Health inspection·June 20, 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 observation, interview, and record review the facility failed to assess, and notify physician of a change in condition timely to ensure skin care was provided to prevent pressure injury for one of three residents (Resident 1). Residents Affected - Few This failure placed a clinically compromised Residents (Resident 1) health and safety at risk. When a facility acquired pressure ulcer/injury developed and worsened resulting in Resident 1 being transferred to the Acute Hospital for further wound evaluation. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: diabetes type II (body does not produce enough insulin, or resist insulin), end stage renal disease (kidneys cease functioning, need for dialysis), congestive heart failure (weakness of the heart). During a review concurrent interview and record review of Resident 1's Medical Record with the Assistant Director of Nursing (ADON), reviewed are as follows: 1. Initial skin assessment on admission, facility cannot provide skin assessment, but did provide Initial admission skin record dated January 22, 2023 @1905, document is blank, no wound assessment notes. 2. Wound Assessment from wound doctor dated February 22, 2023, indicates .Reevaluate for Right first digit wound from brace .pressure from medical device. 3. Wound Assessment from wound doctor dated March 01,2023 indicates . Reevaluate for Right first digit wound from brace. 4. Skin Integrity Report dated admission date September 22, 2022; initial wound date dated February 22. 2023 indicates . Right Index Finger callous/arterial . Necrotic March 31, 2023. 5. Nurse Progress Note dated April 18, 2023 @10:40 Doctor was notified of right index finger worsening, pictures sent. 6. Wound Assessment from wound doctor dated April 26, 2023, indicates . Reevaluate for Right fist digit wound from brace .Refer to surgical consult. (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: 056372 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 056372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Healthcare Center 105 Terracina Blvd. Redlands, CA 92373 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)