Health inspection·October 6, 2023

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 observation, interview and record review, the facility failed to consistently monitor and document a low air loss (LAL-a mattress designed to prevent and treat skin issues) mattress, for prevention of skin injuries as ordered by the physician and listed as an intervention in the care plans for three of three residents (Resident 1, 2, and 3), reviewed for plan of care in order to maintain skin integrity. As a result, Residents 1, 2, and 3 had the potential for worsening skin injuries. Findings: 1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included peripheral vascular disease (a low, progressive circulation disorder), and diabetes (abnormal blood sugar levels), per the facility's admission Record. On 9/12/23 at 10:18 A.M., an observation and interview was conducted with Resident 1. Resident 1 was lying in bed on a LAL mattress with green padded-protection boots on both feet and both ankles were propped up on a pillow. Resident 1 stated she was not doing well today and had necrotic feet (dying tissue in her feet). On 9/12/23, Resident 1's clinical record was reviewed. According to the Minimum Data Set, (MDS-a clinical assessment tool), dated 8/31/23, a cognitive score of 13 was listed, indicating cognition was intact. The functional status indicated Resident 1 was bedridden and did not get out of bed. According to the Physician's Order, dated 6/19/23, .Check LAL Mattress . (maintain skin integrity) Check functionality & mode/setting every shift . According to the Treatment Administration Record (TAR) for 8/1/23 through 9/10/23, the LAL mattress settings were checked 105 times out of 123 opportunities. According to the facility's Care Plan, titled Diabetic ulcers, undated, listed an intervention of low air loss mattress. 2. Resident 2 was admitted to the facility on [DATE], with diagnoses which included pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure) and diabetes, per the facility's admission Record. Page 1 of 5 056017 056017 10/06/2023 LA Jolla Post-Acute 2552 Torrey Pines Rd LA Jolla, CA 92037

F 0656 Level of Harm - Minimal harm or potential for actual harm On 9/12/23 at 11:53 A.M., an observation and interview was conducted with Resident 2. Resident 2 was lying in a bariatric bed (a bed wider than a standard hospital bed which is reinforced to support a higher weight capacity), with a LAL mattress. Resident 2 stated she fell at home and could get up, resulting in a Stage 4 pressure ulcer (a break in the skin from prolonged pressure which extends down to the muscle and bone). Residents Affected - Some On 9/12/23, Resident 2's clinical record was reviewed. According to the MDS, dated [DATE], a cognitive score of 15 was listed, indicating cognition was intact. The functional status indicated Resident 2 was bedridden and did not get out of bed. According to the Physician's Order, dated 6/19/23, .Check LAL Mattress . (maintain skin integrity) Check functionality & mode/setting every shift . According to the Treatment Administration Record (TAR) for 8/1/23 through 9/10/23, the LAL mattress settings were checked 106 times out of 123 opportunities. According to the facility's Care Plan, titled Actual Pressure Ulcer left lateral thigh (Stage 4), undated, listed an intervention of low air loss mattress. 3. Resident 3 was admitted to the facility on [DATE], with diagnoses which included cerebral palsy (a disease that affect a person's ability to move independently), and diabetes, per the facility's admission Records. On 9/12/23 at 11:12 A.M., Resident 3 was observed in bed, lying on a LAL mattress. On 9/12/23, Resident 3's clinical record was reviewed. According to the MDS, dated [DATE], a cognitive score of 15 was listed, indicating cognition was intact. The functional status indicated Resident 3 required 2 persona staff assist for transfers and bed mobility. According to the Physician's Order, dated 6/19/23, .Check LAL Mattress . (maintain skin integrity) Check functionality & mode/setting every shift . According to the Treatment Administration Record (TAR) for 8/1/23 through 9/10/23, the LAL mattress settings were checked 102 times out of 123 opportunities. According to the facility's Care Plan, titled Actual Pressure Ulcer, coccyx (bottom of the spine), dated 7/22/23, listed an intervention of low air loss mattress. On 9/12/23 at 12:55 P.M., an interview was conducted with Licensed Nurse 1 (LN 1). LN 1 stated if LAL mattresses were not routinely checked for proper settings, the mattress could be too firm, which would add pressure to the wound. If under inflated the mattresses would not properly support the wound. LN 1 stated with over or under mattress inflation, the wound could worsen and become larger. On 9/12/23 at 12:59 P.M., an interview was conducted with the treatment nurse (Tx LN). The Tx LN stated LAL mattresses needed to be checked regularly to ensure they were operational and programed at the proper settings. The Tx LN stated if the LAL monitoring was not documented on the TAR, then it 056017 Page 2 of 5 056017 10/06/2023 LA Jolla Post-Acute 2552 Torrey Pines Rd LA Jolla, CA 92037

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was not done. The Tx LN stated mattress settings were very important for wound healing and to prevent the wound from worsening. On 9/12/23 at 1:14 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated LAL mattresses were set according to the resident's weight and needed to be monitored by staff to ensure the correct settings applied. The DON stated if LAL mattresses were not checked as ordered and documented, resident wounds could worsen and become infected. According to the facility's policy, titled Pressure Ulcer, Prevention of, dated 2006, .7. Use appropriate support surface in the resident's bed or chair. 8. Use pressure reducing or relieving devices as necessary .Documentation Guidelines: Date, time, approached to prevent pressure ulcer development, preventative equipment used . According to the facility's policy, title Use of Support Services, undated, .3. Support surfaces will be chosen by matching the potential therapeutic benefit with the resident's specific situation. Considerations for utilizing specialized support surfaces: a. Medical condition, b. Size and weight. c. Mobility and activity levels .e. Presence of pressure injuries, including severity and location . A schedule for inspection and replacement will be established accordingly . 056017 Page 3 of 5 056017 10/06/2023 LA Jolla Post-Acute 2552 Torrey Pines Rd LA Jolla, CA 92037

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 consistently provide wound treatments as ordered by the physician for two of three residents (Resident 1 and Resident 3) reviewed for Quality of Care. Residents Affected - Few As a result, Residents 1 and 3 had the potential for delayed healing and worsening of wounds. Findings: 1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included peripheral vascular disease (a low, progressive circulation disorder), and diabetes (abnormal blood sugar levels), per the facility's admission Record. On 9/12/23 at 10:18 A.M., an observation and interview was conducted with Resident 1. Resident 1 was lying in bed on a LAL mattress (low air loss-a mattress designed to prevent skin injuries), with green padded-protection boots on both feet and both ankles. Resident 1's legs were propped up on a pillow. Resident 1 stated she was not doing well today and had, necrotic feet (dying tissue in her feet). On 9/12/23, Resident 1's clinical record was reviewed. According to the Minimum Data Set, (MDS-a clinical assessment tool), dated 8/31/23, a cognitive score of 13 was listed, which indicated cognition was intact. The functional status indicated Resident 1 was bedridden and did not get out of bed. The skin condition listed venous and arterial ulcers. According to the Physician's Order, dated 4/17/23, .Treatment: bilateral buttocks, sacrum (lower spine) and coccyx (bottom of spine): Cleanse with normal saline, pat dry, apply barrier cream .every shift . According to the Treatment Administration Record (TAR) for 8/1/23 through 9/10/23, of the bilateral buttocks, sacrum, and coccyx, the treatments were completed 105 times out of 123 opportunities. According to the facility's Care Plan, titled Diabetic ulcers; Requires assistance with turning and repositioning: listed interventions of Low Air Loss mattress and Treatment as Ordered. 2. Resident 3 was admitted to the facility on [DATE], with diagnoses which included cerebral palsy (a disease that affect a person's ability to move independently), and diabetes, per the facility's admission Records. On 9/12/23 at 11:12 A.M., Resident 3 was observed in bed, lying on a LAL mattress. On 9/12/23, Resident 3's clinical record was reviewed. According to the MDS, dated [DATE], a cognitive score of 15 was listed, indicating cognition was intact. The functional status indicated Resident 3 required 2 person staff assist for transfers and bed mobility. According to the Physician's Order, dated 4/26/23, .Treatment: Bilateral groin and abdominal folds: 056017 Page 4 of 5 056017 10/06/2023 LA Jolla Post-Acute 2552 Torrey Pines Rd LA Jolla, CA 92037

F 0684 Cleanse with normal saline, apply barrier cream .every shift . Level of Harm - Minimal harm or potential for actual harm According to the Treatment Administration Record (TAR) for 8/1/23 through 9/10/23, for the bilateral groin and abdominal folds, the treatments were conducted 106 times out of 123 opportunities. Residents Affected - Few According to the facility's Care Plan, titled Actual Pressure Ulcer, coccyx (bottom of the spine), Requires turning and repositioning, dated 7/22/23, listed interventions of Low Air Loss mattress and Treatment as Ordered. On 9/12/23 at 12:55 P.M., an interview was conducted with Licensed Nurse 1 (LN 1). LN 1 stated skin and wound treatments needed to be done as instructed by the physician. LN 1 stated if the treatments were not completed, the skin or wounds could worsen. On 9/12/23 at 12:59 P.M., an interview was conducted with the treatment nurse (Tx LN). The Tx LN stated wound treatments needed to be performed consistent, so the skin could heal faster. The TX LN stated if wound treatments were not documented, then they were not done. The Tx LN stated if treatments were missed, residents were at risk of having the treatment areas worsen and possible infection. On 9/12/23 at 1:14 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated if wound treatments were not documented, then they were not done. The DON stated she expected all treatments to be performed according to the physician's order, or else wounds could worsen and become infected. According to the facility's policy, title Wound Treatment Management, dated October 2022, .1. Wound treatments will be provided in accordance with physician orders, including the cleansing. method, type of dressing, and frequency of dressing change . 7. Treatments will be documented on the Treatment Administration Record or in the electronic health record . 056017 Page 5 of 5