Health inspection·November 19, 2025

§483.25 Quality of careQuality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. 42 CPR 483.35(a)(3) Nursing Service The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment (a)Sufficient Staff(3)The facility must ensure that licensed nurses have the specific competencies, and skillsets necessary to care for residents' needs, as identified through resident assessments,and described in the plan of care42 CFR 483.21 (b) (3) (i) Meet Professional Standards of Quality The services provided or arranged by the facility, as outlined by the comprehensive care plan, must— (i)Meet professional standards of quality.(ii)Be provided by qualified persons in accordance with each resident's written plan of care.(iii)Be culturally competent and trauma informed.22 CCR 72311(a)(1)(A) Nursing Services-General (iv)72311 Nursing Service- General (a) Nursing Service shall include, but not be limited to the following(v)1.Planning of patient care, which shall include at least the following:(vi)(A)Identification of care based upon an initial written and continuing assessment of the patient’s needs. 22 CCR 72523 (a) 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.On 3/20/2025, the California Department of Public Health (CDPH) received a notification from the Appeals Department indicating a closed complaint #CA00909919 would need to be re-opened under new intake #CA00952764 to investigate a change of condition for Resident 1 that required surgical intervention. On March 21, 2025, at 11:25 am, an unannounced visit was conducted at the facility to investigate complaint number CA00952764 regarding a residents’ change of condition. The facility failed to ensure: 1)The resident was provided with the necessary treatment and services, consistent with professional standards of practice, to promote healing and prevention of infection of wounds identified by Wound Physician 1.2)Services provided and arranged by the facility met the professional standards of quality of care for nursing assessments upon admission, proper identification of wounds and the necessary treatment for wound prevention.3)Licensed nurses had the competencies and skill sets necessary to care for the residents’ needs, as identified through admission resident assessments, proper identification of wounds and required treatments to prevent progression of current wounds as described in the plan of care These deficient practices resulted in avoidable necrotic (death of cells or tissue through disease or injury) wounds to Resident 1’s lower extremities which included Resident 1’s left inner ankle (wound #8) and right outer ankle (wound #9) wounds; and resulted in an admission to a general acute care hospital (GACH) on 7/14/2024 for sepsis (a serious condition in which the body responds to an infection) related to left foot necrotizing fasciitis (a serious bacterial infection that destroys tissue under the skin) that required surgical amputation (the removal by surgery of a limb because of injury) on 7/15/2024 to Resident 1’s left lower extremity During a review of Resident 1’s “Admission Record” (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission record indicated, Resident 1 was readmitted from the hospital to the facility on 4/25/2024. Resident 1 has a history that includes but not limited to end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), diabetes type II (high levels of sugar in the blood) chronic pain syndrome (persistent pain), atrial fibrillation (an irregular and often very rapid heart rhythm), unspecified dementia (symptoms that negatively affect memory, thinking, and social abilities severely enough to interfere with daily functioning), and chronic obstructive pulmonary disease (disease causing restricted airflow and breathing problems). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated 4/29/2024, Resident 1's MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 9 out of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating moderate cognitive impairment. During a record review of Resident 1's "Progress Nurses Note," dated 4/25/2024, the “Progress Nurses Note” indicated, Licensed Vocational Nurse (LVN) 1 “… notified Resident 1’s primary physician via phone regarding Resident 1’s readmission (4/25/2024) and made aware regarding skin issues … Primary physician provided phone orders to …monitor skin discolorations…[times] 14 days and reassess…” There was no documentation in the “Progress Nurses Note” to indicated nursing staff identified wound #8 and wound #9 individually to the primary physician. During a record review of Resident 1’s “Wound Evaluation & Management Summary,” dated 5/9/2024, the “Wound Evaluation & Management Summary” indicated, Wound Physician 1 identified wound #8 “…Unstageable (Due to Necrosis) of the left [inner] ankle…wound size…1.0x2.0 centimeter [cm- units of measurement]..surface area..2.00 cm...Duration [greater than] 35 days… 100% thick adherent black necrotic tissue…Wound #9 “… Unstageable (Due to Necrosis) of the right [outer] ankle…wound size…1.5x1.0 centimeter ..surface area..1.5 cm... Duration [greater than] 35 days…100% thick adherent black necrotic tissue…” During a concurrent interview and record review on 3/21/2025 at 12 :10 p.m., with the Administrator (ADM), Resident 1’s electronic medical records, “Nursing Admission Assessment” and “Wound Evaluation & Management Summary,” dated 4/25/2024 to 7/14/2024 were reviewed. The ADM stated Resident 1’s wound # 8 and wound #9 could not have developed necrosis (death of cells or tissue through disease or injury) from the time they were identified as discoloration on the “Nursing Admission Assessment” dated 4/25/2024, to the Wound Physician 1 assessment “Wound Evaluation & Management Summary” dated 5/9/2024. The ADM stated on 4/25/2024 discoloration was documented by LVN 1 regarding Resident 1’s left inner ankle (wound #8) and right outer ankle (wound #9); the ADM stated that LVN 1 did not document wounds. The ADM stated on 5/9/2024 Wound Physician 1 documented Resident 1 had a left inner ankle wound (8) and right outer ankle wound (9). The ADM was not able to explain how Resident 1 was assessed to have necrotic wounds per the Wound Physician note of 5/9/25 and that LVN 1 should have identified more than discoloration on the initial readmission assessment on 4/25/2024. During a concurrent interview and record review on 3/21/2025 at 1:35 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1’s “Nursing Admission Assessment (NAA,” dated 4/8/2024 and 4/25/2024 was reviewed. The NAA, dated 4/8/2024, indicated Resident 1’s right outer ankle (wound #9) had a scab (a dry, rough protective crust that forms over a cut or wound during healing) measuring 10.5 centimeters (cm-unit of measurement) x 11.5 cm and residents left inner ankle (wound #8) was documented to have a popped blister measuring 15cm x 9 cm. The NAA indicated, on 4/25/2024, Resident 1 was admitted with left inner ankle discoloration (wound #8) and right foot discoloration (wound #9) no measurements were taken on 4/25/2024. LVN 1 stated his initial assessment of Resident 1 on 4/25/2024 indicated left inner ankle and right outer ankle discoloration and that these areas were not documented as wounds. LVN 1 stated he did not consider the discolored areas, wounds at the time of readmission on 4/25/2024. LVN 1 stated he did not review descriptions of wound #8 and wound #9 documented in previous facility records for Resident 1. LVN 1 stated facility licensed nurses do not stage wounds, only describe them in progress nursing notes. LVN 1 stated the facility NAA defines wound staging for skin assessments. LVN 1 stated as an example on Resident 1’s prior admission on 4/8/2024 the popped blister would be considered a stage II pressure injury. LVN 1 stated only the facility wound physician stages wounds. LVN 1 stated nurses have not had wound training. LVN 1 stated he did not ask the Director of Nurses (DON) for guidance when assessing Resident 1’s skin on 4/25/2024. LVN 1 stated nurses are responsible for accurate resident assessments. LVN 1 stated in his clinical judgement, he appropriately documented Resident 1’s left inner ankle as discoloration and the right outer ankle as discoloration, and he did not consider those areas wounds. LVN 1 stated the facility has never taken any pictures of wounds, and the nurses are responsible for daily skin assessments and notifications to the primary physician if there are any skin changes. LVN 1 stated he was aware of Wound Physician 1’s assessment of Resident 1’s necrotic wounds #8 and #9 on 5/9/2024 and stated he believed his description of discoloration was accurate. During a record review of Resident 1’s “Hospital Discharge records,” dated 4/25/2024, the “Hospital Discharge records” indicated active routine continuous wound care orders signed 4/18/2024, “…Paint all foot ulcers (an open sore on an external or internal surface of the body, caused by a break in the skin or mucous membrane) with betadine and allow to air dry [twice a day] …” During a concurrent interview and record review on 3/21/2025 at 2:10 p.m., with LVN 1, Resident 1’s “Hospital Discharge records,” dated 4/25/2024 was reviewed. LVN 1 stated he was not aware of any wound care treatments being conducted in the hospital prior to Resident 1’s readmission to the facility on 4/25/2024. LVN 1 stated Resident 1was not continued on hospital wound care on 4/25/2024. LVN 1 stated he was the admission nurse for Resident 1 on 4/25/2024, and it is the admission nurse’s responsibility to review and transcribe all incoming discharge orders from the hospital. LVN 1 stated he did not review, transcribe or follow up with active hospital discharge wound orders for Resident 1 upon admission on 4/25/2024. LVN 1 stated during his head-to-toe skin assessment he did not identify the left inner or right outer ankle as wounds, so no wound treatments were obtained. LVN 1 stated in his clinical judgment he believed his assessment was accurate on 4/25/2024 and stated necrosis would not develop from 4/25/2024 to 5/9/2024. LVN 1 stated failure to follow orders and assess and monitor residents accurately could cause harm or injury to residents. LVN 1 stated clinically, nurses have the knowledge to assess and stage wounds, but facility DON instructed licensed nursing staff not to stage wounds. LVN 1 stated licensed nursing staff along with certified nursing staff (CNA) should be monitoring each residents’ skin daily while providing care. LVN 1 stated there was no documentation by nursing staff of changes to Resident 1’s ankles from admission on 4/25/2024 until Wound Physician 1 identified wound #8 and #9 on 5/9/2024. LVN 1 was aware of Physician Wound 1’s assessment of necrotic wounds on 5/9/2024 and could not explain how that could have occurred. LVN 1 stated the necrotic wounds assessed by Wound Physician 1 were in the same location as the discoloration that he documented on 4/25/2024. During a concurrent interview and record review on 3/21/2025 at 2:20 p.m., with LVN 1, Resident 1’s “Care Plan Report,” dated 4/25/2024 was reviewed. LVN 1 stated "right foot”, and "left ankle" were identified as discoloration and not wounds, and interventions were for staff to monitor for signs and symptoms of infection and notify primary physician of any changes. LVN 1 stated the wounds should have been identified on readmission and were not. LVN 1 stated he did not assess correctly during his readmission assessment. LVN 1 stated because he did not assess Resident 1 correctly, Resident 1’s care plans did not meet the needs of Resident 1. During a concurrent interview and record review on 3/21/2025 at 2:48 p.m., with the Director of Staff Development (DSD), Resident 1’s “Wound Evaluation and Management Summary”, dated 5/9/2024 was reviewed. The “Wound Evaluation and Management Summary” indicated, Wound Physician 1 identified, measured and treated ankle wounds (#8 & #9) and indicated wounds were unstageable due to necrosis. The DSD stated per documentation, the ankle wounds to the outer right ankle (wound # 9) and inner left ankle (wound #8) went untreated and unmeasured from 4/25/2024 to 5/9/2024 and were not measured or assessed from 5/9/2024 to 6/27/2024. The DSD stated the Interdisciplinary Team (IDT- group of health care professionals with various areas of expertise who work together to meet the resident’s goals) meetings are conducted for pressure wounds and there were no IDT meetings held for wound #8 and #9. The DSD stated there were no IDT meetings conducted because nursing staff did not identify wounds #8 and #9. During an interview on 3/21/2025 at 4:17 pm, with the Director of Nurses (DON), the DON stated facility staff have had wound education and clinical nurses should be capable of assessing wounds appropriately during skin assessment. The DON stated the facility is not allowed to photograph wounds, the wound physician is the only individual measuring wounds, providing treatment plans and recommendations for residents. The DON stated Resident 1’s wounds # 8 and #9 were not documented as wounds and were instead documented as discoloration during nursing admission assessment on 4/25/2024. The DON stated the licensed nurse (LVN 1) assessed the resident inaccurately during the readmission skin assessment on 4/25/2024 and should have known the difference between discoloration and necrosis. The DON stated the nursing facility staff were not competent during the assessment and care of the wounds for Resident 1 between 4/25/2024 and 6/27/2024. The DON indicated facility nursing staff failed to assess and treat Resident 1’s ankles (wounds #8 and 9) from 4/25/2024 until identified by the Wound Physician 1 on 5/9/2024. The DON stated the IDT team would not have reviewed the discoloration because the facility did not consider discoloration as a wound. The DON stated once identified on 5/9/2024 by Wound Physician 1, no additional wound assessment by the wound physician was conducted until 6/27/2024 when Wound Physician 2 assessed, measured and provided an updated treatment plan for Resident 1’s necrotic ankle wounds (8 and #9). The DON stated licensed nurses did not assess, measure and notify a physician of changes to wound #8 and wound #9 from 5/9/2024 to 6/27/2024. The DON stated it was her expectation that all licensed nursing staff should have been measuring wounds weekly. The DON stated the facility did not have a wound physician from 5/9/2024 to 6/27/2024. The DON stated the facility does not have designated wound nurses and charge nurses are responsible for wound treatments of their residents. The DON stated nursing staff failed to follow protocols for wound policy and procedures indicating accurate assessment, measurement and description of all