Health inspection·June 28, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide wound treatment to an existing wound for one of three sampled residents (Resident 1), per Resident 1's physician's orders and care plan. Residents Affected - Few This deficient practice resulted in Resident 1's right medial leg wound not be treated or assessed, maggots present in Resident 1's wound and Resident 1's transfer to a General Acute Care Hospital (GACH) for evaluation and treatment. This deficient practice had the potential for worsening of the infection to Resident 1's wound resulting in physical as well as psychological harm related to the presence of maggots in Resident 1's right medial leg wound. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of type 2 diabetes mellitus ([DM] a condition associated with abnormally high levels of sugar in the blood). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 4/19/2024, the MDS indicated Resident 1 could understand and be understood by others. The MDS indicated Resident 1 was at risk for developing pressure ulcers (breakdown of skin)/injuries. During a review of Resident 1's Care Plan dated 6/12/2024, the Care Plan indicated Resident 1 had a right medial leg venous ulcer. The Care Plan's goal indicated Resident 1 would have no skin complications throughout the review date of 10/17/2024. The Care Plan's interventions indicated to administer treatment per physician orders. During a review of Resident 1's Physician's Orders dated 6/20/2024, the Physician's Orders indicated to apply Gentamicin Sulfate External Ointment 0.1% (a medicated ointment applied on wound, used to treat infection) to Resident 1's right medial leg topically (applied to body surface) every day shift for green tinged exudate (a fluid which leaks out of damaged tissues) for 14 days. Continued review of the physician's order indicated no other treatment of this wound was ordered such as cleansing or covering it with a dressing. During a review of Resident 1's Care Plan dated 6/20/2024, the Care Plan indicated Resident 1's right medial leg wound would present with no infection. The Care Plan's interventions indicated cleanse with normal saline ([N/S] a solution that is a mixture of Sodium Chloride [salt] and water that has a number of uses in medicine including cleaning wounds), apply Gentamycin 0.1% ointment to the (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555028 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)