Health inspection·January 15, 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** Based on interview and record review, the facility failed to ensure professional standards of practice, to prevent pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for one of five sampled residents (Resident 1) when: Residents Affected - Few 1) Daily skin checks were not documented, 2) Bowel and bladder care were not provided at regular intervals. These failures resulted in Resident 1 developing Stage 2 pressure ulcers (partial-thickness loss of skin, presenting as a shallow open sore or wound) on Resident 1's left and right buttocks. Findings: During a review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated, Resident 1 was admitted to the facility December 2024 with multiple diagnoses which included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's admission Comprehensive Skin Assessment/Evaluation, dated 12/5/24, the Comprehensive Skin Assessment/Evaluation, indicated, .buttocks .clear of any skin breakdown .additional care .incontinence (loss of bowel and bladder control) management . During a review of Resident 1's care plan, initiated 12/5/24, the care plan indicated, .Resident at risk for skin breakdown .check skin daily .notify physician of abnormal findings .keep skin clean and dry to the extent possible . During a review of Resident 1's Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 12/11/24, the MDS indicated Resident 1 was at risk for developing pressure ulcers and did not have any pressure ulcers. During an interview with the Director of Nursing (DON) on 1/15/25 at 10:09 a.m., the DON stated Resident 1 obtained two facility acquired Stage 2 pressure ulcers while residing in the facility. The DON further stated the pressure ulcers were preventable. During a concurrent interview and record review on 1/15/25 at 10:38 a.m. with the Director of Staff Development (DSD), Resident 1's Bowel Continence and Bladder Continence logs dated 12/17/24 through 12/25/24 were reviewed. The Bowel Continence and Bladder Continence logs indicated, (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: 055886 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 055886 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Roseville Care Center 1161 Cirby Way Roseville, CA 95661 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)