Health inspection·December 18, 2025

F600: §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

F658: §483.21(b)(3)(i) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality.

F686: §483.25(b)(1)(i)(ii) (b) Skin Integrity (b)(1) Pressure ulcers Based on the comprehensive assessment of a resident, the facility must ensure that- 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 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. Title 22: § 72311(a)(2) Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. Title 22: § 72311(a)(3)(A) Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (A) The admission of a patient. Title 22: § 72311(a)(3)(B) Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. Title 22: § 72311(a)(3)(C) Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (C) An unusual occurrence, as provided in Section 72541, involving a patient. Title 22: § 72315(f)(1) Nursing Service - Patient Care (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (1) Changing position of bedfast and chairfast patients with preventive skin care in accordance with the needs of the patient. Title 22: § 72315(f)(2) Nursing Service - Patient Care (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (2) Encouraging, assisting and training in self-care and activities of daily living. Title 22: § 72315(f)(3) Nursing Service - Patient Care (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (3) Maintaining proper body alignment and joint movement to prevent contractures and deformities. Title 22: § 72315(f)(4) Nursing Service - Patient Care (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (4) Using pressure-reducing devices where indicated. Title 22: § 72315(f)(5) Nursing Service - Patient Care (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (5) Providing care to maintain clean, dry skin free from feces and urine. Title 22: § 72315(f)(6) Nursing Service - Patient Care (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (6) Changing of linens and other items in contact with the patient, as necessary, to maintain a clean, dry skin free from feces and urine. Title 22: § 72315(f)(7) Nursing Service - Patient Care (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (7) Carrying out of physician's orders for treatment of decubitus ulcers. The facility shall notify the physician when a decubitus ulcer first occurs, as well as when treatment is not effective, and shall document such notification as required in Section 72311(b). FINDINGS: On 11/23/2020 at 11:45 a.m., the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate two complaints about quality of care. The facility failed to provide treatment and care in accordance with the comprehensive plan of care and professional standards of practice to a resident who was dependent on staff for care. Specifically, the facility failed to provide: 1. reliable wound assessments; 2. a Physician and/or NP (Nurse Practitioner) to assess a worsening pressure ulcer (PU: Sore on the skin) in a timely manner; and, 3. implementation of a pressure ulcer (PU: Sore on the skin) care plan at the onset of a PU for one of four sampled residents (Resident 1), to prevent a facility-acquired PU located at the coccyx (tailbone), from worsening. The failures further included: 1. Failure to identify inconsistencies between the facility's electronic medical records titled "Wound - Weekly Wound Observation Tool" and "Skin Integrity Sheet 'Change of Wound Condition'" assessments, and NP B's PU assessment. In addition, the actual dates of when the nurses completed the wound assessments were not the same as when the nurses signed off on the assessments; 2. Failure to start a "PU" care plan until Resident 1's PU was assessed at a Stage 3 (Sore extends into the tissue beneath the skin, forming a small crater. Fat may show, but not muscle, tendon, or bone), which as a result prevented prevention interventions from being started sooner; and, 3. Failure to ensure Resident 1's NP, who assessed Resident 1's facility- acquired PU as a Stage 1 (intact skin with non-blanchable redness of a localized area), assessed Resident 1's worsening PU, until the PU was a Stage 4 (a large wound in which the skin is significantly damaged. Muscle, bone, and tendons may be visible through a hole in the skin). 4. Failure to adhere to the facility's own Policies and Procedures (P&P), including without limitation the P&P concerning Comprehensive Care Plans, and pressure ulcers. These failures resulted in the formation of Resident 1's facility-acquired PU, and that PU worsening to Stage 4. This led to Resident 1 becoming septic (an infection of the blood stream) and being transferred to the acute care facility, where Resident 1 underwent surgical debridement (removal of dead or infected skin tissue) of the wounds, was placed on hospice (end of life care), and subsequently passed away. A review of Resident 1's, "Admission Record," dated 4/19/20, indicated Resident 1 was admitted to the facility on 4/19/20, with diagnoses including: Major depression, unspecified psychosis (person's thoughts and perceptions are disturbed and the individual may have difficulty understanding what is real and what is not), high blood pressure, Type 2 Diabetes (An impairment in the way the body regulates and uses sugar as a fuel. This long-term condition results in too much sugar circulating in the bloodstream, which can lead to disorders of the circulatory, nervous and immune systems), retention of urine, anxiety, muscle weakness, and Raynaud's Syndrome (smaller arteries that supply blood to your skin narrow, limiting blood circulation, causing numbness and coldness in response to cold temperatures or stress) ... Resident 1's Admission Record did not indicate a diagnosis of pressure ulcers. A review of Resident 1's, "History and Physical," dated 4/20/20, indicated Resident 1 was at an acute care facility from 4/14/20 to 4/19/20, due to cellulitis (bacterial skin infection) of her right hand, due to a cat bite. Resident 1 was transferred to the Skilled Nursing Facility, short-term, for physical therapy, and to monitor her right- hand cellulitis and urine retention. Resident 1 was ambulatory (walked) with the use of assistive equipment, a walker or cane. There was no indication of a PU. A review of Resident 1's, "Baseline Care Plan," dated 4/19/20, indicated Resident 1 needed one-person physical assist with personal hygiene, toilet use, dressing, and bed mobility. Resident 1 needed set-up help for eating. A review of Resident 1's, "Braden Scale (predicts PU risk)," upon admission, dated 4/19/20, indicated she was not at risk for pressure ulcers. A review of Resident 1's Braden Scale, dated 4/26/20, indicated Resident 1 was at risk for pressure ulcers. There was no indication Resident 1 had a PU. During a concurrent interview and record review on 2/23/21 at 2:05 p.m., and 4/22/21 at 12:09 p.m., the following information was obtained: a. Resident 1's electronic, "Skin Integrity Sheets," effective date, 7/30/20, and "Wound - Weekly Observation Tool," effective dates, 8/7/20, 8/14/20, 8/21/20, 8/28/20, and 9/11/20, indicated Resident 1's PU wound to her coccyx was assessed as an abrasion, epithelial tissue was pink in color and moist, and the length ranging from 1.0 cm (centimeter) to 1.5 cm x width ranging from 0.03 cm to 0.05 cm. The wound assessment sheets dated 7/30/20, 8/7/20, 8/14/20, 8/21/20, and 8/28/20, were signed on 11/3/20, by Resident Care Coordinator (RCC) I. The wound assessment sheet dated 9/11/20, was signed on 11/3/20, by Licensed Staff D. Resident 1 was transferred to the acute care facility on 10/26/20, Resident 1's, "Wound - Weekly Observation Tool," effective date 9/18/20, indicated Resident 1's wound was a Stage 2 PU (an intact blister or a shallow open sore, which are often red or pink and surrounded by red and pink irritated skin. These sores can be moist if pus or fluid is present). The wound assessment sheet was signed on 11/2/20, by Licensed Staff G, after Resident 1 was transferred to the acute care facility on 10/26/20, b. The "Wound - Weekly Observation Tool," effective dates 10/1/20 and 10/21/20, indicated Resident 1's PU was a Stage 3, length ranging from 1.5 cm to 3.5 cm x width ranging from 0.5 cm to 2 cm. The wound assessment sheet, dated 10/1/20, was signed on 10/27/20, by RCC E. The wound assessment sheet, dated 10/21/20, was signed on 10/27/20, by Licensed Staff C. Resident 1 was transferred to the acute care facility on 10/26/20, c. The "Skin Integrity Sheet," effective date 10/8/20, indicated Resident 1 had three new wounds on the right buttocks, total circumference of 6 cm x 6.6 cm because of, "Moisture Associated Skin Damage [MASD (inflammation of the skin caused by prolonged exposure to urine, stool...)]." The wound assessment sheet was signed on 10/27/20, by RCC I, after Resident 1 was transferred to the acute care facility on 10/26/20, and d. The "Skin Integrity Sheet," effective date 10/14/20, indicated Resident 1's right buttocks wounds were because of MASD; the length ranging from 0.5 cm to 4.4 cm x width ranging from 0.8 cm to 5 cm. The wound sheet was signed on 11/1/20, by Licensed Staff C, after Resident 1 was transferred to the acute care facility on 10/26/20. The DON (Director of Nursing) stated the irregularities of the "Wound - Weekly Observation Tool" and "Skin Integrity Sheets" effective dates and the date the documents were signed could be due to late entries or because the documents were opened in the software system but not locked (closed) until a later date. During an interview on 4/21/21 at 12:43 p.m., Licensed Staff G stated, if the nurse's signature date on a, "Wound - Weekly Observation Tool," was not the same as the effective date, one of two things occurred; the nurse forgot to close out of the software after they finished their documentation or, the nurse never finished the assessment until the lock date (signature date/closed date). Licensed Staff G stated the date the "Wound - Weekly Observation Tool," was signed, was the date the wound assessment was completed. During an interview on 4/22/21 at 5:54 p.m., RCC I stated, when he did resident wound assessments, he used a facility in-house wound form. RCC I stated he must have inputted his data on the "Wound - Weekly Observation Tool" and "Skin Integrity Sheet," software forms late, causing the irregularities of the effective dates and the date the documents were signed. RCC I stated he would then give the in-house wound forms to the Administrator, DON, and the Minimum Data Set (MDS--an assessment tool) Coordinator. During interviews on 2/22/21 at 12:05 p.m., 2/23/21 at 2:05 p.m., 4/7/21 at 10:12 p.m., and 4/22/21 at 12:09 p.m., when the Administrator and DON were asked about the wound assessment date irregularities, they did not mention there was an in-house wound form given to them by the treatment nurse. The facility did not provide any additional wound forms to verify Resident 1's PU assessments were completed on the effective date. A review of Resident 1's, "NP B Progress Note," dated 9/29/20, indicated Resident 1 had been ambulating 110 ft. with a front-wheeled walker while on short-term services, but since she was transferred to long-term services, Resident 1 had progressive deconditioning (physical change). Resident 1 was now bed-bound and had a Stage 1 decubitus ulcer (injury to the skin and its underlying tissue due to prolonged pressure on it). During a concurrent interview and record review on 4/6/21 at 3:31 p.m., Resident 1's, "Wound - Weekly Observation Tool," dated 9/18/20, indicated Resident 1's facility-acquired PU, located on her coccyx, had worsened to a Stage 2. Resident 1's, "Wound - Weekly observation Tool," dated 9/25/20 and 10/1/20, indicated Resident 1's PU was assessed at a Stage 3. Resident 1's, "Skin Integrity Sheet," dated 10/1/20, indicated Resident 1's PU was assessed at a Stage 3. NP B stated that, on 9/29/20, he did a physical assessment on Resident 1 and assessed her facility- acquired PU at a Stage 1. "If the nurses documented anything other than a Stage 1 on 9/18/20, 9/25/20, and 10/1/20, they were wrong in their assessments." NP B stated the nurses' assessments were inaccurate. During an interview and record review on 4/6/21 at 5:09 p.m., the DON stated the treatment nurse was not wound-certified. When the treatment nurse was off, other nurses would do the "Weekly Wound Assessments," and they were also not wound-certified. A review of Resident 1's, "Skin Integrity Sheet," effective date 7/30/20, indicated Resident 1 had developed a Stage 1 PU. Per review of Resident 1's care plan, nursing effective (x) staff did not create a care plan for a PU until 10/1/20, when Resident 1's PU was assessed at a Stage 3. During an interview on 4/21/21 at 1:50 p.m., Physician A stated he oversaw NP B. Physician A stated, if NP B documented Resident 1's PU was a Stage 1, then it was a Stage 1. Physician A stated he believed NP B knew the difference between a Stage 1, Stage 2, and Stage 3 PU. Physician A stated it would be very rare that a PU went from a Stage 1 to a Stage 3 in two days (9/29/20 to 10/1/20). The facility job description titled, "Department Supervision," revision 8/2006, indicated: "4. The DON Services and/or the Nurse Supervisor/Charge Nurse, as a minimum, is responsible for: a. Making daily resident visits to observe and evaluate the resident's physical and emotional status ... c. Reviewing individual resident care plans for appropriate goals, approaches, and revisions based on nursing needs; d. Assuring that the resident's plan of care is being followed ... g. Charting and documenting medical records as necessary; h. Keeping nursing service personnel informed of status of the residents and other related matters through written reports ..." The facility job description titled, "Director of Nursing Services," revised 8/2006. "... n. Assuring that nursing care personnel are administering care and service