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, Page 1 of 2 055886 055886 01/15/2025 Roseville Care Center 1161 Cirby Way Roseville, CA 95661

F 0686 On 12/17/24 bowel and bladder care were not provided to Resident 1 from 10:58 a.m. to 6:41 p.m. Level of Harm - Minimal harm or potential for actual harm On 12/18/24 bowel and bladder care were not provided to Resident 1 from 12:23 p.m. to 8:52 p.m. On 12/20/24 bowel and bladder care were not provided to Resident 1 from 10:15 a.m. to 8:53 p.m. Residents Affected - Few On 12/21/24 bowel and bladder care were not provided to Resident 1 after 6:23 p.m. On 12/22/24 bowel and bladder care were not provided to Resident 1 after 8:26 a.m. On 12/23/24 bowel and bladder care were not provided to Resident 1 from 5:56 a.m. to 12:13 p.m. On 12/24/24 bowel and bladder care were not provided to Resident 1 from 3:44 p.m. to 10:03 p.m. On 12/25/24 bowel and bladder care were not provided to Resident 1 from 3:44 p.m. to 9:58 p.m. The DSD acknowledged providing bowel and bladder care only once per shift put Resident 1 at risk for skin breakdown. The DSD stated the expectation was for residents to receive bowel and bladder care every two hours. The DSD confirmed there was no documentation indicating daily skin checks were being performed for Resident1. During a review of Resident 1's Communication to Physician , dated 12/28/24, the Communication to Physician indicated, .Pt (patient) has stage II PI (Stage 2 pressure ulcer) to bilateral (both sides) buttocks . During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 had two Stage 2 pressure ulcers. During a review of the facility's policy and procedure (P&P) titled, Prevention of Pressure Ulcers , dated April 2020, the P&P indicated, .for existing pressure injury risk factors .repeat risk assessment weekly .inspect skin on a daily basis .inspect pressure points .keep the skin clean .clean promptly after episodes of incontinence . 055886 Page 2 of 2