Health inspection·July 24, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an observation, interview, and record review the facility failed to practice pressure related injury preventive practices for three out of seven residents (Resident 1, 2, and Resident 3): 1. Nursing staff did not follow doctor's order for a low air loss mattress ([LALM], a mattress that provides airflow to help keep skin dry, as well as to relieve pressure, treat pressure sores and prevents pressure sores) for Resident 1, 2, and 3. 2. Nursing staff did not follow up on LALM order status. 3. Nursing staff did not ensure Resident 1, 2, and 3 had LALM to prevent pressure injuries (localized area of tissue damage that develops when prolonged pressure or shear forces are applied to the skin and underlying tissues). These deficient practices placed Resident 1,2, and 3 at risk for further skin damage and it placed residents at risk for developing pressure injuries. Findings: During an observation on 7/24/2025 at 1146 a.m. Resident 1, 2, and 3 did not have a LALM on their bed. 1. A review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included diabetes mellitus ([DM]a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension ([HTN]high blood pressure). During a review of Resident 1's History and Physical (H&P) dated 7/21/2025, the H&P indicated Resident 1 could make his needs known but could not make medical decisions. During a review of Resident 1's electronic record, unable to locate Minimum Data Set ([MDS] a resident assessment tool) due to Resident 1's recent admission to the facility. During a review of Resident 1's Doctor Orders, dated 7/21/2025, the orders indicated Resident 1 had an order for a LALM for skin maintenance. During a review of Resident 1's Interdisciplinary Team (IDT) Skin Review Notes, dated 7/23/2025, the IDT notes indicated Resident 1 would use a LALM as a pressure redistributing device. IDT notes indicated a LALM was recommended for Resident 1 due to wounds and immobility. The IDT notes indicated Resident 1 had a wound on his coccyx (last bone at the bottom (base) of the spine) extending to left buttock (either of the two round fleshy parts that form the lower rear area of a human trunk) and wound was noted with 100% necrosis (death of cells or tissues in the body, occurs when cells are deprived of blood supply (ischemia) or injury). IDT notes indicated Resident 1 was at risk for wound decline or slow healing due to his comorbidities (simultaneous presence of two or more diseases or medical conditions) and limited mobility. 2. A review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 2's diagnosis included pressure ulcer (a localized injury to the skin and underlying tissues that occurs due to prolonged pressure or pressure combined with shear and/or friction) of sacral region (located at the base of the spine), stage 2 (partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red or pink wound bed) and dementia (the loss of cognitive functioning [ability to think and reason], thinking, remembering, and reasoning). During a review of Resident 2's H&P dated 7/22/2025, the H&P indicated Resident 2 had fluctuating ability to make medical decisions.During a review of Resident 2's Doctor Residents Affected - Few Page 1 of 6 055519 055519 07/24/2025 Downey Post Acute 13007 S. Paramount Blvd. Downey, CA 90242

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Orders, dated 7/22/2025, the orders indicated Resident 2 had an order for LALM for skin maintenance. During a review of Resident 2's IDT Skin Review Notes, dated 7/23/2025, the IDT notes indicated Resident 2 would use a LALM as a pressure redistributing device. IDT notes indicated a LALM was recommended for Resident 2 due to wounds and immobility. The IDT notes indicated Resident 1 had a coccyx pressure injury stage 2. IDT notes indicated Resident 2 was at risk for wound decline or slow healing due to his comorbidities and limited mobility. During a review of Resident 2's electronic record, unable to locate MDS due to Resident 2's recent admission to the facility. 3. A review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnosis included fracture (a break or discontinuity in a bone) of left humerus (bone of the upper arm) and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 3's H&P dated 7/7/2025, the H&P indicated Resident 3 could make needs known but could not make medical decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making was intact. The MDS indicated Resident 3 needed maximal assistance (helper does more than the effort) for toileting hygiene, shower/bathing, and dressing. The MDS indicated Resident 3 needed supervision for eating and oral hygiene. The MDS indicated Residents 3's skin and ulcer/injury treatment was a pressure reducing device for bed. During a review of Resident 3's Skin Evaluation, dated 7/18/2025, skin evaluation indicated Resident 3 had bilateral buttock redness and redness to bilateral heels. During a review of Resident 3's Doctor Orders, dated 7/22/2025, the orders indicated Resident 2 had an order for LALM for skin maintenance During an interview on 7/24/2025 at 1:11 p.m. with Treatment Nurse (TN), TN stated a resident with a risk in developing a pressure injury would benefit from having a LALM. TN stated a LALM is recommended for wound management because it helped alleviate pressure on skin. TN stated a doctor must order a LALM, nurse puts order in computer and LALM arrives the next day. TN stated all nursing staff were responsible on checking on LALM order status. During a concurrent interview and record review on 7/24/2025 at 1:39 p.m. with TN, Resident 1's Doctor Orders, dated 7/21/2025, were reviewed. The doctor's orders indicated Resident 1 had an order for LALM. TN stated if a resident has an order for a LALM that resident should have a LALM. TN stated Resident 1 had a pressure injury and redness on his buttocks and would benefit from using a LALM as a preventive measure. During a concurrent interview and record review on 7/24/2025 at 1:50 p.m. with TN, Resident 2's Doctor Orders, dated 7/22/2025, were reviewed. Doctor orders indicated Resident 2 had an order for a LALM. TN stated she did not know a LALM was ordered for Resident 2 and she did not know why he did not have a LALM. TN stated Resident 2 needed a LALM because he had skin issues and it would prevent his skin from getting worse. During a concurrent interview and record review on 7/24/2025 at 2:02 p.m. with TN, Resident 3's Doctor Orders, dated 7/21/2025, were reviewed. The doctor's orders indicated Resident 3 had an order for a LALM. TN stated Resident 3 had a stage 1 pressure injury (redness, intact skin, typically over a bony prominence) and needed LALM for preventive measures. During an interview on 7/24/2025 at 2: 10 p.m. with TN, TN stated she did not know why the residents did not have a LALM. TN stated she did not know a LALM was ordered for Resident 1, 2, and 3. TN stated the person that ordered the LALM should have notified her. TN stated if there was an order, nursing must follow the order. During an interview on 7/24/2025 at 2:17 p.m. with Maintenance Supervisor (MS), MS stated he ordered LALM when the TN or Director of Nursing (DON) notified him of a resident that needed one. MS stated he usually had extra LALM's that are kept in-house and he currently had 3 available. MS stated nursing had only notified him Resident 1 needed a LALM and he ordered it. MS stated Resident 1 had not received the LALM and he forgot to 055519 Page 2 of 6 055519 07/24/2025 Downey Post Acute 13007 S. Paramount Blvd. Downey, CA 90242

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few follow up on the LALM order. MS stated he was not aware of other residents waiting for LALM because no one notified him. During an interview on 7/24/2025 at 3:34 p.m. with the DON, the DON stated the purpose of using a LALM is to help relieve skin pressure, help with wound healing and prevent pressure injuries. The DON stated it was important for residents that need a LALM used a LALM for wound prevention and comfort. The DON stated if a resident did not receive a LALM resident can potentially develop a pressure injury, pressure injury can get worse and it can create a slow healing process. The DON stated she did not know why Resident 1, 2, and 3 did not have a LALM. The DON stated TN should have noticed the LALM order during her treatment rounds with those residents and followed up on the order. The DON stated after a LALM got ordered it took 1 day for a resident to receive a LALM. The DON stated Resident 1, 2, and 3 had an order for a LALM and nursing should have provided a LALM to those residents. During a review of facility's Policy and Procedure (P&P) titled Skin and Wound Monitoring and Management, dated 4/2025, the P&P indicated it was the facility's policy for residents with pressure injuries to receive necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. The P&P indicated to prevent the development of skin breakdown or prevent existing pressure injuries from worsening a pressure relieving/reducing and redistributing device (low air loss mattress) would be provided to residents. 055519 Page 3 of 6 055519 07/24/2025 Downey Post Acute 13007 S. Paramount Blvd. Downey, CA 90242

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure Braden scale assessment (tool used in Skilled Nursing Facilities to assess a patient's risk of developing pressure injuries [localized area of tissue damage that develops when prolonged pressure] or shear forces [horizontal force that causes the bony prominence to move across the tissue as the skin is held in place] are applied to the skin and underlying tissues) was accurately performed for one resident (Resident 1) out of 4 sampled residents. 1. Facility did not ensure Resident 1 was correctly assessed during Braden Scale assessment. 2. Facility did not ensure Nursing staff had the knowledge of scoring resident during the Braden Scale assessment. This deficient practice placed Resident 1 at a low risk of developing pressure injuries and potentially caused Resident 1 not to receive the preventive measures in developing pressure injuries. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnosis included pressure ulcer of sacral region (located at the base of the spine), stage 4 (full-thickness skin and tissue loss) and dementia (a progressive state of decline in mental abilities).During a review of Resident 1's History and Physical (H&P) dated 11/4/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), the MDS indicated Resident 1's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 1 was dependent (helper does all of the effort) on staff for toileting hygiene. The MDS indicated Resident 1 required supervision for oral hygiene. The MDS indicated Resident 1 required set up assistance for eating. During a review of Resident 1's Braden Scale for Predicting Pressure Sore Risk, dated 11/8/2024, the Braden scale indicated Resident 1 had a score of 15 (Scores: 15 and above - low risk, 13-14 moderate risk, 10-12 high risk, and less than 9 severe risk). The Braden scale indicated Resident 1 had a low risk of developing a pressure injury. During a review of Resident 1's Braden Scale for Predicting Pressure Sore Risk, dated 10/22/2024, the Braden scale indicated Resident 1 had a score of 15. The Braden scale indicated Resident 1 had a low risk of developing a pressure injury During a review of Resident 1's Braden Scale for Predicting Pressure Sore Risk, dated 10/15/2024, the Braden scale indicated Resident 1 had a score of 15. The Braden scale indicated Resident 1 had a low risk of developing a pressure injury. During a review of Resident 1's Braden Scale for Predicting Pressure Sore Risk, dated 9/18/2024, the Braden scale indicated Resident 1 had a score of 15. The Braden scale indicated Resident 1 had a low risk of developing a pressure injury. During a review of Resident 1's Weights and Vitals Summary, dated 10/9/2024 11/09/2024, the Summary indicated Resident 1 lost 16 pounds in 1 month. The summary indicated Resident 1 weighed 113 pounds on 10/9/2024 and weighed 97 pounds on 11/9/2024. During a review of Resident 1's Interdisciplinary Team (IDT) Skin Review Notes, dated 10/18/2024, the IDT notes indicated Resident 1 had a sacrococcyx (fused bone formed by the sacrum and coccyx [tailbone]) pressure injury that was unstageable (a type of pressure ulcer where the wound bed is completely obscured by slough [dead tissue] or eschar [dead tissue that forms over healthy skin and over time falls off]. The IDT notes indicated Resident 1 was at risk for slow healing or worsening of wound due to poor oral intake and fragile appearance. The IDT notes indicated Resident 1 was at high risk for skin integrity breakdown. During a review of Resident 1's Interdisciplinary Team (IDT) Skin Review Notes, dated 10/18/2024, the IDT notes indicated Resident 1 had a sacrococcyx pressure injury that was unstageable. IDT notes indicated Resident 1's health conditions were incontinence, compromised nutritional status and decreased sensory perception (ability 055519 Page 4 of 6 055519 07/24/2025 Downey Post Acute 13007 S. Paramount Blvd. Downey, CA 90242

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to understand and interact with the environment using senses of sight, smell, hearing, taste, touch). IDT notes indicated Resident 1 was at risk for slow healing or worsening of wound due to poor oral intake and fragile appearance. The IDT notes indicated Resident 1 was at high risk for skin integrity breakdown. During a review of Resident 1's IDT Skin Review Notes, dated 10/24/2024, the IDT notes indicated Resident 1 had a sacrococcyx pressure injury that was unstageable. The IDT notes indicated Resident 1's health conditions were incontinence, declining condition (a gradual decrease or deterioration in health or physical condition), compromised nutritional status and decreased sensory perception. The IDT notes indicated Resident 1 was at risk for slow healing or worsening of wound due to poor oral intake and fragile appearance. The IDT notes indicated Resident 1 was at high risk for skin integrity breakdown During a review of Resident 1's IDT Skin Review Notes, dated 11/7/2024, the IDT notes indicated Resident 1 had a sacrococcyx pressure injury that was unstageable. The IDT notes indicated Resident 1's health conditions were incontinence, declining condition (a gradual decrease or deterioration in health or physical condition), compromised nutritional status and decreased sensory perception. The IDT notes indicated Resident 1 was at risk for slow healing or worsening of wound due to poor oral intake and fragile appearance. The IDT notes indicated Resident 1 was at high risk for skin integrity breakdown. During a review of Resident 1's IDT Skin Review Notes, dated 11/14/2024, the IDT notes indicated Resident 1 had a sacrococcyx pressure injury that was unstageable. The IDT notes indicated Resident 1's health conditions were immobility, incontinence, malnutrition, declining condition, compromised nutritional status and decreased sensory perception. The IDT notes indicated Resident 1 was at risk for slow healing or worsening of wound due to poor oral intake and fragile appearance. The IDT notes indicated Resident 1 was at high risk for skin integrity breakdown. During an interview on 7/24/2025 at 1:29 p.m. with Treatment Nurse (TN), TN stated a Braden Scale was used to predict which resident had had a risk of developing pressure injuries. TN stated if a resident had a high Braden score it meant the resident had a low risk of developing a pressure injury. TN stated if a resident had a low Braden score nursing would implement interventions to prevent pressure injuries. TN stated if a resident was not eating and lost weight, the resident would get a lower Braden score and would put that resident at risk for developing a pressure injury. TN stated it was important to accurately assess residents to provide the correct care and identify residents that are at risk at developing pressure injuries. TN stated a resident with a pressure injury should not receive a low-risk Braden score, they should at least have a score of moderate risk. TN stated a resident with a low-risk Braden score should not have any pressure injuries. During an interview on 7/24/25 at 3:10 p.m. with the Director of Nursing (DON), the DON stated a Braden Scale was used to know if a resident was at risk of developing skin wounds. The DON stated she used the Braden Scale score to implement changes for residents at risk of developing skin breakdown. The DON stated if a resident sits on a wet diaper, they are at risk of developing a pressure injury. The DON stated it was important to accurately assess residents so they can get the care they need. The DON stated if a resident did not get a correct Braden Scale score, the resident had potential to develop a pressure injury or their pressure injury could get worse. The DON stated if a resident scored low, they had a low risk of developing a pressure injury and if they scored a high, they had a high risk of developing a pressure injury. The DON stated if a resident did not eat and was incontinent that would be a moderate risk of developing a pressure injury. The DON stated Resident 1 should not have a low risk of developing a pressure injury because she was incontinent, had weight loss, and was skinny. The DON stated resident 1's Braden Scale should have not been marked as rarely moist because she was incontinent and could be sitting on a wet diaper. During a review of facility's Policy and Procedure (P&P) 055519 Page 5 of 6 055519 07/24/2025 Downey Post Acute 13007 S. Paramount Blvd. Downey, CA 90242

F 0726 titled Skin and Wound Monitoring and Management, dated 4/2025, the P&P indicated nursing staff would complete a Braden Scale to identify risks and to identify any alterations in skin integrity noted at that time. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055519 Page 6 of 6