wound Category: Pressure yes... Stage 3 x... Non-pressure.." "Additional wound: Location: Right ischium... Wound Category: Pressure yes... Pressure Injury: Stage 2 x (Partial-thickness loss of skin, presenting as a shallow open sore or wound) ...Pain: Yes..." During a review of Resident 1's record from [name of the hospital] ED titled "Physician Note" (PN), dated 8/19/25, the PN indicated, "Unstageable pressure injury sacrum, stage II pressure injury right ischium, stage III pressure injury left ischium...This wound was present on admission... Category: Other Wounds... Location: Sacrum... Discovery Time: 08/17/2025 21:18." During an interview and record review with Medical Records Asst (MRA), and Licensed Nurse 1 (LN 1) on 11/6/25 at 11:44 a.m., MRA found Resident 1's "Shower Day Skin Inspection," (SDSI, with a drawing of a naked human body, anteriorly and posteriorly to mark and label skin changes noted during a shower) sheets were dated 8/2/25, 8/7/25, 8/9/25, 8/11/25, 8/13/25, 8/14/25. LN 1 confirmed the SDSI sheets were Resident 1's shower sheets. LN 1 stated the Certified Nursing Assistant (CNAs) should mark (with an x or shading) and label the SDSI sheets of their observations during a shower. The process would then have the CNAs informing the nurse of any unusual or new redness or sores. The process then should be that the nurse would assess the resident's skin areas as identified by the CNAs. The LNs should then collaborate with the Treatment Nurse (TN). LN 1 confirmed this did not happen. During a continued interview and record review with LN 1 and MRA on 11/6/25 at 11:44 a.m., LN 1 stated Resident 1's SDSI sheet dated 8/11/25 was marked as "open area" at the posterior buttocks (back of the bottom) and SDSI sheet dated 8/16/25 was circled and marked "Red" at the posterior buttocks. LN 1 stated that the remainder of the SDSI sheets were all marked with shading at the posterior buttocks area but were not labeled with words such as open or red as it should have been. LN 1 stated that nurses should have assessed, documented and informed the Treatment Nurse (TN) of Resident 1's changes in her skin as indicated on the shower sheets. LN 1 further stated that if redness and open skin areas were left untreated, they could get infected and result in possible pressure sores. LN 1 continued to say that the nurses are also expected to complete Resident 1's "Weekly Nursing Summary" (WNS) assessments to evaluate skin changes, and other health status changes. LN 1 stated that the last completed WNS was 7/31/25, and that the nurses did not conduct the WNS for Resident 1 for the month of August 2025. LN 1 emphasized the importance of completing the WNS assessment to capture Resident 1's health decline or change of condition. The MRA confirmed that she did not have copies of the WNS assessment sheets. During an interview with LN 3 on 11/12/25 at 12:39 p.m., LN 3 acknowledged that she signed Resident 1's SDSI sheets however she cannot recall the dates. LN 3 said she doesn't perform skin assessments unless the CNA reported to her that there was a difference between resident's current skin condition from the previous skin assessment. LN 3 continued to say, CNA 2 wrote down "open area" on 8-11-25 in the SDSI sheet. LN 3 stated if there is an open skin on the sacrum area and it is not treated, it could get infected and may lead to a pressure sore as it was on the boney part of the human body. During an interview with LN 2 on 11/6/25 at 1:05 p.m., LN 2 stated Resident 1 was dependent on staff with her Activities of Daily Living (ADL, refers to basic self-care tasks like bathing, dressing, and eating) needs. Resident 1 was unable to turn to her side without the help from the staff, and the facility staff used the Hoyer lift (a mechanical device used to lift and/or transfer a person from place to place) to transfer Resident 1 to bed, wheelchair, and shower chair. LN 2 confirmed she signed Resident 1's SDSI sheets dated 8/9/25 and 8/14/25. LN 2 stated that although it was not labeled with words indicating the problem, the SDSI sheets were marked with black ink at the posterior buttocks which indicated an issue with that area. LN 2 verbalized, a signed SDSI sheet meant that she was aware of Resident 1's skin changes, and LN 2 should have assessed and documented her findings and informed the TN. However, LN 2 was not sure if she had assessed Resident 1's skin as the process (after identifying skin abnormality on the shower sheet) required. During an interview with CNA 1 on 11/6/25 at 1:33 p.m., CNA 1 acknowledged she gave showers to Resident 1 on 8/2/25, 8/7/25, 8/9/25, 8/13/25, 8/14/25. CNA 1 stated that Resident 1 was unable to turn to sides, recline on her bed without the assistance from the nursing staff. CNA 1 admitted that she saw redness and a rash on 8/2/25, 8/7/25, 8/9/25, 8/13/25, 8/14/25 to Resident 1's skin on her posterior buttocks as she marked on the SDSI sheet. However, CNA 1 stated she did not label with words her markings on the SDSI sheets, "I should have labeled it, so they [nurses] know what I saw." During an interview with the Director of Nursing (DON) on 11/6/25 at 1:51 p.m., the DON acknowledged that CNA 1 and CNA 2 gave showers to Resident 1 as indicated on the SDSI sheets. The DON further acknowledged LN 2 and LN 3 signed the SDSI sheets acknowledging they received and reviewed the reports for Resident 1. The DON stated the facility's process was for the nurses to review the SDSI sheets, assess and document the resident's skin as reported by the CNA on the SDSI sheets, and then the nurse should collaborate with the TN for further physician order/treatments. The DON confirmed that all SDSI sheets (on 8/2/25, 8/7/25, 8/9/25, 8/13/25, 8/14/25) indicated an unusual finding on posterior buttocks of Resident 1. The DON further stated that these assessments/findings were not documented in the resident's chart such as on the Treatment Administration Record (TAR, tool nurses use to document and manage wound care treatments) and progress notes as the process indicated. The DON stated the expectati