Health inspection·October 2, 2024

The following reflects the findings of the California Department of Public Health during the investigation of complaint number 898481. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Representing the Department: 39763, HFEN A deficiency was written for complaint #898481 at F-tag 656/G. F 656 42 CFR §483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. (3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (iii) Be culturally-competent and trauma-informed. On 5/16/24, at 10 a.m. an unannounced visit was conducted at the facility to investigate a complaint regarding a resident with pressure sores. Resident 1 was a 56 year-old male admitted to the facility on 8/6/21, with diagnoses including hemiplegia (muscle weakness or partial paralysis [unable to move body] on one side of the body that can affect the arms, legs, and facial muscles]) and hemiparesis (one-sided muscle weakness) following cerebral infraction (occurs as a result of disrupted blood flow to the brain and you may become paralyzed on one side of the body, or lose control of certain muscles) affecting right dominant (ruling or governing) side, other symptoms and signs involving cognitive functions (such as attention, memory, and executive functions [reasoning, planning, problem solving, and multitasking]), following unspecified cerebrovascular disease (a variety of medical conditions that affect the blood vessels of the brain and the circulation [movement of blood] in the brain), unspecified severe protein calorie malnutrition (refers to a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), nutritional deficiency (occurs when the body is not getting enough nutrients such as vitamins and minerals) and need for assistance with personal care. Based on observation, interview, and record review, the facility failed to develop and implement a care plan (CP- documents the resident's needs based on an identified problem, documents interventions necessary to be implemented by the whole healthcare team to meet the established goal) for one sampled resident (Resident 1) identified as a high risk for developing pressure injuries (PI- is localized damage to the skin and underlying soft tissue usually over a bony prominence). This failure resulted in Resident 1 developing Deep Tissue Injury (DTI - intact or non-intact skin with localized area of persistent non-blanchable [the skin does not turn white when touched with a finger] deep red, maroon, purple discoloration or epidermal [outer layer of skin] separation revealing a dark wound bed or blood-filled blister [raised skin filled with fluid]) to the left foot, a blister to right heel, and an unstageable PI (obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the PI cannot be confirmed because it is obscured by slough [yellow or white material consisting of dead cells which attaches to the wound bed] or eschar [dead tissue that forms over healthy skin]. If slough or eschar is removed, a Stage 3 [Full-thickness loss of skin, in which adipose (fat) is visible] or Stage 4 [Full-thickness skin and tissue loss with exposed muscle, tendon [flexible tissue, similar to a rope], ligament [a band of tissue that connects bones, joints or organs], cartilage [a strong, flexible connective tissue that protects joints and bones] or bone are visible in the pressure injury] are revealed) to the coccyx (tailbone). During an observation on 5/16/24 at 10:13 a.m., outside of Resident 1's room, Resident 1 was observed lying on his bed. Resident 1 was on his right side facing the wall with a lightweight blanket draped across his body. Resident 1 had pillows elevating his legs with his heels floating above the bed. During a concurrent observation and interview on 5/16/24 at 1:03 p.m. with Certified Nursing Assistant (CNA 3), outside Resident 1's room, Resident 1 was noted on his right side facing the wall with a lightweight blanket draped across his body. Resident 1 had pillows elevating his legs with his heels floating above the bed. CNA 3 stated she was assigned to care for Resident 1. CNA 3 stated Resident 1 was dependent with activities of daily living (ADLs - daily basic tasks such as bathing, dressing, toileting, and eating) and she stated Resident 1 had multiple sores (referring to PIs). There was no meal tray noted in Resident 1's room. CNA 3 confirmed Resident 1 did not have a meal tray in his room and Resident 1 was not assisted with lunch. CNA 3 stated the last time she checked Resident 1 was at 10 a.m. CNA 3 stated she was assigned to the dining room for the lunch meal service. CNA 3 stated "No one covers (no staff would assist Resident 1 with ADLs) while I'm on break or when I'm assigned in the dining room." CNA 3 confirmed Resident 1 was in the same position she left him in at 10 a.m. (3 hours). During a review of Resident 1' s quarterly "Minimum Data Set," (MDS- a standardized assessment tool used to evaluate the health and functional abilities of residents in nursing homes) dated 2/13/24, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status- an assessment of cognition [mental processes including perception, memory, and thought]) score was 4 (a score of 0-7 indicates resident has severely impaired cognition). The MDS indicated Resident 1 was dependent on staff for eating, toilet hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement), rolling in bed, moving from a lying to sitting position in bed, and transferring from bed to chair or chair to bed. During a review of Resident 1's "Braden Scale for Predicting Pressure Ulcer Risk Evaluation," (Braden Scale measures a patient's risk of developing a PI) dated 2/27/24, indicated Resident 1 scored 12 (score of 10-12 indicates the resident is a high risk for developing a pressure injury). During a review of Resident 1's "Nutrition/Dietary Note," (NDN) dated 4/12/24, the NDN indicated Resident 1's current weight was a 125 pounds on 4/5/24 in comparison to 141 pounds on 3/3/24 (16 pounds and 11.3% weight loss in approximately one month). The NDN indicated, "Significant weight loss at 1 mo (month) and 6 mo is unplanned and undesired. . .Diet: regular diet (general or normal diet), regular texture, thin liquids . . . (Resident 1) continues with GT (gastrostomy tube is a tube inserted through the wall of the abdomen directly into the stomach to provide nutrition and fluids directly to the stomach) in place . . . This writer visited (Resident 1) this morning. . . (Resident 1) has a thin appearance and muscle wasting (loss of muscle mass) to bilateral calf muscles. (Resident 1) eats better at lunch and dinner, (sic) and is assisted with meals but eats slowly. . .Due to significant weight losses; (sic) recommended restart enteral feedings (tube feeding delivers liquid nutrition through a flexible tube that goes directly into the stomach) for nocturnal feedings (when the tube feeding is done overnight). Recommended Jevity 1.5 (is calorically dense, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) @ (at) 65 cc (cubic centimeters- unit of measure)/hr. (hour) x.(times) 12 hours. . . Goal: Enteral feeding/PO (by mouth) intakes to meet estimated nutritional needs; maintain adequate hydration status; improve skin integrity; no significant weight variance (changes in weight)." During a review of Resident 1's "SBAR (situation, background, appearance, and review) Communication Form," (SBAR) dated 4/20/24, the SBAR indicated, "Wound Nurse notified me Resident has a new DTI in left foot (4/20/24)." During a review of Resident 1's "SBAR," dated 4/25/24, the SBAR indicated Resident 1 had a blister to right heel (4/25/24). During a review of Resident 1's "SBAR," dated 4/26/24, the SBAR indicated, "(Resident 1) noted to have a 4.2x3utd [sic] (unable to determine) pressure injury to coccyx today (4/26/24). . ." During a review of Resident 1's "SBAR," dated 4/28/24, the SBAR indicated, "(Resident1) continues to be on monitoring for unstageable pressure injury to the coccyx, and blister to left heel, (Resident 1) turned and repositioned every 2 hours as tolerated." During a review of Resident 1's "SBAR," dated 5/3/24, the SBAR indicated, "Assessed by Wound Specialist with MD orders: left posterior (back) heel unstageable (4/28/24), left lateral (to the side of, or away from, the middle of the body) plantar (the thick tissue on the bottom of the foot) foot DTI larger (4/20/24), Coccyx clarified to sacrococcyx (the fused sacrum [a triangular bone in the lower back] and coccyx) unstageable and larger (4/26/24), right heel clear fluid bister now DTI and larger (4/25/24)". During a review of Resident 1's "NDN," dated 5/12/24, the NDN indicated the following weights for Resident 1: 11/1/23 - 144.6 pounds (lbs) 2/3/24 - 141.4 lbs 4/5/24 - 125 lbs 4/26/24 - 127.8 5/3/24 - 116.5 lbs (11.3 lbs, 8.9% weight loss in 1 week; 24.9 lbs, 17.6% in 3 months; 28.1 lbs, 19.4% in 6 months). The NDN dated 5/12/24 indicated, "Skin: US (unstageable) to left posterior heel, Sacrococcyx. . . (Resident 1) was placed on nocturnal feedings & (and) has snacks bw (between) meals." During a concurrent interview and record review on 5/30/24 at 12:44 p.m. with Director of Nursing (DON), The SBAR dated 4/20/24, 4/25/24, and 4/26/24, were reviewed. DON confirmed Resident 1 developed three PIs while in the facility's care. DON stated Resident 1 also had a significant weight loss. Resident 1's active care plans (care plans CNAs were able to view in point of care (POC= electronic charting system), was reviewed. There was no care plan developed and implemented for PI prevention. DON confirmed the findings and stated Resident 1 was sent out to the acute hospital (2/5/24) and when Resident 1 was sent out, the nurses deactivated Resident 1's care plans. DON was informed Resident 1 had no lunch meal tray on 5/16/24. DON reviewed Resident 1's NDN dated 4/12/24 and 5/12/24, DON confirmed Resident 1 had orders to receive PO diet, snacks, and G-tube feedings. Resident 1's "Documentation Survey Report," DSR dated 4/2024 and 5/2024, was reviewed and there was no documentation Resident 1 was provided 65 out 177 meals. DON confirmed the findings and stated Resident 1 should get a regular diet and should get three meals a day. During a review of the facility's policy and procedure (P&P) titled, "Pressure Injury Prevention," revised September 1, 2020, the P&P indicated, "To provide interventions for Residents identified as high risk for developing pressure injuries Policy The licensed Nurse will develop a care plan that contains interventions for Residents who have risk factors for developing pressure injuries or for those Resident who have pressure injuries and at risk of developing additional pressure injuries. . .II. Regardless of the score, the Licensed Nurse will develop and individualized care plan for the Resident's risk factors in consultation with the following: . . .C. Registered Dietician . . .III. The nursing staff will implement interventions identified in the care plan which may include,(sic) but are not limited to the following: . . . B. Repositioning and turning C. Heel and elbow protectors . . . E. Off-loading pressure from heels . . . K. Monitoring food and fluid intake . . .VII. Licensed Nurses will document the effectiveness of the pressure injury prevention techniques in the Resident's medical record on a weekly basis A. Interventions that are not effective or that the resident refuses . . . C. The care plan will be initiated on admission and updated as necessary . . ." In violation of the above cited the facility failed to develop and implement a care plan for Resident 1 who was identified as a high risk for developing pressure injuries. This failure resulted in Resident 1 developing a DTI to the left foot, a blister to the right heel, and an unstageable PI to the coccyx. This violation has a direct or immediate relationship to the health, safety, or security of long-term health care facility resident other than class "AA" or "A" violations therefore this violation constitutes a "B" citation.