Health inspection·October 16, 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 observation, interview and record review, the facility failed to implement the facility ' s policy and procedure titled Clean Dressing Change to prevent infection during wound care of the pressure ulcer (a skin injury resulting from prolonged unrelieve pressure in the body). Licensed Vocational Nurse (LVN 1) failed to change gloves and wash hands after touching a soiled wound dressing during wound care for one of three sample residents (Resident 2) who had Stage 4 pressure ulcer (skin injury that involves full-thickness tissue loss that exposes bone, tendon, or muscle). Residents Affected - Few This deficient practice had the potential for Resident 2 to develop severe wound infection, pain and could lead to delayed healing process and a decline in the resident ' s wellbeing. Findings: During a review of the admission record indicated Resident 2 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included diabetes (a disease in which your blood glucose, or blood sugar, levels are too high) hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated), sepsis (a severe blood infection), and ESBL (Extended Spectrum Beta Lactamase- an enzyme that makes some bacteria resistant to many antibiotics ) Resistance. During a review of Resident 2's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/5/2024, indicated the resident's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was moderately impaired. The MDS indicated Resident 2 was dependent (resident does none of the effort to complete the activity) on facility staff for eating, toileting, showers, lower body dressing. The MDS further indicated Resident 2 was dependent with care (helper does all the activity) with turning and mobility. During an observation on 10/16/2024, at 10:40 AM, in Resident ' s 2 room, the Treatment Nurse (TN1) was observed providing wound treatment to Resident 1 with ulcer on the left heel. During the wound care, TN 1 put on a pair of clean gloves to remove a soiled dressing (stained with blood and brownish drainage) from the resident's left heel and placed the soiled dressing into a disposal bag without changing the soiled gloves and did not wash hands. Then TN 1 opened a clean normal saline (salt solution) bottle to wet a 4x4 gauze (sterile or clean pads used to clean wound). Then TN 1 picked the wet 4x4 gauze up wearing the soiled gloves, which touched the soiled dressing, and cleaned the ulcer of the left ankle without changing the gloves or washing hands. After cleaning the wound, TN 1 proceeded treating the wound ulcer on the left heel and applied clean dressing without changing gloves and washing hands. TN 1 proceeded to perform the wound care treatment as ordered to Resident 2's right mid back with stage 4 wound (full thickness tissue loss with exposed bone, tendon, or muscle) (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: 055989 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 055989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754 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)