Health inspection·October 4, 2023

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 conduct a weekly skin evaluation and assessment follow up of the sacrococcyx and left lower leg pressure injury (bedsore, the breakdown of skin integrity due to pressure, occurs when a bony prominence is under persistent contact with an external surface) for one sampled resident (Resident 1). Resident 1 did not receive a weekly assessment follow up and debridement on 8/31/2023 to evaluate the pressure injuries. This deficient practice caused an increased risk in harm to the resident. Residents Affected - Few Findings: A review of the medical record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic respiratory failure, dependence on ventilator, end stage renal disease, gastrostomy, anemia in chronic kidney disease, dependence on renal dialysis and diabetes mellitus, dysphagia, and unstageable and peripheral vascular disease (PVD). According to a review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 8/29/2023, Resident 1 was severely impaired cognitively and was totally dependent in bed mobility, transfers, locomotion on and off unit, dressing, eating toilet use, personal hygiene, and bathing. The MDS further indicated Resident 1 had a Stage II pressure injury (usually open wounds with swelling, discoloration, and pain), a Stage IV pressure injury (the largest and deepest of all bedsores, characterized by severe tissue damage, may look like a reddish crater on the skin. Muscles, bones, and/or tendons may also be visible at the bottom of the pressure injury) and an unstageable pressure injury (when the stage is not clear, the base of the wound is covered by a layer of dead tissue that may be yellow, grey, green, brown, or black). A review of the wound consultant/surgical consult note for Resident 1, dated 8/24/2023 indicated Resident 1 would require ongoing surveillance, weekly debridement, and follow-up at an interval of one week. On 8/24/2023, the wound consultant note indicated Resident 1 had a sacrococcyx wound that extended to the right and left buttocks and left lateral lower leg of Resident 1. According to the documentation a 17-point comprehensive skin examination was performed. The sacrococcyx buttocks was documented as having no signs of infection and the wound area was evaluated and measured 14.5 cenitmeters (cm) x 15.0 cm x 1.9 cm. with undermining at 2.3 cm at 2 o'clock and 1.7 cm at 3 o'clock with a moderate amount of serosanguineous drainage (the most common type of wound drainage secreted by an open wound in response to tissue damage. It is a thin and watery fluid that is pink in color), 95% granulation (the development of new tissue and blood vessels in a wound during the healing process) and 5% epithelial tissue, with no odor present. The wound had increased in size from the last assessment and (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: 056242 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 056242 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057 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)