Health inspection·October 15, 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 consistent with the professional standards of practice to help prevent pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one of three sampled residents (Resident 1) by failing to ensure Resident 1's bilateral (both) heel protectors (device that can help prevent and treat heel pressure ulcer) were place on the resident's heels as ordered by the physician. Residents Affected - Few This deficient practice had the potential for development and worsening of Resident 1's pressure ulcer. Findings: During a review of Resident 1's admission Record, the admission Record indicated that Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included respiratory failure (when lungs are unable to get enough oxygen into your blood) with hypoxia (body does not have enough oxygen to function normally), and type two (2) diabetes mellitus (high levels of sugar in the blood). During a review of Resident 1's Minimum Data Set (MDS -a federally mandated assessment tool), dated 7/23/2024, the MDS indicated that Resident 1 was cognitively impaired (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and dependent from staff for transfer, dressing, toilet use, personal hygiene, and bathing. During a review of Resident 1's Physician Order Summary Report, the Physician Order Summary Report indicated the following: a. Heel protectors for skin integrity management with an order date of 1/26/2024. During a concurrent observation and interview on 10/15/2024 at 11:35 a.m., with the Licensed Vocational Nurse 1 (LVN 1) and Certified Nurse Aide 1 (CNA 1), observed Resident 1 inside the resident's room in bed without heel protectors. CNA 1 stated that CNA 1 removed Resident 1's heel protectors earlier that day (10/15/24). During interview on 10/15/2024 at 4:15 p.m., with the Director of Nursing (DON), the DON stated that Resident 1 should have had bilateral heel protector placed as per the physician order to prevent possible further skin breakdown. During a review of the facility`s policy and procedure, titled Pressure Sore Management, dated Page 1 of 2 056412 056412 10/15/2024 Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335

F 0686 3/2024, the facility policy indicated that all available measures shall be taken to reduce skin breakdown and pressure sores. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056412 Page 2 of 2