Health inspection·August 16, 2023

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to monitor and assess Resident 1 ' s surgical staples on the resident ' s surgical incision (a cut made through the skin and soft tissue to facilitate an operation or procedure) in the right upper hip for one of two sampled residents (Resident 1) in accordance with professional standards of practice. Residents Affected - Few The facility ' s licensed nurses did not complete an assessment or monitor Resident 1 ' s surgical staples after Resident 1 ' s right hip surgery since admission to the facility. This deficient practice had the potential for increased risk for infection from Resident 1 ' s surgical wound with prolonged staples. Findings: A review of Resident 1 ' s Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including fracture of unspecified part of neck of right femur (the bone of the thigh), subsequent encounter for closed fracture (the bone is broken, but the skin is intact) with routine healing, chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). A review of Resident 1 ' s admission reassessment dated [DATE], indicated Resident 1 most recent admission 5/18/23 at 7:20 PM with a surgical incision on right upper hip measuring 17.2 centimeters (cm; a unit of measurement) in length, 0.1 centimeter wide. The admission reassessment indicated that Resident 1 was noted with right upper hip surgical incision and was on wound vacuum machine (type of therapy that uses a machine to gently pull fluid from the wound over time). A review of Resident 1 ' s Non-Pressure Sore Skin Problem report with effective date of 5/19/23, weekly progress report section indicated the following information: 1. 5/24/23 the reportindicated Removed the wound vac, and wound site clean, no discharge, no redness. Surgical site has staples on it, and intact. 2. 5/25/23 the report indicated Resident 1 seen by nurse practitioner (NP 1) and noted with right upper hip surgical incision, no new order. Clean with normal saline pat dry, paint with Betadine cover with dry dressing. The Report did not indicate further documented evidence after 5/5/23 through 6/15/23 (Resident 1 ' s discharge) while Resident 1 resides at the facility, that showed an assessment of Resident 1 ' s surgical hip wound that mentioned if staples were still intact. Page 1 of 2 055135 055135 08/16/2023 Montrose Healthcare Center 2123 Verdugo Blvd. Montrose, CA 91020

F 0658 Level of Harm - Minimal harm or potential for actual harm A review of Resident 1 ' s admission reassessment dated [DATE] indicated Resident 1 ' s most recent facility admission dated 6/5/23 with a with a surgical incision on right upper hip measuring 17.2 centimeters (a unit of measurement) in length, 0.1 centimeter wide. Noted with right upper hip surgical incision. The admission reassessment did not indicate further documented evidence that showed an assessment of Resident 1 ' s surgical hip wound that mentioned if staples were still intact. Residents Affected - Few A review of Resident 1 ' s Discharge summary report dated 6/15/23, did not indicate documented evidence that showed an assessment of Resident 1 ' s staples on right hip surgical site. The discharge summary report indicated Resident 1 was discharged from the facility to the GACH( General acute care hospital) on 6/15/23 at 5:32 PM. A review of Resident 1 ' s nursing progress notes did not indicate an assessment or monitoring of Resident 1 ' s staples on the right hip surgical site from readmission dated 6/5/23 to 6/15/23. During an interview on 8/09/23 at 12:32 PM with Resident 1 ' s Hospice Case Manager outside of the facility, Hospice Case Manager stated Resident 1 ' s surgical wound staples were discovered on Resident 1, during admission assessment by the Hospice Nurse. Hospice Nurse called and notified Resident 1 ' s orthopedic surgeon who stated that Resident 1 ' s staples should have been removed months ago after Resident 1 ' s surgery. Hospice Case Manager stated the hospice nurse removed Resident 1 ' s staples. During a validation interview on 8/16/23 at 4 PM with the facility ' s Director of Nursing (DON 1), DON 1 stated the facility did not complete an assessment or monitoring of Resident 1 ' s right hip staples after Resident 1 ' s wound vac was removed on 5/24/23, until Resident 1 ' s last stay in the facility on 6/15/23. 055135 Page 2 of 2