Health inspection·December 16, 2025

483.25 (b)(i)(ii) Quality of care Quality 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. (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. 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 skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care 42 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)(B) Nursing Services-General 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 based upon an initial written and continuing assessment of the patient's needs. (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 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 August 4, 2025, at 2:30 p.m., an unannounced visit was conducted at the facility to investigate complaint number 2578554 regarding a Resident 1's facility acquired pressure ulcer (wounds to the skin and underlying tissue resulting from prolonged pressure, friction, or shear while a patient is receiving care). The facility failed to ensure: 1) Skin interventions, treatment, measurements and services provided to Resident 1 were consistent with professional standards of practice, to maintain skin integrity and ensure healing and prevent further worsening of facility acquired pressure ulcers. 2) Services provided and arranged by the facility met professional standards of quality of care for Resident 1 when Resident 1's wound measurements were not conducted from 5/23/25 to 6/9/25. 3) Licensed nurses had the specific competencies, and skill sets necessary to care for Resident 1's skin needs when the facility did not implement identified preventative skin interventions. These failures resulted in an avoidable Stage 2 pressure ulcer to left buttocks and shearing (a type of skin damage that occurs when tissue layers are pulled in opposite directions, causing them to separate) to the right buttocks that progressed to two avoidable Stage 4 (a severe form of pressure injury that involves full-thickness tissue loss, exposing bone, tendon, or muscle) pressure ulcers (left and right buttocks), suffering, pain and loss of mobility. Resident 1 stated because of the pressure ulcers he acquired, he did not feel the facility acted promptly in providing the care he needed to improve, which caused him to limit his rehabilitation. Resident 1 pursued being transferred to another facility prior to making the decision to be discharged home on 8/8/25 with wound care and a wound vacuum (wound vac-medical device that uses suction to promote wound healing) but no other facility accepted to admit him with his current wounds. Resident 1 experienced psychosocial harm when he felt hopeless in his recovery and did not feel the facility addressed his psychosocial needs as well as not providing quality of care During a review of Resident 1's "Admission Record" (a summary of important information regarding a Resident 1 which include Resident 1 identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission record indicated Resident 1 was admitted from the general acute care hospital to the facility on 5/2/25 for rehabilitation following surgical spinal procedure to treat injuries from a fall. Resident 1 has a history that includes, but is not limited to, cervical vertebral fracture with surgical intervention(a break in one or more of the seven vertebrae (bones) that make up the neck that required a surgical procedure to repair and stabilize structure), impaired/decrease mobility (a limitation in the independent and purposeful movement of the body or one or more extremities), idiopathic peripheral autonomic neuropathy (damage to the nerves that control automatic bodily functions, such as heart rate, blood pressure, digestion, and bladder function), ankylosing spondylitis (a chronic inflammatory disease that primarily affects the spine), cirrhosis of the liver (disease characterized by the formation of scar tissue (fibrosis) that replaces healthy liver cells), muscle weakness (a decreased ability of muscles to generate force or contract effectively), and neuromuscular dysfunction of the bladder (nerve damage to the brain, spinal cord, or peripheral nerves disrupts the coordination between the nerves and muscles needed to store and empty urine). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive [the process of acquiring knowledge and understanding through thought, experience, and the senses] and physical function) assessment dated 8/4/25, 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 15 out of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating no cognitive impairment. Resident 1's therapy assessment of activities of daily living (ADL's) indicated he required moderate to maximum staff assistance with transfers, turning and repositioning and care needs. During an interview and observation on 8/4/25 at 3:45 p.m., with Resident 1, Resident 1 was observed up in his wheelchair with a wound vac attached along the side of the wheelchair, and Staff wheeled Resident 1 to a private area at his request for the interview. Resident 1 stated he had concerns with the care he received. Resident 1 stated, he came into the facility with hopes of rehabilitating from his back surgery. Resident 1 stated his goal was to improve with physical therapy in order to go back home. Instead, Resident 1 stated, his experience was altered in a way where the facility staff did not provide care for his wounds which interfered with his therapy and ability to rehabilitate to go home sooner than expected. Resident 1 stated, the facility delayed treating his wounds to his buttocks which caused him to lose hope for his recovery and interfered with his physical therapy and rehabilitation. Resident 1 stated, he "mentally, physically and emotionally" has declined since his arrival into the facility. Resident 1 stated the care he received did not meet his expectations for care and rehabilitation. Resident 1 stated, he came into the facility without any wounds and now has plans to be discharged home with two wounds to his buttocks and a wound vac in place. Resident 1 felt the facility should have taken actions once his wounds were initially identified to prevent them from getting worse and to work on healing them. Resident 1 stated he was told he could not go to another facility for rehabilitation because other facilities denied him due to his wounds. Resident 1 stated his wounds had limited his ability to receive further physical therapy. Resident 1 stated "I came here for therapy, and the wounds have affected me enough where I can't do therapy to get better. I will refuse therapy because of my wounds, yes, they will give me pain medications, but I don't feel like going. I came to do therapy; I didn't come here to get wounds." Resident 1 stated he had a meeting with the facility leadership regarding his concerns, and he was told things would get better, but they did not and remained the same. During a review of Resident 1's electronic medical record "Admission Summary Note," dated 5/2/25, the "Admission Summary Note" indicated Resident 1 did not have any open skin areas to his buttocks on admission documented on skin assessment. During a concurrent interview and record review on 9/24/25 at 10:30 a.m., with the Director of Nurses (DON), Resident 1's electronic medical record, "Skin/Wound Note," dated 5/5/25, and "IDT (IDT-a collaborative group of healthcare professionals and other relevant individuals who work together to plan, coordinate, and deliver care for a patient or resident) Note" dated 5/16/25 were reviewed. The "Skin/Wound Note" on 5/5/25 indicated, "... Primary medical provider reassessed skin and noted stage 2 PU to left buttocks..." The DON stated, the "IDT Note" dated 5/16/25 indicated the wound was present on admission but that was not accurate. The DON stated the wound was first observed three days after admission. The DON stated there were no facility records indicating it was identified on admission. The DON stated that the pressure ulcer found on 5/5/25 on Resident 1's left buttocks was facility acquired. The DON stated Resident 1 had the "standard" interventions implemented on admission for all residents which included baseline labs and turning and repositioning. The DON stated wound treatment for Resident 1's left buttock started on 5/5/25 and was measured on 5/5/25 as 2 cm x 2 cm (centimeters (cm)a unit of measurement - 2.54 cm= 1 inch) the wound was measured on 5/16/25 and 5/22/25 with the same measurements. The DON stated the next measurement was not until 6/9/25 when the wound specialist completed an assessment and Resident 1's left buttock wound measured 4.5 cm x 3 cm and a second wound on the right buttock measuring 5 cm x 3 cm was identified. The DON stated the treatment nurse should follow professional standards for wound care and should have been documenting any changes for size, dimension, and description every week and as needed during daily treatments for Resident 1, and that was not done. The DON stated Resident 1 had a type of insurance that delayed approval of the wound specialist assessment until 6/9/25 and the facility did not initiate the wound specialist consultation until after the approval. During a concurrent interview and record review on 9/24/25 at 11:30 a.m., with the licensed vocation nurse (LVN 1), Resident 1's electronic medical record, "Skin & Wound Evaluation," dated 5/5/25, 5/16/25, 5/22/25 and 6/9/25 were reviewed. The "Skin & Wound Evaluation" on 5/5/25 indicated, "...stage 2 PU to left buttocks 2cm x 2cm..." on 5/16/25 "...stage 2 PU to left buttocks 2cmx2cm..." on 5/22/25 "...stage 2 PU to left buttocks 2cmx2cm..." on 6/9/25 "....left buttocks PU unstageable 4.5x3cm and right buttocks shearing 5cmx3cmx0.1cm..." LVN 1 stated she is the facility treatment nurse and her roles and responsibilities include measuring residents' wounds weekly in order to identify if wounds are healing and treatment is appropriate. LVN 1 stated Resident 1's wound measurements were not conducted from 5/23/25 to 6/9/25 and should have been done weekly by professional standards that the facility follows. LVN 1 stated it would have been difficult to determine if Resident 1's wound was healing without an accurate assessment and measurement. LVN 1 stated she did not measure Resident 1's wounds weekly and "missed it". LVN 1 stated from the measurement taken on 5/22/25 to wound specialist assessment on 6/9/25 new shearing was found on Resident 1. LVN 1 stated on 6/6/25 during assessment with Resident 1's primary care provider identified a second wound, and it was not measured. LVN 1 stated no staff documented any measurement changes from 5/23/25 to 6/9/25. LVN 1 stated it was not until the facility wound specialist assessed Resident 1 on 6/9/25 that additional wound measurements were conducted. LVN 1 stated the wound specialist assessed Resident 1 as having an unstageable PU to left buttock and a shearing to the right buttock. LVN 1 stated she is not wound certified but was trained by a previous wound nurse. LVN 1 stated in her new role as a treatment nurse she did not realize she missed the measurements for Resident 1. LVN 1 stated it is important to relay detailed information concerning wounds to a resident's primary care physician or wound specialists to identify further needs for each resident, this did not occur for Resident 1 and Resident 1's wounds worsened. During a concurrent interview and record review on 9/24/25 at 1:50 p.m., with the LVN 2, Resident 1's electronic medical record, "Admission Summary Note," dated 5/2/25, was reviewed. LVN 2 was the admitting nurse for Resident 1. The "Admission Summary Note" indicated, LVN 2 completed a full body assessment of Resident 1 on 5/2/25. LVN 2 stated he documented two surgical sites (chest and neck) on Resident 1. LVN 2 stated there was no visible skin breakdown to Resident 1's buttocks. LVN 2 stated that he is knowledgeable in wound care and is certified by a wound care certification program and would be able to identify the presence of pressure ulcers or injuries. LVN 2 stated, Resident 1's Braden scale (used to predict a patient's risk for developing pressure injuries: 19-23 No Risk, 15-18 Mild Risk, 13-14 Moderate Risk, 10-12 High Risk, and 9 or less Severe Risk) score was 17 which indicated resident was at mild risk for skin breakdown. LVN 2 stated, "standard" interventions used for Resident 1 included turning and repositioning every two hours, and baseline labs. During a concurrent interview and record review on 9/24/25 at 2:03 p.m., with the LVN 3, Resident 1's electronic medical record, "Skin & Wound Evaluation," dated 5/5/25, 5/16/25, 5/22/25 and 6/9/25 was reviewed. LVN 3 stated Resident 1 was admitted with no pressure ulcers. LVN 3 stated during the weeks of 5/26/25 to 6/7/25 she worked two times on the floor as the "fill in" treatment nurse and, there was no instruction indicating she was required to or that it was necessary to measure Resident 1's wounds. LVN 3 stated, she was not aware that the "usual wound specialist" was not overseeing the wound care for Resident 1 per the facility's (professional) standards. LVN 3 stated she assumed that all wounds were measured and accounted for every Monday by the full-time treatment nurse. LVN 3 stated she did not measure Resident 1's wounds on the days she covered for the full-time treatment nurse. LVN 3 stated because she used her "naked eye" to assess Resident 1's wounds she believed there was not a change of condition. LVN 3 stated wounds require measurement and detail explanation of appearance, to communicate to physicians. LVN 3 stated, since Resident 1 developed two different pressure ulcers at the facility, she would consider the "standard" interventions that