Other·June 12, 2019

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 standard survey. Complaint # CA00587473. The investigation was limited to the specific complaint and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Health Facilities Evaluator Nurse 38542. A deficiency was identified from this investigation. GLOSSARY: ADL: Activities of Daily Living Cm: centimeter CNA: Certified Nurse Assistant DON: Director of Nursing ED: Emergency Department LN: Licensed Nurse MASD: Moisture-Associated Skin Damage MD: Medical Doctor MDS: Minimum Data Set r/t: related to SBAR: Situation Background Appearance Review and Notify TAR: Treatment Administration Record

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 06/10/2019 SS=D CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity 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: 89NE11 Facility ID: CA080000107 If continuation sheet 1 of 7 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: _______________ 555873 (X3) DATE SURVEY COMPLETED 05/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SOUTH BAY POST ACUTE CARE 553 F St Chula Vista, CA 91910 (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 §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a licensed nurse performed and documented a complete skin assessment and developed a care plan for one of three sampled Residents (Resident 1) who was identified with a new skin issue. As a result, Resident 1, who was admitted at low risk for developing a pressure ulcer (skin injury caused by pressure), developed two unstageable wounds to her buttocks that twice required debridement (surgical removal of damaged tissue) in the hospital and treatment with antibiotics and a wound vacuum (an apparatus used to suction excess fluids from a wound). Resident 1, a 62-year old female, was admitted to the facility on 4/2/18, with diagnoses which included diabetes mellitus (high blood sugar level), morbid obesity (very overweight), and the need for assistance with personal care, per the facility's Admission Record. Resident 1 was admitted to the facility for skilled therapy services, per the facility's Admission Note. On 6/11/18, a record review of Resident 1's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 89NE11 Facility ID: CA080000107 If continuation sheet 2 of 7 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: _______________ 555873 (X3) DATE SURVEY COMPLETED 05/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SOUTH BAY POST ACUTE CARE 553 F St Chula Vista, CA 91910 (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 clinical records was conducted. According to documentation on the Initial Admission Record, dated 4/2/18, Resident 1 had no skin problems on admission. Also on 4/2/18, nursing assessed Resident 1 using the Braden Scale for Predicting Pressure Sore Risk. According to the assessment, the resident scored 17 indicating she was at low risk for developing a pressure ulcer. Nursing initiated a care plan on 4/2/18 for potential/actual impairment to skin integrity r/t decreased mobility. Interventions listed on the plan included, educate resident/family/caregivers of causative factors and measures to prevent skin injury; encourage good nutrition and hydration in order to promote healthier skin; and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. There were no listed interventions to monitor the resident's skin for signs of skin breakdown. On 4/9/18, nursing assessed Resident 1's abilities to perform her ADLs and her skin condition using the MDS assessment tool. Per the documentation, Resident 1 required one person to assist with her ADLs and was assessed to be at risk for developing pressure ulcers. Based on nursing weekly summaries from 4/3/18 to 4/28/18, there was no documentation to show the resident had any skin breakdown. On 4/29/18, the CNA documented, "some redness on bottom, applied barrier cream." There was no documentation to show the CNA notified nursing, nursing assessed the resident, notified the resident's physician, or developed a new care plan to address the problem. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 89NE11 Facility ID: CA080000107 If continuation sheet 3 of 7 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: _______________ 555873 (X3) DATE SURVEY COMPLETED 05/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SOUTH BAY POST ACUTE CARE 553 F St Chula Vista, CA 91910 (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 4/30/18, LN 6 documented in the Progress Notes the resident's daughter alerted nursing the resident had, "a rash of very small red dots" all over her body. LN 6 documented, in the same note, she examined the resident and noted the rash was dispersed and scattered to all the resident's extremities and trunk. Nursing initiated a new care plan for the rash on 4/30/18. Interventions included, monitor skin rashes for increased spread or signs of infection. There was no documentation to show nursing assessed the redness on the resident's bottom, identified the day before by the CNA. The next documentation related to the resident's skin on her bottom, was on 5/10/18, ten days later, when the resident's physician gave LN 1 a telephone order to treat both Resident 1's buttocks with Venelex (Trademark), (a medication used to treat pressure sores) once a day for MASD (skin damage caused by moisture). LN 1 failed to document an assessment of Resident 1's skin, including the location, description and measurement of the affected areas. Nursing did not develop a care plan for the MASD. LN 5 completed the Licensed Nurse Weekly Summary on 5/13/18. Under Section 9 Skin Condition, LN 5 documented, "generalized petechial rash MASD", and checked, "free of any open areas", but failed to document the treatment ordered to the MASD or an assessment of the resident's buttocks for a response to the treatment. Although three different nurses, LNs 1, 7 and 8 signed the TAR to say they treated the resident's buttocks as ordered, from 5/10/18 to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 89NE11 Facility ID: CA080000107 If continuation sheet 4 of 7 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: _______________ 555873 (X3) DATE SURVEY COMPLETED 05/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SOUTH BAY POST ACUTE CARE 553 F St Chula Vista, CA 91910 (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 5/14/18, there was no documentation to show nursing assessed the area for response to the treatment. LNs 7 and 8 were unavailable for interview at the time of the investigation. On 5/14/18, Resident 1 was transferred to the hospital for altered mental status and hypoglycemia (low blood sugar), as documented on the facility's SBAR Communication Form (an assessment tool to describe a change in a resident's condition). According to the Emergency/Urgent Care Center Department Nursing Flowsheet, dated 5/14/18 at 3:55 P.M., the goal for maintaining baseline skin integrity in the ED was met, with no skin breakdown; however, on 1/16/18 at 10:13 A.M., during an interview with the ED nurse, she stated she did not conduct a head to toe skin assessment including assessment of the resident's skin on her buttocks. Resident 1 was admitted to the hospital from the ED on 5/14/18. The hospital's Pressure Ulcer Flowsheet Summary Report, dated 5/14/18 at 11 P.M., indicated Resident 1 had a 13 cm x 15 cm pressure ulcer on the left buttock and an 11 cm x 13 cm pressure ulcer on the right buttock which were unstageable and were present on admission to the hospital. On 5/21/18, Resident 1 had excisional debridement (surgery to remove damaged tissue) of her sacral (buttock) decubitus ulcer (pressure ulcer). The debrided tissue measured 15 cm x 15 cm and at its deepest level was at the level of the muscle. On 5/24/18, Resident 1 was re-admitted to the facility. The Admission Note, dated 5/25/18, indicated Resident 1 was readmitted to the facility with a pressure ulcer on the buttocks with a wound vacuum. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 89NE11 Facility ID: CA080000107 If continuation sheet 5 of 7 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: _______________ 555873 (X3) DATE SURVEY COMPLETED 05/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SOUTH BAY POST ACUTE CARE 553 F St Chula Vista, CA 91910 (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 6/6/18, Resident 1 was re-admitted to the hospital. Admitting diagnoses included, "Large gluteal (buttocks) decubitus ulcer, on antibiotics, with evidence of necrotic tissue," per the Transfer Summary, dated 7/2/18. Per the same document, Resident 1 underwent a second surgical debridement on 6/8/18. On 6/18/18 at 2:57 P.M., a joint interview and record review of Resident 1's clinical records was conducted with DON 1. DON 1 confirmed Resident 1 had no MASD or any skin breakdown on the sacral area on initial admission. DON 1 stated nursing did not document an assessment or progress note when the skin breakdown was discovered, nor did they develop a care plan. DON 1 also stated nursing did not bring Resident 1's skin issue to his attention and there was no interdisciplinary team meeting to discuss how to manage the resident's identified MASD. DON 1 stated, a care plan should have been developed for Resident 1's skin issue. On 8/20/18 at 3:12 P.M., an interview with LN 2 was conducted. LN 2 stated when there was a diagnosis of MASD, nursing should have developed a care plan. On 1/14/19 at 11:33 A.M., an interview with CNA 1 was conducted. CNA 1 stated on initial admission, Resident 1 did not have a "bed sore", and, was able to do a lot for herself. CNA 1 also stated when Resident 1 came back from hospitalization, Resident 1 needed extensive assistance and was totally dependent on repositioning and for any movement. According to CNA 1, Resident 1 was, "in pain whenever there was pressure on the pressure ulcer area" and that, "bothered" Resident 1. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 89NE11 Facility ID: CA080000107 If continuation sheet 6 of 7 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: _______________ 555873 (X3) DATE SURVEY COMPLETED 05/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SOUTH BAY POST ACUTE CARE 553 F St Chula Vista, CA 91910 (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 1/16/19 at 10:25 A.M., an interview with the surgeon (MD 1) who performed the surgical debridement of Resident 1's pressure ulcer was conducted. MD 1 stated Resident 1's pressure ulcer was deep and to the level of the muscle when debridement was done on 5/21/18. MD 1 stated debridement was again done on 6/8/18 and 6/17/18 and both times, the debridement went to the level of the bone because it was exposed and MD 1 had to make sure it was not osteomyelitis (infection of the bone). MD 1 also stated, the pressure ulcer could not have developed from the ED to the treatment floor. MD 1 stated Resident 1's pressure ulcer developed at the nursing facility. On 1/23/19 at 5:30 P.M., an interview with DON 2 was conducted. DON 2 stated Resident 1's skin condition could not have developed from MASD to unstageable from the time Resident 1 was discharged from the ED to admission to the hospital's treatment floor. Per the facility's policy titled Resident Assessment- Facility Acquired Skin Management System, " ...Procedures: 1. If a resident is noticed with any new skin issues, ...a head to toe assessment by a licensed nurse will be performed ...2. A plan care of care will also be initiated to address areas of actual skin breakdown ...6. A Skin Integrity Committee will be in place..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 89NE11 Facility ID: CA080000107 If continuation sheet 7 of 7