Health inspection·April 22, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an accurate documentation of wound care treatment for two (2) of 2 sampled residents (Residents 1 and 2) on the residents Treatment Administration Record (TAR) in accordance with the facility's policy titled Charting and Documentation. This deficient practice resulted in the medical records inaccurate representation of care provided to Residents 1 and 2. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included pressure ulcer (also known as pressure injuries - localized damage to the skin and/or underlying tissue usually over a bony prominence) on the sacral (tailbone) region of unspecified stage and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a slight loss of strength in a leg, arm, or face) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 3/27/2025, the MDS indicated Resident 1 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 was dependent (helper does all the effort) with toileting hygiene and shower and required substantial/maximal assistance (helper does more than half the effort) with oral and personal hygiene, upper and lower body dressing and putting on/taking off footwear. The MDS further indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with eating. During a review of Resident 1's physician's order dated 2/22/2025 timed at 11:35 AM, the physicians order indicated daily dressing changes to Resident 1's Sacro-coccyx (pertains to both large triangular shaped bone in the lower spine that forms part of the pelvis and the tailbone) pressure injuries for 28 days. The physicians order indicated to cleanse Resident 1's Sacro-coccyx with normal saline (NS-a saltwater solution), pat dry, apply Santyl ointment (used to remove damaged tissue from chronic skin ulcers), cover with alginate (a light, nonwoven fabrics derived from algae or seaweed) sheet then cover with foam dressing. During a review of Resident 1's Treatment Administration Record (TAR) for the month of March 2025, the TAR was left blank/ was not signed on 3/18/2025 for Resident 1's Sacro-coccyx wound care order to clean with NS, pat dry, apply Santyl ointment, cover with alginate and cover with foam dressing. Page 1 of 3 055818 055818 04/22/2025 Royal Gardens Healthcare 2339 W. Valley Blvd. Alhambra, CA 91803

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. During a review of Resident 2's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included stage three (3) pressure ulcer (Full-thickness loss of skin. Dead and black tissue may be visible) on right lower back, stage four (4) pressure ulcer (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) on left hip, unstageable (the wound cannot be accurately categorized as to what stage because the base of the wound is obscured) pressure ulcer on the left ankle, and pressure induced deep tissue damage of right heel. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had severe impairment in cognitive skills for daily decision making. The MDS also indicated Resident 2 was dependent with eating, oral and toileting hygiene, shower, upper and lower body dressing and putting on/taking off footwear. During a review of Resident 2's physician's order dated 2/24/2025 timed at 1:50 PM, the physicians order indicated daily dressing changes to Resident 2's pressure injuries for 30 days. The physicians order included the following: a) Left buttock - cleanse with NS pat dry, apply Medi Honey (a medical- grade honey dressing that can be used to treat a variety of wounds) then cover with dry dressing. b) Left medial (toward the middle) knee- cleanse with NS, pat dry, apply Santyl ointment then cover with dry dressing. c) Left trochanter (a bumpy, raised area on a thigh bone where muscles and tendons attach) - cleanse with NS, pat dry, apply Santyl ointment and Medi honey then cover with dry dressing. d) Right heel - cleanse with NS, pat dry, apply Betadine solution (an antiseptic used to kill germs and prevent infection particularly on the skin), cover with abdominal pad then wrap with kerlix gauze (a highly absorbent gauze used for wound care). e) Right lateral (situated at or on the side) knee - cleanse with NS, pat dry, apply Santyl ointment then cover with dry dressing. f) Right medial knee - cleanse with NS, pat dry, apply Santyl ointment then cover with dry dressing. g) Sacro-coccyx - cleanse with NS, pat dry, apply barrier cream then cover with dry dressing. During a review of Resident 2's TAR for the month of March 2025, the TAR indicated the daily pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) wound treatments for 3/16/2025 and 3/18/2025 timed for 7 AM - 3 PM (day shift) did not have the initial of the Registered Nurse (RN)/ Treatment Nurse (TN) on the following sites: a) Left buttock - cleanse with NS, pat dry, apply Medi Honey then cover with dry dressing. b) Left medial knee- cleanse with NS, pat dry, apply Santyl ointment, then cover with dry dressing. c) Left trochanter - cleanse with NS, pat dry, apply Santyl ointment and Medi honey, then cover with dry dressing. 055818 Page 2 of 3 055818 04/22/2025 Royal Gardens Healthcare 2339 W. Valley Blvd. Alhambra, CA 91803

F 0842 d) Right heel - cleanse with NS, pat dry, apply Betadine solution, cover with abdominal pad then wrap with kerlix gauze. Level of Harm - Minimal harm or potential for actual harm e) Right lateral knee - cleanse with NS, pat dry, apply Santyl ointment then cover with dry dressing. Residents Affected - Some f) Right medial knee - cleanse with NS, pat dry, apply Santyl ointment then cover with dry dressing. g) Sacro coccyx - cleanse with NS, pat dry, apply barrier cream then cover with dry dressing. During a concurrent interview and record review on 4/22/2025 at 11:58 AM, Resident 1 and 2's TAR for the month of March 2025 were reviewed. Resident 1's MAR was not signed on 3/18/2025 for Resident 1's wound care on the resident's Sacro coccyx and Resident 2's MAR were left blank/ not signed on 3/16/2025 and 3/18/2025 for Resident 2's left buttock, left medial knee, left trochanter, right heel right lateral knee, right medial knee and Resident 2's Sacro coccyx. RN 1 stated RN 1 was covering for the Treatment Nurse (TN) on 3/16/2025 and 3/18/2025, and confirmed the TAR was inaccurate because licensed nurse who completed the treatment missed to check and initial/ sign RN 1 provided on 3/16/2025 and 3/18/2025 for both Residents 1 and 2. RN 1 also stated the wound care treatment should be documented after it was provided to confirm they were done. During an interview on 4/22/2025 at 2:30 PM, the Director of Nursing (DON) stated RN 1 or whoever was providing the wound care treatment to Resident 1 and 2 should have checked and initaled/ signed the residents' TAR after the wound care treatment was provided to validate the treatments were done. The DON also stated, the TAR should be signed after providing the wound care treatment to ensure accuracy of documentation in the residents' medical record. During a review of the facility's undated policy and procedure (P&P) titled, Charting and Documentation, indicated that all services provided to the resident, .shall be documented in the resident's medical record. The policy also indicated that documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. The policy further indicated, documentation of the procedures and treatments will include care -specific detail, including date and time the procedure/treatment was provided, name and title of the individual (s) who provided the care, and the signature and title of the individual documenting. 055818 Page 3 of 3