Other·February 9, 2017

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 survey for the investigation of complaint number CA00471937. Representing the Department of Public Health: HFEN 29917 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

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

F314 02/10/2017 Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. This REQUIREMENT is not met as evidenced by: Based on staff interviews, policy and document review, the facility failed to prevent the formation of pressure ulcers for 1 of 4 residents (Resident 1) when a care plan was not LABORATORY 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: M1HO11 Facility ID: CA030000067 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: _______________ 056073 (X3) DATE SURVEY COMPLETED 01/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SACRAMENTO POST-ACUTE 5255 Hemlock Street Sacramento, CA 95841 (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 developed with defined approaches for a resident at risk and preventative interventions were not provided consistently to address all identified needs based on Resident 1's comprehensive assessment. Findings: Review of Resident 1's medical record, included a form titled Resident Admission Record, which revealed Resident 1 was admitted to the facility on 1/2/14 with a tracheotomy (surgical opening on the neck to facilitate breathing) and diagnoses of quadriplegia (paralysis of all 4 extremities). Documentation on both, Skin Observation assessment and the Resident Progress Notes completed on admission by Licensed Nurse (LN1), dated 1/2/14, revealed Resident 1's skin as being "intact with no pressure ulcers (open wounds or skin breakdown), No hx [history] of pressure ulcers with no redness or soreness noted during skin assessment. On 1/22/16, during an interview with the Director of Medical Records (DMR) at 3:45 p.m., she reviewed the medical record and confirmed that, during the first seven days of the resident's stay (January 2nd through 9th, 2014), documentation failed to show evidence the resident's skin condition was assessed or monitored for pressure ulcers by licensed nursing staff. There was no evidence any interventions were consistently provided in the Progress Notes from January 2nd through 8th, 2014, and the DMR concurred that there were no Care Plans initiated upon admission or thereafter that indicated Resident 1's skin condition was assessed, that the resident was at risk for pressure ulcers, or of any preventative measures to be provided to prevent skin breakdown. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M1HO11 Facility ID: CA030000067 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: _______________ 056073 (X3) DATE SURVEY COMPLETED 01/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SACRAMENTO POST-ACUTE 5255 Hemlock Street Sacramento, CA 95841 (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 On 8/3/2016, at 3 p.m., in an interview with LN2, she reviewed Resident 1's Care Plans, Observation Reports and Resident Progress Notes from January 2nd through 8th, 2014, and concurred that there were no Care Plans initiated upon admission or thereafter that indicated Resident 1's skin condition was assessed, that the resident was at risk for pressure ulcers, or of any preventative measures to be provided. LN2 further stated that, after knowing that the resident was a quadriplegic and could not turn on his own, "It should have been automatic [Resident 1 was paralyzed and therefore was at risk for pressure ulcers] for the nurses to routinely change the resident's position every 2 hours and conduct periodic skin assessments." Review of the clinical record of Resident 1 revealed the following 3 pressure ulcers were documented in the resident's Progress Notes within seven days of admission to the facility: 1. RIGHT BUTTOCKS - An entry, dated 1/8/14 at 3:11 a.m., indicated Resident 1 was observed by LN1 to have, "...an open area on bilateral (both right and left) buttocks, measuring 8 cm x (by) 4 cm by 2 cm (cm=centimeter-Units of measure)." 2. POSTERIOR (back side of) LEFT HEEL On 1/9/14, an observation, documented at 5:28 p.m., indicated the development of a pressure ulcer on the resident's posterior left heel. The document titled, Pressure Ulcer Report, identified the wound as a Stage II pressure ulcer [partial thickness loss of the skin with a red moist wound base], measuring 4 x 4 cm, depth UTD [unable to determine], with light exudate [cells and fluid that have leaked out of blood vessels] of serrosanguinous [yellowish fluid leaking from the body or a wound] drainage. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M1HO11 Facility ID: CA030000067 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: _______________ 056073 (X3) DATE SURVEY COMPLETED 01/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SACRAMENTO POST-ACUTE 5255 Hemlock Street Sacramento, CA 95841 (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 3. LEFT BUTTOCK - On 1/9/14 at 4:54 p.m., an entry was made into the facility's Skin-Pressure Ulcer Report describing a Stage II pressure ulcer to the left buttock. This wound measured 4 x 2 cm x UTD. Facility's Policy and Procedure titled, Pressure Ulcers/Skin Breakdown, last revised date, October 2010, indicated that, "The nursing staff and Attending Physician will assess and document an indiviual's significant risk factors for developing pressure sores: for example, immobility, recent weight loss, and a history of pressure ulcer(s). In addition the nurse shall assess and document/report the following:...Resident's mobility status." Facility's Policy and Procedure titled, Prevention of Pressure Ulcers, last revised date, October 2010, indicated: .."The facility should have a system/procedure to assure assessments are timely...Identify risk factors for pressure ulcer development... for a person in bed...Change position at least every two hours or more frequently if needed....Determine if resident needs a special matress...Risk Factor - Bed Fast...change position at least every two hours and more frequently if needed...Risk Factor - Immobility... When in bed, every attempt should be made to "float heels" [keep heels off of the bed] by placing a pillow from knee to ankle or with other devices as recommended ...For residents with risk factors, implement preventative measures as indicated... " There was no documented evidence that the facility followed the policy and procedure on intervening and preventing the formation of pressure ulcers in Resident 1's care plans. Subsequent documentation review of Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M1HO11 Facility ID: CA030000067 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: _______________ 056073 (X3) DATE SURVEY COMPLETED 01/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SACRAMENTO POST-ACUTE 5255 Hemlock Street Sacramento, CA 95841 (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's clinical record revealed the following documented additional assessments of his wounds on the form titled Skin-Pressure Ulcer Report: 1. RIGHT BUTTOCKSAn entry dated 1/9/14 at 13:12 (1:12 p.m.) indicated a Stage II Pressure Ulcer and the wound size was noted to be 8cm x 4 cm and the depth of the wound was UTD. The document noted the wound was dark purple in color with some skin peeling off, irregular shaped edges, erythema (redness of the surrounding skin surface), no exudate, no drainage, and no odor. An entry dated 1/16/14 at 13:07 (1:07 p.m.) indicated a Stage II Pressure Ulcer that now measured 10 cm x 3 cm and the depth was again noted as UTD. The note indicated that the wound now had light serosanguinous exudate on the edges, no signs and symptoms of infection, dark purple in color with some skin peeling off, irregularly shaped edges, wound area with redness, and no odor. An entry dated 1/21/14 at 15:59 (3:59 p.m.) noted a Stage II Pressure Ulcer measuring .09cm [sic] x2.08cm with the depth again noted to be UTD. 2. POSTERIOR LEFT HEEL An entry dated 1/16/14 at 12:58 (12:58 p.m.) indicated a Stage II Pressure Ulcer measuring 4 cm x 3 cm, with a light serosanguinous exudate described as an open area. All documentated assessements were provided by the facility to the Department per request by the Administrator (ADMIN) on 4/26/16 at 12:30 p.m. There were no further documented assessments of this wound provided. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M1HO11 Facility ID: CA030000067 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: _______________ 056073 (X3) DATE SURVEY COMPLETED 01/25/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SACRAMENTO POST-ACUTE 5255 Hemlock Street Sacramento, CA 95841 (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 3. LEFT BUTTOCK All documentated assessements were provided by the facility to the Department per request by the Administrator (ADMIN) on 4/26/16 at 12:30 p.m. There were no further documented assessments of this wound provided. On 1/23/14 Resident 1 was transferred to the General Acute CAre Hospital (GACH). Review of Resident 1's clinical record from the GACH indicated staff there assessed the wounds on admission with the following notations in the document titled Wounds: 1. COCCYX (small bone at the base of the spine)- An entry dated 1/23/14 at 0900 (9a.m.) indicated an unstageable full thickness pressure ulcer, tunneled deep tissue wound, unable to get exact measurements. 2. HEEL LEFT - An entry dated 1/23/14 at 0832 (8:32 a.m.) indicated an unstageable necrotic (dead tissue) wound 3 cm in diameter. 3. RIGHT HIP- An entry dated 1/23/14 at 0900 (9 a.m.) indicated a Stage II pressure ulcer with a dressing in place. 4. LEFT FOOT - An entry dated 1/23/14 at 08:35 (8:35 a.m.) indicated an unstageable wound described as a "2 cm round blood blister to the sole of the foot." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M1HO11 Facility ID: CA030000067 If continuation sheet 6 of 6