Other·December 20, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for the investigation of a complaint. Complaint number: CA00496408 Category: Quality of Care/Treatment. See F314. Representing the California Department of Public Health: Health Facilities Evaluator Nurse 36709. Inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

F314 SS=D TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES CFR(s): 483.25(c)

F314 Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to: LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OJKN11 Facility ID: CA080000029 If continuation sheet 1 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055505 (X3) DATE SURVEY COMPLETED 11/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROYO VISTA NURSING CENTER 3022 45th St San Diego, CA 92105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE a) Create a plan of care related to the increased risk an immobilizer on Resident 54's right leg posed to the development of pressure ulcers. When nursing noted the resident had a wound on the back of her leg, they failed to implement measures to prevent further skin breakdown related to the use of the immobilizer. b) Implement the plan of care to prevent skin breakdown on Resident 54's heels and buttocks and failed to review and revise Resident 54's plan of care once the resident developed skin breakdown. As a result, Resident 54 developed pressure ulcers on the outside of her right lower leg, top of the right foot, right buttock, and right heel requiring hospitalization for treatment of the wounds. a) Resident 54 was admitted to the facility on 9/19/15 with diagnoses that included peripheral vascular disease (blood circulation disorder) and history of fall with fracture (broken bone), per the facility's Admission Record. According to Resident 54's nursing admission note, dated 9/19/15, Resident 54 had, "...Redness on coccyx (tailbone) area. With immobilizer on right leg..." An immobilizer used for a femur (thighbone) fracture would extend from the resident's ankle to above her knee to her thigh. According to Resident 54's record titled, Norton Plus Pressure Ulcer Scale (a tool used to measure risk to develop pressure ulcers), dated 9/19/15, the resident was at high risk to develop pressure ulcers. Nursing initiated a care plan for Resident 54's risk for skin breakdown related to immobility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OJKN11 Facility ID: CA080000029 If continuation sheet 2 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055505 (X3) DATE SURVEY COMPLETED 11/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROYO VISTA NURSING CENTER 3022 45th St San Diego, CA 92105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and incontinence on 9/19/15 but did not develop a care plan for the risk for developing a pressure ulcer from the immobilizer on her right leg. On 9/24/15, Resident 54's physician ordered staff to assess the resident's right leg for skin integrity and circulation every shift. On 9/29/17, LN 2, documented on the NonPressure Sore Skin Problem Report, Resident 54 had a "purplish bruise" on the right lateral (side) lower leg that measured 4 centimeters (cm) by 2.5 cm. There was no documentation to show nursing considered the bruise on the back of her leg may have been a suspected deep tissue injury (SDTI) caused by pressure from the leg immobilizer. A deep tissue injury is a pressure related injury to the tissue under intact skin that initially has the appearance of a bruise. There was no documentation to show nursing notified Resident 54's physician of the resident's "bruise" on her right lower leg on 9/29/15. Nursing did not initiate a care plan for the identified "bruise". According to Resident 54's Change of Condition note, dated 10/1/15 at 9:40 A.M. by LN 1, the resident had, " ...Open area behind right leg ... Wound bed is beefy red... Immobilizer in place on right leg..." Nursing notified the resident's physician who ordered a daily application of antibiotic ointment to the area until it was healed. There was no documentation to show nursing informed the resident's physician the wound may have been caused by pressure from the immobilizer. The interdisciplinary team (IDT) Skin Committee met on 10/9/15 and documented Resident 54 was, "...Regarding the open FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OJKN11 Facility ID: CA080000029 If continuation sheet 3 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055505 (X3) DATE SURVEY COMPLETED 11/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROYO VISTA NURSING CENTER 3022 45th St San Diego, CA 92105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE wound behind her right leg noted on 10/1/15... Resident unable to tell how she got the wound. Pt (patient/resident) is using right leg immobilizer secondary to her right femur fracture. IDT recommends to cont (continue) current treatment..." There was no documentation to show the IDT discussed pressure from the leg immobilizer was a possible cause of the resident's wound behind her leg. The IDT failed to develop a care plan for the "bruise" identified on 9/29/15, which developed into a "wound" on 10/1/15. On 10/20/15, Resident 54's "bruise" on the right lateral lower leg measured 4 cm by 1.5 cm and was covered by, "100% yellow slough (non-viable tissue indicative of a pressure ulcer), per documentation on the Non-Pressure Sore Skin Problem Report: Weekly Progress Report, completed by LN 2. There was no documentation to show the physician was notified of this change in the wound on the resident's leg, and there were no new treatment orders for the wound. According to Resident 54's Treatment Administration Record (TAR), for October 2015 and November 2015, nursing did not document they did the ordered treatments to the resident's right lower leg from 10/20/15 through 10/31/15. On 10/29/15, LN 2 noted a second "skin tear" according to Resident 54's record titled NonPressure Sore Skin Problem Report. This time, the wound was noted to be on the resident's, "...Right anterior (top) foot. 2 cm x (by) 1 cm, well approximated (wound edges close together), over the previous bruise, red wound bed..." The resident's physician was notified and ordered, the resident's "skin tear" was to be cleansed, treated with antibiotic ointment, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OJKN11 Facility ID: CA080000029 If continuation sheet 4 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055505 (X3) DATE SURVEY COMPLETED 11/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROYO VISTA NURSING CENTER 3022 45th St San Diego, CA 92105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and covered every day until healed. Nursing again failed to identify the leg immobilizer as a possible cause for this new wound. Nursing developed a care plan for Resident 54's "skin tear" on her right anterior leg, dated 10/29/15. LN 2 documented on 11/3/15 the resident's "skin tear" on her right foot measured 4.5 cm x 4 cm with, "...70% red tissue [with] 30% yellowish adherent slough... small amount of serosanguineous exudate (watery bloody drainage) ..." LN 2 completed Resident 54's IDT Skin Committee note, on 11/5/15, " ...On 10/29/15, noted a skin tear over a bruise on the resident's right anterior leg ... with a red wound bed ... Today the wound has increased in size ... IDT recommends to continue current treatment..." There was no documentation to show nursing notified the resident's physician of the increase in the size of the wound. According to Resident 54's record titled NonPressure Sore Skin Problem Report: Weekly Progress Report, completed by LN 2 on 11/10/15 the resident's right anterior leg "skin tear", the wound measured 4.5 cm x 6 cm with 75% slough. According to Resident 54's physician orders, dated 11/11/15, treatment for the resident's wound was changed from an antibiotic ointment to a debridement medicine to remove dead tissue from the wound on the, "anterior right leg open area." The facility failed to revise the care plan when the wound did not respond to treatment and the orders were changed on 11/11/15. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OJKN11 Facility ID: CA080000029 If continuation sheet 5 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055505 (X3) DATE SURVEY COMPLETED 11/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROYO VISTA NURSING CENTER 3022 45th St San Diego, CA 92105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 11/17/15, one week later, LN 2 completed a Change of Condition Note, " ...Open area on the right anterior foot has ... 50% necrotic tissue. Resident was complaining of pain whenever her right leg is touched ..." The DSD (Director of Staff Development) was interviewed on 2/23/17 at 2:40 P.M. After reviewing Resident 54's wound report, dated 10/29/15, the DSD stated, "This is not a skin tear, it is a medical device induced wound Stage III". A Stage III wound is a full thickness loss of skin where fatty tissue is visible in the ulcer. A concurrent interview and record review was conducted with LN 3 on 3/3/17 at 11:58 A.M. LN 3 stated Resident 54's leg immobilizer increased the resident's risk for pressure ulcers. LN 3 stated the progression of the wound on Resident 54's right lateral lower leg was descriptive of a Suspected Deep Tissue Injury (SDTI). LN 3 stated, "Bruises don't open." LN 3 stated a pressure ulcer was usually first identified as redness, a blister or loss of skin before the wound developed 100% slough. A concurrent interview and record review was conducted with the shower aide on 3/9/17 at 11:57 A.M. The shower aide stated she remembered Resident 54 and her brace was removed for showers. The shower aide stated, "I remember she (Resident 54) had pressure ulcers where the brace was." A concurrent interview and record review was conducted with the director of nursing (DON), on 8/16/17 at 12:35 P.M. The DON said Resident 54's record did not indicate interventions to prevent the development or worsening of pressure ulcers were implemented. The DON said Resident 54's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OJKN11 Facility ID: CA080000029 If continuation sheet 6 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055505 (X3) DATE SURVEY COMPLETED 11/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROYO VISTA NURSING CENTER 3022 45th St San Diego, CA 92105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE wounds were misidentified as a "bruise" and a "skin tear." The DON stated, "It's important to identify if a wound is a pressure ulcer for consistency and continuity of treatment." The DON acknowledged the treatment for Resident 54's right leg wound, ordered on 10/1/15, was not done from 10/20/15 to 10/31/15. The DON further stated, "If the doctor ordered a treatment it should be documented on the TAR, or in a progress note as to why it was not done." LNs 1 and 2 no longer worked at the facility and were unavailable for interview. According to the facility's policy titled Wound Care & (and) Treatment Guidelines, dated 5/07, "Policy: It is the policy of this facility to provide excellent wound care to promote healing... 13. Documentation of the treatment should be done immediately after the treatment... 14. The care plan should reflect the current status of the wound and appropriate goals." According to the facility's policy titled Skin Assessment, dated 5/07, "...Purpose: To identify residents at risk for skin breakdown and institute appropriate preventative measures. Procedures: ...4. The care plan will be updated and implemented based on the needs identified by the comprehensive assessment and the score on the pressure ulcer risk assessment form. 5. If skin breakdown is present, protocols for wound care will be followed." According to The National Pressure Ulcer Advisory Panel, 4/16, indicated, "...Medical device related pressure injuries result from the use of devices designed and applied for ...therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury would be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OJKN11 Facility ID: CA080000029 If continuation sheet 7 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055505 (X3) DATE SURVEY COMPLETED 11/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROYO VISTA NURSING CENTER 3022 45th St San Diego, CA 92105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE staged using the staging system..." (http://www.npuap.org/resources/educationaland-clinical-resources/npuap-pressure-injurystages/) b) On 9/19/15, when Resident 54 was admitted to the facility, nursing assessed the resident to be at high risk for pressure ulcers. Nursing initiated a care plan for the risk for skin breakdown related to immobility and incontinence. Interventions included to assist the resident in repositioning every two hours, and to float heels (placing pillows under the calves to relieve pressure from the heels lying in direct contact with the bed mattress). According to Resident 54's admission Minimum Data Set (MDS) assessment (an assessment of the resident's abilities), dated 9/25/15, Resident 54 required extensive assistance of two or more staff for bed mobility. Staff failed to document they turned and repositioned Resident 54 every two hours on 24 occasions between 9/19/15 and 10/3/15. Between 9/19/15 and 10/18/15, there was no documentation in the resident's record to show staff were offloading the resident's heels from the mattress to prevent breakdown to the resident's heels. On 10/18/15, LN 4 documented on a Change of Condition form, Resident 54 had, "...Purple skin discoloration, mushy, painful and warm to touch on right hell [sic] measuring 8 cm x 9 cm..." On Resident 54's Weekly Pressure Sore Report, on 10/18/15 nursing identified the wound on the resident's right heel as a suspected deep tissue injury (SDTI). On 10/18/15, Resident 54's physician ordered treatment to the resident's SDTI. Nursing was to cleanse the wound, apply Proderm (a topical spray that penetrates the top layer of skin and stimulates capillaries), and cover it every day FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OJKN11 Facility ID: CA080000029 If continuation sheet 8 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055505 (X3) DATE SURVEY COMPLETED 11/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROYO VISTA NURSING CENTER 3022 45th St San Diego, CA 92105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE until healed. Nursing initiated a care plan for Resident 54's SDTI on her right heel on 10/18/15. New interventions included an air loss mattress (ALmattress that contains air cells that inflate and deflate to relieve pressure points), which was ordered on 10/20/15. LN 2 documented on a Change of Condition form, on 10/20/15, Resident 54 had, "skin irritation" on both buttocks, "raw and reddened". Nursing failed to document measurements of the skin irritation to show the extent of the raw reddened areas on the resident's buttocks. The resident's physician ordered treatment with an anti-fungal medication to the resident's buttocks twice daily on 10/20/15. LN 2 completed Resident 54's IDT Skin Committee note, on 10/23/15, "Presented to IDT regarding the SDTI noted on 10/18/15 on the right heel and skin irritation noted on 10/18/15 on bilateral (both) inner buttocks... Resident alert and oriented x 1, not able to verbalize needs, requires extensive assist with bed mobility and repositioning..." No new interventions were added to the care plan. On 10/24/15, LN 2 documented on Resident 54's Weekly Pressure Sore Report on 10/24/15, the resident now had an unstageable pressure ulcer on her right buttock measuring 1 x 4.5 cm with 100% slough. An unstageable ulcer represents a full thickness tissue loss where the wound bed is covered by dead tissue that impedes healing. The resident's physician ordered treatment with a debridement agent (medication that breaks up and removes dead skin tissue), and covering every day until healed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OJKN11 Facility ID: CA080000029 If continuation sheet 9 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055505 (X3) DATE SURVEY COMPLETED 11/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROYO VISTA NURSING CENTER 3022 45th St San Diego, CA 92105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The next assessment of the pressure ulcer was documented on 11/3/15 showing the wound had not changed. LN 2 completed Resident 54's IDT Skin Committee note, on 11/5/15, and documented the resident's pressure sore on her buttocks was, " ...still same size today ..." On 11/10/15, over two weeks since the physician ordered the debridement agent, documentation on the pressure ulcer report showed the resident's wound remained the same. There was no documentation to show the physician was notified. On 11/17/15, LN 2 completed a Change of Condition Note for Resident 54. Per the note, " ...Resident's pressure ulcer on the right buttock was getting worst [sic]. Last week it was only 1 cm x 4.5 cm with 100% yellow adherent slough but today, it measures 6 cm x 3.5 cm x 0.8 cm with 50% black necrotic (dead) tissue and 50% yellow slough with moderate amount of serosanguineous exudate ..." According to the facility's policy titled Pressure Ulcer - Documentation, dated 5/07, "...Procedures ...A pressure ulcer sheet (Weekly Pressure Ulcer Report) will be started as soon as a pressure ulcer is identified ... Treatments ordered by the physician will be used for a two-week period. If no improvement, the physician will be called for an evaluation... Information regarding the presence of pressure ulcer must be transferred to the care plan. This must be done as soon as a pressure ulcer is identified..." Resident 54's physician was notified of the deterioration in the resident's wounds on 11/17/15 and gave orders to transfer the resident to the acute hospital. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OJKN11 Facility ID: CA080000029 If continuation sheet 10 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055505 (X3) DATE SURVEY COMPLETED 11/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROYO VISTA NURSING CENTER 3022 45th St San Diego, CA 92105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE An interview was conducted with the treatment nurse (LN 5) on 3/3/17 at 3:51 P.M. LN 5 said the resident's physician should have been notified of the status of the resident's wounds as she expected the physician would have changed the treatment orders. LNs 2 and 4 no longer worked at the facility and were unavailable for interview. According to Resident 54's Emergency Department Nursing Flowsheet, dated 11/17/15, the resident's chief complaint was increased necrotic right foot wound. According to Resident 54's acute hospital Pressure Ulcer Flowsheet Summary Report, dated 11/18/15, four pressure ulcers were present on admission to the hospital. 1. Pressure ulcer on right buttock was unstageable, wound was "black" and measured 4 x 2.4 cm. " ...Wound Care Note: recommend plastics consult as wound will need I&D (incision and drainage) ..." 2. Pressure ulcer dorsum (top) of right root was unstageable, wound was "Yellow/Blk (black)" and measured 4 x 4 x 0.5 cm. with small amount purulent (thick oozing- often associated with infection) drainage. 3. Pressure ulcer lateral lower right leg was Stage II, wound was "Red/Yellow" and measured 3 x 0.5 x 0.5 cm with small amount of purulent drainage. 4. Pressure ulcer on right heel was unstageable, wound was "Black" and measured 4 x 4 cm. Resident 54 was discharged from the hospital on 11/24/15, per the Discharge Summary. According to the summary, the resident was treated at the hospital for a right foot gangrenous ulcer, infected with MRSA FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OJKN11 Facility ID: CA080000029 If continuation sheet 11 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055505 (X3) DATE SURVEY COMPLETED 11/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARROYO VISTA NURSING CENTER 3022 45th St San Diego, CA 92105 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (methicillin resistant staphylococcus aureus) and pseudomonas and a right buttock ulcer, also infected with MRSA. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OJKN11 Facility ID: CA080000029 If continuation sheet 12 of 12