Health inspection·December 23, 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 provide care and services, for one of three sampled residents (Resident 1), by failing to: Residents Affected - Few Follow the facility's Policy and Procedure (P&P) to implement interventions to promote the prevention of pressure ulcer/pressure sore (localized damage to the skin and/or underlying tissue usually over a bony prominence (areas where bones are close to the surface) development for Resident 1, who was on a low air loss mattress (LAL, mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) and was at high risk for developing a pressure ulcer. This deficient practice had the potential to result in Resident 1 developing a pressure ulcer and/or worsening of Resident 1's existing pressure ulcers. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included a pressure ulcer of other site, Stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible), pressure ulcer of the left buttock, unstageable (a type of pressure sore that cannot be accurately staged due to the presence of necrotic tissue (dead tissue) or eschar (a thick, hard crust) covering the wound bed), pressure ulcer of the right buttock, unstageable, pressure ulcer of the sacral region, and heart failure (a heart disorder which causes the heart to not pump the blood efficiently), unspecified. During a review of Resident 1's History and Physical (H&P), dated 11/26/2024, the H&P indicated, Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment care planning tool), dated 11/28/2024, the MDS indicated, Resident 1 had intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated, Resident 1 was dependent (helper provided all the effort or the assistance of two or more helpers was required for the resident to complete the activity) with toileting hygiene, lower body dressing, and putting on/taking off footwear. The MDS indicated, Resident 1 was dependent in rolling left to right (the ability to roll from lying on back to left and right side and return to lying on back on the bed). The MDS indicated, Resident 1 had one Stage 3 pressure ulcer that was present upon admission or reentry, three unstageable pressure ulcer that were present upon admission/reentry, and two venous and arterial ulcers. The MDS indicated, Resident 1 had a pressure reducing device for the bed, Page 1 of 2 056228 056228 12/23/2024 West Haven Healthcare 1495 West Cameron Ave. West Covina, CA 91790

F 0686 Level of Harm - Minimal harm or potential for actual harm turning/repositioning program, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care, and applications of ointments/medication other than to feet. During a review of Resident 1's Braden Scale (BS), dated 12/13/2024 and timed at 10:03 AM, the BS indicated, Resident 1 was at high risk for developing pressure sores. Residents Affected - Few During an observation of Resident 1 on 12/23/2024 at 10:41 AM with a Licensed Vocational Nurse 1 (LVN 1), Resident 1 was laying on a LAL mattress with one flat sheet and another flat sheet that was folded that was used to lift and/or reposition Resident 1. During an interview on 12/31/2024 at 12:39 PM with LVN 3, LVN 3 stated only one sheet and a disposable chux pad (a disposable under pad or bed pad that is used to protect furniture or bedding from stains caused by urinary incontinence) can be on the LAL mattress. LVN 3 stated a flat sheet cannot be used for turning a resident because it defeats the purpose of the LAL mattress requirement. LVN 3 stated any garment could cause pressure to the skin and could cause more injury to the wound. LVN 3 stated a flat sheet used for turning should not be there. LVN 3 stated when LVN 3 does a resident's wound treatment, LVN 3 checks to see the resident's LAL setting and if the resident has one sheet and a disposable chux pad. During a concurrent observation and interview on 12/23/2024 at 1:31 PM, Resident 1 was observed laying on a LAL mattress with three layers on the LAL mattress. The layers included a flat sheet, a folded flat sheet, and a disposable chux pad. LVN 2 stated there was only supposed to be one flat sheet and a chux pad only. LVN 2 stated Resident 1's wound could get worse. During an interview on 12/23/2024 with the Director of Nursing (DON), the DON stated for a resident on a LAL mattress, there should only be a draw sheet and a chux pad. The DON stated the sheets should be thin. The DON stated if there are more layers than that, it would interfere with the effectiveness of the LAL mattress. The DON stated the healing process could be affected and slow down the healing process. During a review of the facility's P&P, titled, Pressure Ulcer Prevention, dated 2/9/2024, the P&P indicated, the facility would identify residents at risk for pressure ulcers and provide care and services to promote the prevention of pressure ulcer development. During a review of the facility's P&P, titled, Wound Management, dated 2/9/2024, the P&P indicated, a resident who has a wound would receive necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. During a review of the facility's P&P, titled, Support Surface Guidelines, dated 2/9/2024, the P&P indicated, the facility would implement measures to reduce tissue pressure that included frequent repositioning, protective devices, and the use of support services. 056228 Page 2 of 2