Health inspection·December 5, 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 and record review, the facility failed to ensure proper care was provided to prevent a blister (a painful swelling on the surface of the skin), for one of three sampled residents (Resident 1). Residents Affected - Few This failure placed a clinically compromised Residents (Resident 1) health and safety at risk, when a facility acquired blister to the right heel (back of the human foot below the ankle) developed while in the facility. Findings: During a review of Residents 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus (a disease in which there is too much sugar in the blood and the body is not able to control the sugar ), muscle wasting and atrophy (a condition with shrinking and loss of muscle), and depression (a condition with feeling of sadness and hopelessness). During an interview on November 19, 2024, at 8::55 AM, with Resident 1, Resident stated, They told me, I got a blister on my foot. I did not have any wounds on my feet until I got here. During an interview on November 19, 2024, at 10:15 AM, with Wound Treatment Nurse (WTN), WTN stated, She has a wound on her right heel which started as a blister some weeks ago. During an interview on November 19, 2024, at 10:20 AM, with Assistant Director of Nursing (ADON), ADON stated, The blister on her right heel developed after admission but was already there before November 1, 2024. During a phone interview on December 3, 2024, at 10:40 AM, with the ADON, ADON acknowledged that Resident 1 did not have wounds on her heels upon admission [DATE]). ADON stated, A fluid blister was observed on October 30, 2024. Review of following facility records: 1. admission Skin Issues: October 5, 2024, 10:43. Skin warm and dry, skin color within normal limit and turgor (the ability of skin to change shape and return to normal) is normal. Resident does not have an external device. Foot evaluation completed . Skin Issue: # (number) 001 . Lower back . #002: Right shin . 2. Braden Evaluation ([Severe risk total score: less than 9, High risk total score: 10-12, moderate Page 1 of 2 055872 055872 12/05/2024 Citrus Nursing Center 9440 Citrus Ave Fontana, CA 92335

F 0686 risk total score: 13-14, Mild risk: total score: 15-18]): .Braden score: 13.0 Level of Harm - Minimal harm or potential for actual harm 3. Situation, Background, Assessment and Recommendation (SBAR) communication record dated October 30, 2024, indicate, . Noted fluid blister to right heel 2x2cm, . Residents Affected - Few 4. Progress Notes: Skin issue: .# 003: New skin issue. Location: Right heel. Issue type: Blister. Wound acquired in-house. Wound is new . 5. Order Summary: October 30, 2024, 16:41: Wound Treatment: Wound type: blister. Wound site: right heel. Cleanse with normal saline pat dry apply dry dressing daily, every day shift for 30 days. 6. Care Plan: Focus: The resident is at risk for skin breakdown pressure ulcer r/t (related to) history of pressure injury impaired mobility, incontinence, DM (diabetes mellitus) Date initiated: October 7, 2024. Revision on: November 19, 2024. Goal: The resident will have intact skin, free of redness, blisters or discoloration by/through review date. During a review of the facility ' s policy and procedure (P&P), titled, Pressure Injury Prevention and Management, revised September 2023, the P&P indicated, This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries . 055872 Page 2 of 2