Health inspection·March 17, 2025

The following reflects the findings of the California Department of Public Health during the investigation of complaint number 922849. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. A deficiency was written for Complaint #922849 at F-tag 687/G. F687 Foot Care §483.25(b)(2) Foot care. To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must: (I) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and (ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments. On 10/9/24, an unannounced visit was conducted at the facility to investigate a complaint regarding resident provision of care and lack of follow up with a podiatrist. Based on observation, interview, and record review, the facility failed to ensure podiatry (the medical field that specializes in the diagnosis, treatment, and study of disorders affecting the foot, ankle, and lower leg) care and treatment for one of three sampled residents (Resident 1). This failure resulted in Resident 1 requiring surgical intervention (a procedure performed on the body to treat a medical condition) and Intravenous (IV - given through the vein) antibiotics (medicines that treat bacterial infections [invasion and growth of germs in the body] by killing bacteria or preventing them from reproducing) for the infection to his left (first and second toes) foot and right (fourth toe) foot. Resident 1 is a 61-year-old male who was admitted to the facility on 7/13/2023 and has a diagnosis history of Quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord [bone structure that supports your body] injury), Chronic Obstructive Pulmonary Disease (COPD - a chronic lung disease causing difficulty in breathing). Tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing), Diabetes Mellitus (DM - condition characterized by high blood sugar). During an interview on 10/9/24 at 8:50 a.m. with Family Member (FM) 1, FM 1 stated she had been asking the facility for almost a year to get Resident 1 seen by a podiatrist due to issues (not specific) with his left and right toenails. FM 1 stated, "I never got a response" and Resident 1 was "finally," seen by a podiatrist recently (9/25/24) and was diagnosed with three ingrown toenails (occurs when the toenail grows into the skin next to it. It's a problem that can cause pain, inflammation, and infection) (not specific on what foot the ingrown toenails were) "that were infected" and required IV antibiotics. During a review of Resident 1's "CODING SUMMARY (CS)," dated 11/14/23, the CS indicated, Resident 1 diagnosis including Quadriplegia, Chronic Obstructive Pulmonary Disease, Tracheostomy, Diabetes Mellitus. Resident 1's annual Minimum Data Set (MDS- an assessment tool) under the section "BIMS (Brief Interview for Mental Status - an assessment of cognition [mental processes including perception, memory, and thought])," dated 10/10/24, the BIMS indicated, Resident 1 had a score of 15 (cognition intact). The MDS under the section "GG (an assessment of the level a care a resident requires)," dated 7/10/24, the GG indicated, Resident 1 was dependent on staff for lower body dressing and taking off/putting on footwear. During a review of Resident 1's Physician Orders (PO), dated 10/1/23, the PO indicated, Resident 1 had an order for podiatry consult for foot care. During a review of Resident 1's care plan for skin integrity (CPSI - skin integrity is the overall health and condition of your skin) dated 2/12/24, the CPSI indicated, Resident 1 had a, "right 4th toe redness/ingrown (toenail)." Interventions included, "Skin Evaluation Scheduled with Care." There was no care plan noted for Resident1's left (first and second toes) foot infection. During a review of Resident 1's "Podiatry Note (PN)," dated 9/25/24, the PN indicated, Resident 1 was seen by a podiatrist for complaint of "painful nails (did not specify where)." The PN indicated Resident 1 had infected ingrown toenails to both left and right foot. The PN indicated Resident 1 had mechanical debridement (the removal of damaged or infected tissue from the nail bed and surrounding areas) of the toenails to both left and right foot. The PN indicated the left first and second toes and the right fourth toe required partial avulsion (a surgical procedure that removes part or all the nail plate from the nail bed. Commonly used for ingrown toenails and nail infections). The PN indicated Resident 1 would start on IV antibiotics (9/25/24) for the infected toenails to the left and right foot. During a review of Resident 1's General Surgery Consultation (GSC), dated 10/2/24, the GSC indicated, Resident 1 was one-week post-(after) surgery for nail avulsion to the left hallux (big toe), left second toe and right fourth toe. During a concurrent interview and record review on 10/9/24 at 1:18 p.m. with Registered Nurse (RN 1), Resident 1's "Podiatry Service Note (PSN)," dated 2/23/24 was reviewed. The PSN indicated Resident 1 had Onychomycosis (a fungal infection of the nail that causes discoloration, thickening, and separation from the nail bed) to both left and right foot which gradually worsened. The PSN indicated, Resident 1 had long thick toenails to both left and right foot requiring care and Resident 1 was to return for further podiatry care in 9 weeks as needed. RN 1 stated Resident 1 was seen recently by a podiatrist in September 2024 (approximately 30 weeks) after his last appointment on 2/23/24. During an interview on 10/22/24 at 2:25 p.m. with Risk and Regulatory Analyst (RRA), RRA stated the facility did not have any documentation of any type regarding assessments or monitoring of Resident 1's left and right foot prior or after his podiatry appointment on 2/23/24. In violation of the above cited standards, the facility failed to ensure podiatry care and treatment for one of three sampled residents (Resident 1). This violation had a direct or immediate relationship to the health, safety, or security of patients or residents and constitutes a class "B" citation.