Health inspection·May 7, 2024

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** Based on interview, medical record review, and facility document review, the facility failed to ensure one of two sampled residents (Resident 1) was provided with the necessary care and services to prevent the development and worsening of pressure injuries. Residents Affected - Few * Resident 1 was evaluated to have a Stage 1 pressure injury to his sacral coccyx on 1/3/24. Resident 1's sacral coccyx pressure injury had advanced to a Stage 2 pressure injury on 1/11/24. On 1/17/24, Resident 1's wound was evaluated by Wound Specialist 1 as an unstageable pressure injury. The facility failed to ensure Resident 1's sacral coccyx unstageable pressure injury was continued to be treated by Wound Specialist 1. This failure posed the risk for Resident 1's pressure injury to deteriorate and develop additional pressure injuries. Findings: Review of the facility's P&P titled Skin and Wound Monitoring and Management revised 12/2023 showed it is the policy of the facility that a resident having a pressure injury receives the necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. Medical record review for Resident 1 was initiated on 5/6/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS dated [DATE], showed Resident 1 required substantial to maximal assistance to roll left and right in bed. The MDS further showed Resident 1 was at risk for developing pressure injuries and did not have any pressure injuries on admission to the facility. Review of Resident 1's Skin Pressure Ulcer Weekly dated 1/3/24,showed Resident 1 developed a sacral coccyx Stage 1 pressure injury with non-blanchable redness, measuring 6.2 cm (length) x 6.0 cm (width). Review of Resident 1's Skin Pressure Ulcer Weekly dated 1/11/24,showed Resident 1 developed a Stage 2 pressure injury on the sacral coccyx area, measuring 6.0 cm (length) x 6.0 cm (width) x 0.1 cm (depth). Review of Resident 1's Order Summary Report dated 1/31/24, showed a physician's order for a wound care consult dated 1/13/24. Review of Resident 1's Wound Specialist evaluation dated 1/17/24, showed Wound Specialist 1 was (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055570 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)