Health inspection·August 27, 2025

The following reflects the findings of the California Department of Public Health during the investigation of Complaint number CA00964824 / 2320737 and CA00964234 / 2320739. Survey ID FDC5-H1 State Citation B 230022287 was written for F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §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: On 5/27/25 at 1:35 pm, an unannounced visit was conducted at the facility to investigate a complaint regarding pressure ulcers. During their stay at the facility, Resident 4 developed a pressure ulcer on the sacrum (the bony structure at the base of the back), which progressed to osteomyelitis (a bone infection). Additionally, Resident 4 developed pressure ulcers on the left calf and both heels due to wearing therapeutic moon boots (designed to maintain proper foot and ankle alignment) that were brought from home. The facility failed to develop and implement a plan of care to prevent pressure ulcers (damage to the skin and underlying tissue, usually over a bony prominence) for Resident 4. This system failure resulted in Resident 4 developing multiple pressure injuries, wound deterioration, subsequent serious life-threatening infection, and unnecessary pain. During a review of record titled “Adv – Skin Check”, dated 3/20/25, at 5:41 pm, indicated Resident 4 was admitted with the following skin integrity concerns: A pressure injury to left hip, an abrasion on the right leg, redness to coccyx (tailbone area), scrapes on the right knee and surrounding area, and scrapes on both feet and toes. A review of a Braden Scale assessment (predicting pressure injury risk) dated 3/20/25, indicated Resident 4 risk a score of 13 (moderate for acquiring a pressure injury), a score of 12 indicated a high risk. A review of a Minimum Data Set (MDS, resident assessment) dated 3/27/25, indicated Resident 4 had limited range of motion on one side (left), required substantial maximal assistance when rolling side to side, and dependent on staff for moving from a lying position to sitting on the side of the bed. Resident 4 was identified as at risk for developing pressure ulcers. Resident 4 was bed and wheelchair bound. During a record review of record titled “Order Summary Report”, with a date range of 3/1/25 - 3/31/25, indicated a wound consultation with an order date of 3/20/25. A review of the care plans from 3/20/25 to 5/13/25 indicated no plan of care for pressure ulcer prevention for Resident 4. The first care plan was created on 4/13/25. During a record review of record titled “Adv Skin”, dated 4/3/25, at 11:23 pm, indicated that Resident 4 had blanching redness (redness that turns white when pressed, indicating blood flow) to coccyx. A review of physician treatment orders from 3/20/25 to 5/13/25 indicated no skin care treatments for the blanchable redness at the coccyx or sacrum. The first treatment order for the “buttocks” was dated 4/13/25. During a record review of record titled “Progress Note New”, dated 4/11/25, at 8 pm, indicated that Resident 4 returned to the facility after spinal surgery. Resident 4’s skin was described as having a surgical incision on his back, blanchable redness to coccyx, and redness on both right and left hips with “patches on top”. During a record review of record titled “Order Summary Report”, with a date range of 4/1/25 - 4/30/25, indicated a second wound consultation with an order date of 4/11/25. During a record review of record titled “Progress Note New”, dated 4/20/25, at 11:15 am, indicated Resident 4 had a Braden skin assessment with the risk of developing pressure ulcers Score of 10, which indicated a high risk of developing pressure ulcers. During a record review of a record titled “Progress Note New”, dated 4/20/25, at 11:03 am, indicated Resident 4 has a facility acquired unstageable (base of the wound is not visible to determine the stage) deep tissue pressure injury on the sacrum (bony structure located at the base of the back), measuring 6 centimeters (cm) in length and 9 cm in width. Resident 4 was described as in bed most of the day and required maximum assistance moving and being repositioned in bed. During a record review of a record titled “Order Summary Report”, with a date range of 4/1/25 to 4/30/25, indicated an order for a Low Air Loss Mattress (LALM, a mattress with continual air flow to help prevent skin breakdown) with a start date (date intervention to begin) of 4/22/25. A review of the IDT Progress notes for Skin from the start of admission on 3/20/25 through 5/13/25, indicated the first meeting was on 4/24/25. During a record review of record titled “Wound Care Progress Note”, dated 4/28/25, indicated Resident 4 had multiple wounds. This is the first progress note from the wound care doctor, over a month from the date of the first wound consult order, over 2 weeks from the second. The wound on Resident 4’s sacrum (bony structure located at the base of the back) was described as a new unstageable pressure injury, measuring 6.5 centimeters (cm) in length,10 cm in width, with no measurable depth. During a record review of record titled “Wound Care Progress Note”, dated 5/12/25, indicated Resident 4’s sacral wound is described as follows: Unstageable due to necrosis (death of tissue) pressure injury on sacrum (bony structure located at the base of the back), measuring 6.5 cm in length,10 cm in width, and 1 cm in depth. Wound bed is described as having 60% necrotic tissue and progress is described as deteriorated. At this time a procedure where the necrotic muscle was cut away using a surgical blade was completed by the wound care doctor. During a record review of record titled “SBAR Summary for Provider”, dated 5/13/25, at 2:20 pm, indicated a change in condition regarding a skin wound or ulcer. The MD (Medical Director) was notified of Resident 4’s surgical wound reopening, and a decline of the wound on the sacrum. Orders were given to send Resident 4 to the acute care hospital to be evaluated. During a record review of the acute care hospital note titled “ED Provider Notes”, date 5/13/25, indicated that Resident 4 was admitted to the acute care hospital with diagnoses of sacral (area of the lower back and buttocks) abscess (a localized collection of infection), decubitus ulcer Stage 3 (pressure injury to the muscle) at sacrum possible to the bone, cellulitis (bacterial infection of the skin), quadriplegia (paralysis or weakness in arms and legs), and osteomyelitis (an infection of the bone). The ED note indicated sepsis due to high white blood cell count (sign of infection). 2. During a review of record titled “Personal Effects Inventory Form”, dated 3/20/25, indicated that Resident 4 arrived at the facility with a pair of black and grey therapeutic boots. A review of physician’s orders from 3/20/25 to 5/13/25, indicated no orders for the therapeutic moon boots that Resident 4 brought from home. A review of the care plans from 3/20/25 to 5/13/25 indicated no plan of care for direct care staff to utilize therapeutic moon boots. During a record review of record titled “Progress Notes New”, dated 4/7/25, at 2:10 am, indicated Resident 4 left the facility for a scheduled surgery. Resident 4 left the facility in his own wheelchair, wearing therapeutic boots, with family accompanying him. Resident 4 was readmitted to the facility on 4/11/25. During a record review of record titled “Wound Care Progress Note”, dated 4/28/25, indicated Resident 4 had a new unstageable pressure injury on right heel, measuring 1.5 centimeters (cm) in length, 2 cm in width, with no measurable depth, and noted to be “boot caused”. New unstageable pressure injury on left calf, measuring 4 cm in length, 3 cm in width, noted to be “caused by Moon boot”. During a record review of record titled “Wound Care Progress Note”, dated 5/12/25, indicated Resident 4 continued to have wounds that were cause by “moon boots” with the addition of a new stage 2 pressure injury to left heel, measuring 0.7 cm in length, and 1cm in width. During a telephone interview with Resident 4’s family member (FM) on 6/12/25, at 12:45 pm, the family member expressed concerns with the care provided. They stated that it took a long time to get an air mattress, at least a couple of weeks, and they were concerned about how it would affect Resident 4’s skin. FM expressed concern regarding the proper use of Resident 4’s air mattress. During a visit on 5/2/25 they witnessed a staff member adjusting the air setting on the bed and were told the setting wasn’t correct. They had requested a pad for Resident 4’d wheelchair multiple times but claim one was never provided. They eventually brought a pad from home. On 5/7/25 they saw the pressure wound on Resident 4’s bottom and were shocked at how bad it was. They stated that he went back to the local hospital on 5/13/25 and passed away on 6/7/25. They stated that Resident 4 experienced unnecessary suffering due to his wounds before his passing. During an interview with Licensed Nurse A (LN A) on 7/9/25, at 1:35 pm, LN A stated that skin assessments are completed at the time of admission. Skin issues are reported to the facility doctor and all pressure injuries are seen by the wound care doctor. It is LN A’s expectation that the wound care doctor will follow up on referrals within a week, and sooner for residents with urgent needs. Wound measurements are taken on the initial assessment. All wounds are followed by a wound care nurse, including areas of redness that have the potential to progress into a pressure injury. Low Air Loss mattress (LAL, a mattress with continual air flow to help prevent skin breakdown) mattresses are typically only provided to residents with Stage 3 or greater pressure injuries, unless they have other high-risk reasons. LN A stated the LAL mattress can be considered earlier than Stage 3 and that was done by the IDT Skin team. LN A recalled Resident 4 wearing therapeutic boots. Resident 4 was wearing the boots all the time until the wound care specialist requested that they only be worn when up. LN A does not recall any special training regarding the use of the boots. During an interview with the Director of Rehab (DOR), on 7/9/25, at 2:30 pm, DOR stated that they recall working with Resident 4. DOR remembers working with Resident 4 and that Resident 4 had been wearing a pair of therapeutic boots that were brought in from home. DOR stated that training is only provided for equipment that comes from therapy, therefore there was no training provided for the boots that Resident 4 was using. DOR confirmed that Resident 4 was always wearing the boots until the wound specialist advised otherwise. DOR did not evaluate the moon boots Resident 4 brought from home. During an interview with the Director of Nursing (DON), on 7/15/25, at 1:30 pm, DON confirmed that Resident 4 had a Braden scale score of 13 on 3/20/25, which indicated they were not at high risk for pressure injuries. While reviewing Resident 4’s medical records DON confirmed that Resident 4 did have factors at the time of admission that indicated a high risk for pressure injuries and that her expectation is that a care plan would be developed and implemented to address those risks. While reviewing the care plans for Resident 4, DON confirmed that there was not a care plan in place for the risk of pressure injuries until 4/13/25. Resident 4 arrived at the facility with a pair of personal therapeutic boots. DON confirmed that there was not a care plan nor physician orders for therapeutic boots in place until 4/13/25. It is her expectation that both a care plan and orders should have been in place, and that staff should have been provided with training regarding the use of the boots. DON confirmed the boots were not evaluated for appropriateness for Resident 4. DON confirmed the first documentation assessing Resident 4 by the wound care doctor was on 4/28/25, over a month after the first consult was ordered. It is her expectation that a resident would be seen a week after the first consult is made. DON confirmed that the wound care doctor does visit the facility on a weekly basis. DON confirmed that a LA mattress was not ordered for Resident 4 until 4/22/25, and that it would have been a benefit to Resident 4 if the LAL mattress was provided sooner, due to having a planned spinal surgery and his risk factors. DON stated that after the initial skin assessment is completed on admission it is the treatment nurse’s responsibility to complete a second skin check. DON was unable to locate documentation supporting changes in the resident’s skin condition on coccyx or sacrum prior to the wound care doctor’s documentation. DON agreed that there are inconsistencies in the skin documentation and orders regarding the coccyx, buttocks, and the sacrum making the documentation difficult to follow. During an interview with CNA A, on 7/15/25, at 3:15 pm, Certified Nursing Assistant (CNA A) stated that they had not had any specific training regarding the use of therapeutic boots. CNA stated Resident 4 wore the boots all the time to keep his feet from moving side to side. During an interview with LN B, on 7/15/25, at 3:30 pm, LN B stated that they do not recall any special training regarding therapeutic boots since they have worked at the facility. It is LN B’s expectation that if a resident needed special equipment such as therapeutic boots, that the instructions for use would be found in the care plan or the doctor’s order. If the resident was found using equipment that was not ordered LN B would notify the doctor to ensure that the equipment was appropriate for the resident. LN B stated that they do not recall any special training regarding therapeutic boots since they have worked at the facility. It is LN B’s expectation that if a resident needed special equipment such as therapeutic boots, that the instructions for use would be found in the care plan or the doctor’s order. If the resident was found using equipment that was not ordered LN B would notify the doctor to ensure that the equipment was appropriate for the resident. In violation of the above cited standards, the facility failed to ensure Resident 4 received care to prevent pressure ulcers consistent with professional standards of practice, including but not limited to the development and implementation of a plan of care to prevent pressure ulcers. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.