Health inspection·May 1, 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 observation, interview and record review, the facility failed to intervene and document wound care prevention and management according to professional standards of practice and per the facility ' s policy and procedure titled, Skin and Wound Monitoring and Management, for 2 of 3 sampled residents (Residents 1 and 2) by failing to: Residents Affected - Some 1. Document wound care treatments ordered by the physician in the treatment record for Resident 1. 2. Document Resident 2 ' s wound measurements upon admission. 3. Order and treat Resident 2 ' s moisture associated skin damage (MASD – skin damage caused from prolonged exposure to moisture) upon admission. These deficient practices had the potential to cause harm to Resident 1 and Resident 2 by worsening their wounds/skin conditions, due to lack of accountability, not ascertaining a baseline to monitor worsening of a wound, and the possibility of not providing treatments as ordered which could cause wounds to worsen. These deficient practices also had the potential to cause skin breakdown by not providing preventative treatment typical to the standard of care. Findings: a. During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including pressure ulcer/injury stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of the sacral region (lower back), cognitive communication deficit (communication difficulties arising from problems with cognitive processes like attention, memory, and problem-solving rather than speech or language issues), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool) dated 12/3/2024, the MDS indicated Resident 1 had severe cognitive (ability to think and reason) impairment and was dependent on staff for toileting hygiene and personal hygiene. During a review of Resident 1 ' s Skin Evaluation Note, dated 9/24/2025, the Skin Evaluation Note indicated Resident 1 was admitted to the facility with a pressure ulcer/injury stage 4 of the sacral coccyx (lower back). During a review of Resident 1 ' s Physician ' s Order, dated 11/8/2025, the Physician ' s Order indicated to cleanse the sacral coccyx pressure ulcer/injury stage 4 with normal saline (a saltwater Page 1 of 3 055894 055894 05/01/2025 Broadway by the Sea 2725 E. Broadway Long Beach, CA 90803

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some solution), pat dry, apply medical-grade honey (treatment used to debride [a medical procedure that involves removing dead, infected, or damaged tissue from a wound or surgical site] bad tissue from wounds) to the wound bed (the base or open area of a wound), and cover with foam (designed to manage an ideal wound environment for healing) dressing daily, ordered on 11/8/2025. During a review of Resident 1 ' s Treatment Administration Record (TAR), dated 11/2024, the TAR indicated there was no documentation indicating treatments were provided to Resident 1 ' s sacral coccyx on 11/8/2024 and 11/24/2024 as ordered. b. During a review of Resident 2 ' s Face Sheet, the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including need for assistance with personal care, muscle weakness, cognitive communication deficit, and dementia. During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment and was dependent on staff for toileting hygiene, showering/bathing, and dressing. The MDS further indicated Resident 2 was at risk for developing pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) during the assessment period. During a review of Resident 2 ' s LN Initial admission Record, dated 11/16/2024, the LN Initial admission Record indicated Resident 1 had MASD of sacral region left and right buttocks. During a review of Resident 2 ' s Physician ' s Orders, dated 11/19/2024, the Physician ' s Orders indicated to apply zinc oxide barrier cream (a protective barrier that helps prevent moisture loss from the skin and enhances the healing process of wounds) daily to bilateral (both sides) buttocks for MASD ordered on 11/19/2024. During a review of Resident 2 ' s Licensed Nursing (LN) Initial admission Record (Nursing Assessment), dated 4/29/2025 and timed at 4 p.m., the LN admission Record indicated Resident 2 was admitted with a sacral wound. The LN Initial admission Record did not indicate the size or wound type. During an observation on 4/30/2025 at 10:02 a.m., with Licensed Vocational Nurse (LVN) 1, in Resident 2 ' s room, Resident 2 had redness with excoriations (raw, irritated skin) on her bilateral buttocks. LVN 1 stated Resident 2 was readmitted yesterday, and she had not yet evaluated her skin and therefore did not know if the excoriations were new or not. During an interview on 4/30/2025 at 12:15 p.m., with LVN 1, LVN 1 stated MASD occurs when a resident has been sitting in their urine and/or feces for a long period which eventually leads to irritation and skin breakdown. LVN 1 stated Resident 2 had MASD upon her original admission on [DATE] which has been ongoing, and a skin barrier should have been applied right away to prevent more irritation but was not ordered until 11/19/2024. During an interview on 4/30/2025 at 2:58 p.m., with the Director of Nursing (DON), the DON stated if a resident has MASD she would expect a barrier cream to be ordered to protect the skin. The DON stated Resident 2 received an order for a barrier cream on 11/19/2024, three days after the MASD was identified upon admission on [DATE]. The DON stated it should not have been ordered three days later. During a follow-up interview on 5/1/2025 at 11:10 a.m., with the DON, the DON stated Resident 2 was admitted on [DATE] but measurements for the wound on her sacral region were not done. The DON stated the admitting nurse should document the measurement of wounds upon admission so the team could 055894 Page 2 of 3 055894 05/01/2025 Broadway by the Sea 2725 E. Broadway Long Beach, CA 90803

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some have a baseline to see if the wound got worse or not and then make a short-term care plan until they come up with a care long term plan. The DON stated Resident 1 ' s physician orders for his wounds were ordered daily and should be documented. The DON stated if it was not documented they cannot be sure if it was done or not and could cause a wound to get worse. During an interview on 5/1/2025 at 1:49 p.m., with Physician Assistant (PA) 1, PA 1 stated if a resident had MASD the typical treatment would be to apply barrier cream the same day, and it should not take three days to intervene with this type of treatment unless there was a good medical reason. During an interview on 5/1/2025 at 2:20 p.m. with LVN 1, LVN 1 stated although she worked at the facility prior to 11/2024, she changed roles from a charge nurse to a treatment nurse on 11/7/2024. LVN 1 stated during that time in 11/2024 she was being trained as a treatment nurse. LVN 1 stated she never missed providing wound care treatment for any of her residents and is not sure why Resident 1 ' s sacral wound care for 11/8/2024 and 11/24/2024 was not documented in the TAR. During a review of the facility ' s policy and procedure (P&P) titled Skin and Wound Monitoring and Management, dated 3/2015, the P&P indicated the purpose of the policy was to promote interventions that prevent pressure ulcers, promote healing of pressure ulcers that are present, and provide care and services to prevent the development of additional, avoidable pressure injuries. The P&P further indicated the nurse responsible for assessing and evaluating the resident ' s condition on admission and readmission is expected to take the following actions: a. Assess and evaluate the resident ' s condition and is expected to identify factors related to the possibility of skin breakdown or the development of pressure ulcers which include exposure of skin to urinary or fecal incontinence and co-morbid conditions. b. Risk factors identified should be documented in the clinical record and be addressed through the care plan. c. A licensed nurse will document the measuring of the skin injury and staging of the skin when necessary. d. Treatments per physician order should be documented in the resident ' s clinical record at the time they are administered. e. Any changes in the condition of the resident ' s skin as identified daily, weekly, monthly, or otherwise must be communicated to the resident/responsible party, the resident ' s physician, and others as necessary to facilitate healing. f. Once an area of alteration in skin integrity has been identified, assessed, and documented, nursing shall administer treatment to each affected area per the Physician ' s Order. 055894 Page 3 of 3