Health inspection·March 27, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop comprehensive and resident-centered pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) Care Plans for two of three sampled residents (Residents 2 and 3). These deficient practices had a potential for Resident 2 and 3 ' s documented pressure ulcers to experience a delay in wound healing or to show no signs of improvement. Findings: a. During a review of Resident 2 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including stage 4 pressure ulcer (full-thickness skin and tissue loss, potentially exposing bone, tendon, or muscle) of the sacral (lower back) region and a right hip stage 4 pressure ulcer. During a review of Resident 2 ' s Minimum Data Set (MDS – a resident assessment tool) dated 2/24/2025, the MDS indicated Resident 2 ' s cognition was moderately impaired, and was dependent (helper does all the effort) on facility staff to complete activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 2 ' s untitled Care Plan dated 12/19/2024, the Care Plan indicated Resident 2 had a pressure ulcer. The Care Plan ' s interventions included encouraging resident to frequently shift weight and educating the resident/representative on the importance of keeping skin clean and moisturized. b. During a review of Resident 3 ' s Face Sheet, the Face Sheet indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including of Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 3 ' s MDS dated [DATE], the MDS indicated Resident 3 required substantial/maximum assistance (helper does more than half the effort) from facility staff to complete ADLs. During a review of Resident 3 ' s untitled Care Plan dated 3/5/2025, the CP indicated Resident 3 had a pressure ulcer on the right buttock and a deep tissue injury (a type of pressure injury that occurs when prolonged pressure or shear forces damage the underlying soft tissues, such as muscles, tendons, and bones) to the right and left heel. The Care Plan ' s interventions included encouraging Page 1 of 4 055918 055918 03/27/2025 Villa Del Sol Post Acute 16910 Woodruff Ave. Bellflower, CA 90706

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident to frequently shift weight and educating resident/representative on importance of keeping skin clean and moisturized. During an interview on 3/26/2025 at 2:44 p.m., the Treatment Nurse (TN 2) stated Residents 2 and 3 could not reposition themselves without assistance from staff and per the Care Plan interventions, it includes encouraging Residents 2 and 3 to educate residents to frequently shift their weight, which was not feasible. The TN 2 stated the Care Plan ' s interventions should have included for staff to reposition Residents 2 and 3 every 2 hours to prevent further skin breakdown as Residents 2 and 3 currently have skin breakdown and are at high risk for further skin breakdown. The TN 2 stated the purpose of Care Plans is for staff to know how to provide the appropriate care to the residents based on their care needs. During an interview on 3/27/2025 at 4:22 p.m., the Director of Nursing (DON) stated Care Plans should be resident centered because the care plans are individualized based on their needs and/or problems. The DON stated resident centered Care Plans should indicated the plan of care for each resident. During a review of facility ' s policy and procedure (P&P) titled Comprehensive Care Plans, dated 12/19/2022, the P&P indicated the comprehensive care plan will describe resident specific interventions that reflect the resident ' s needs and preferences and align with the resident ' s cultural identity, as indicated. 055918 Page 2 of 4 055918 03/27/2025 Villa Del Sol Post Acute 16910 Woodruff Ave. Bellflower, CA 90706

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record, the facility failed to revise one of three sampled residents (Resident 3) pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) Care Plan after Resident 3 ' s pressure ulcer/injury stage 1 (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness) progressed to a pressure ulcer/injury stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible). This deficient practice had the potential for Resident 3 to experience delayed wound healing and treatment. Findings: During a review of Resident 3 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 3 was originally admitted to the facility on [DATE] with a readmission date of 3/14/2025 with the diagnosis of Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 3 ' s Minimum Data Set (MDS – a resident assessment tool) dated 3/19/2025, the MDS indicated Resident 3 required substantial/maximum assistance (helper does more than half the effort) from facility staff to complete activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a concurrent interview and record review on 3/27/2025 at 1:25p.m., with the Treatment Nurse (TN 2), Resident 3 ' s Care Plans was reviewed. The Care Plan indicated; Resident 3 had a pressure ulcer/injury stage 1 on the right buttock which was reclassified/regressed to a right buttock pressure ulcer/injury stage 3 on 3/24/2025. The TN 2 stated Resident 3 ' s pressure ulcer stage 1 progressed to a stage 3 and the care plan ' s interventions were unchanged. The TN 2 stated the Care Plan should have been revised to include interventions after Resident 3 ' s pressure ulcer was reclassified. During an interview on 3/27/2025 at 2:25 p.m. the Director of Staff Development (DSD) stated Resident 3 ' s Care Plan should have been revised when Resident 3 ' s pressure ulcer progressed to a stage 3. The DSD stated there is a big difference between a stage 1 and a stage 3 pressure ulcer. The DSD stated the Care Plan interventions should have been updated which included to reposition frequently, a low air loss mattress and the new treatment orders. During an interview on 3/27/2025 at 4:22 p.m., the Director of Nursing (DON) stated Care Plans should be revised when there are any changes in pressure ulcers. The DON stated additional interventions, or different treatments will need to be added if the pressure ulcers get worse or if the treatment changes. During a review of the facility ' s policy and procedure (P&P) titled Comprehensive Care Plans, dated 12/19/2022, the P&P indicated the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 055918 Page 3 of 4 055918 03/27/2025 Villa Del Sol Post Acute 16910 Woodruff Ave. Bellflower, CA 90706

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 one of three sampled residents (Resident 3) pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) were assessed by the treatment nurse (TN 1) after Resident 3 was readmitted to the facility on [DATE]. Residents Affected - Few This deficient practice had the potential to result in a delay in treatment for Resident 3 ' s pressure ulcers. Findings: During a review of Resident 3 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 3 ' s Minimum Data Set (MDS – a resident assessment tool) dated 3/19/2025, the MDS indicated Resident 3 required substantial/maximum assistance (helper does more than half the effort) from facility staff to complete activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 3 ' s Skin Check assessment dated [DATE], the skin check assessment indicated Resident 3 had deep tissue injury (a type of pressure injury that occurs when prolonged pressure or shear forces damage the underlying soft tissues, such as muscles, tendons, and bones) on bilateral heels and a stage one pressure ulcer (intact skin with a non-blanchable area of redness) on the buttocks. During an interview on 3/27/2025 at 1:25 p.m., the Treatment Nurse 2 (TN2) stated when a resident is admitted , the skin/wound assessment should be completed as soon as possible by a treatment nurse. The TN 2 stated Resident 3 was admitted on [DATE] and TN 1 completed the skin/wound assessment on 3/19/2025. During an interview on 3/27/2025 at 4:16 p.m., with the Director of Staff Development (DSD), the DSD stated resident ' s skin including pressure ulcers which should be assessed by the treatment nurse as soon as possible because a resident ' s skin condition could change within 24 hours. During an interview on 3/27/2025 at 4:22 p.m., with the Director of Nursing (DON), the DON stated treatment nurses are trained specifically on wound assessments including staging and measurements. The DON stated skin assessments should be completed the same day or the next day a resident is admitted to the facility. The DON stated there is the potential for skin or wound changes to go unnoticed, if the skin assessment is delayed. During a review of the facility ' s policy and procedure (P&P) titled Pressure Injury Prevention and Management, dated 9/12/2023, the P&P indicated assessments of pressure injuries will be performed by a licensed nurse and documented on the electronic health record. The P&P indicated the staging of pressure injuries will be clearly identified to ensure correct coding on the MDS. The P&P indicated the licensed nurse will conduct a pressure injury risk assessment, using the Braden Scale for Predicting Pressure Ulcer Risk, on all residents upon admission/readmission. 055918 Page 4 of 4