Health inspection·July 9, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to identify a skin rash (an area of irritated or swollen skin that can be red, itchy, painful, or bumpy) for one of one sampled resident (Resident 1) when Licensed Vocational Nurse (LVN) 1 discharged Resident 1 without doing a skin check (a visual examination of the skin surface) on 5/29/2025.This failure resulted in delayed treatment for Resident 1's skin rash and had the potential to result in physical decline to Resident 1.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 11/21/2023 and readmitted the resident 1/12/2024 with diagnoses including type 2 diabetes mellitus (a chronic [persistent or long-lasting] disease characterized by high blood sugar levels due to insufficient insulin [a hormone which regulates the amount of sugar in the blood] production) and major depressive disorder (mental health condition where a person experiences a persistent low mood, loss of interest in activities and other symptoms that significantly impact daily life). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/29/2025, the MDS indicated Resident1's cognitive (the ability to think and process information) skills for daily decision making were moderately impaired. The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene, toileting hygiene, shower/bathing, upper/lower body dressing, putting on/taking off footwear, and personal hygiene.During a review of Resident 1's Post Discharge Plan of Care, dated 5/29/2025, the care plan indicated Resident 1 was discharged home 5/29/2025. The Plan of Care indicated the skin condition assessment was left blank (a space left to be filled in on a document). During a review of Resident 1's Care Plan (CP) titled Pressure sore. (Resident 1) is at risk to develop pressure sores related to aging process.fragile skin., initiated 11/21/2023, revised 6/12/2025, the CP's goal indicated Resident 1's risk to having skin breakdown would be reduced with appropriate interventions. The CP's interventions indicated that staff would assess [Resident 1's] skin condition daily during care and [conduct] weekly body checks.During an interview on 7/7/2025 at 10:18 am with Family Member (FM) 1, FM 1 stated FM 1 took Resident 1 home from the facility on 5/29/2025. FM 1 stated FM 1 gave Resident 1 a shower on 5/29/2025 at FM 1's home and observed Resident 1's entire body was covered with bleeding scabs. FM 1 stated this made FM 1 angry because no one at the facility told FM 1 Resident 1 had a rash and FM 1 did not know how to treat the rash. During an interview on 7/8/2025 at 10:53 am with Registered Nurse (RN) 1, RN 1 stated it was part of the facility's discharge process for licensed nurses to conduct skin checks on residents (in general) prior to discharge. RN 1 stated skin check [assessments] should be documented on the discharge plan of care. RN 1 stated residents needed to have skin check [assessments] prior to discharge to determine if the resident needed treatment and to educate the family members if needed.During an interview on 7/8/2025 at 11:10 am with LVN 1, LVN 1 stated LVN 1 signed the discharge plan of Residents Affected - Few Page 1 of 2 055126 055126 07/09/2025 Chino Valley Health Care Cente 2351 S Towne Avenue Pomona, CA 91766

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few care for Resident 1 on 5/29/2025. LVN 1 stated LVN 1 did not conduct a skin check [assessments] on Resident 1 prior to Resident 1's discharge. During an interview on 7/8/2025 at 11:30 am with RN 2 (home health nurse), RN 2 stated RN 2 assessed Resident 1 in Resident 1's home on 5/30/2025. RN 2 stated Resident 1 complained of itching and RN 2 observed a rash all over Resident 1's body. During an interview on 7/8/2025 at 1:20 pm with the Administrator (ADM), the ADM stated that according to the discharge paperwork a skin check should be completed by a licensed staff [nurse] prior to a [resident's] discharge. During a review of the facility's Policy and Procedure (P&P) titled, Discharge Summary and Plan, dated 2001, revised October 2022, the P&P indicated, When a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge.The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of discharge.During a review of the facility's undated Policy and Procedure (P&P) titled, Alteration in Skin Integrity, the P&P indicated, Residents with alterations in skin integrity will be assessed by licensed staff, orders for treatment will be obtained .Physician will be notified and appropriate orders obtained.Notification of family/responsible party. 055126 Page 2 of 2