Health inspection·November 25, 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 record review and interview, the facility failed to ensure that a total dependent resident (Resident 1) received necessary treatment and services, to promote healing, and prevent new pressure ulcers (deep tissue injury) from developing. Residents Affected - Few This facility failure resulted in Resident 1 acquiring a new stage 3 pressure ulcer (full thickness tissue loss) to the right buttock. Findings: Review of Resident 1's medical record indicated, resident was admitted to the facility on [DATE] with diagnoses that included history of respiratory failure (a condition that makes it difficult to breathe on your own), Tracheostomy (opening in the windpipe to help with breathing), Quadriplegia (paralysis (loss of the ability to move and sometimes feel of all four limbs), Epilepsy (is a chronic brain disorder that causes repeated seizures, which are episodes of abnormal electrical activity in the brain), Diabetes (high sugar in the blood). Review of Resident 1 ' s admission Minimum Data Set (MDS (a standardized assessment tool that measures health status in nursing home residents)) dated 8/8/24 indicated, Resident 1 was totally dependent on staff for all activities of daily living including repositioning. During a review of Resident 1's admission nursing assessment dated [DATE], the assessment indicated, resident was with a stage 3 (full thickness tissue loss) pressure ulcer to the sacrococcyx (is the fused sacrum and coccyx bones in the human body). And no other pressure ulcers were documented for Resident 1 on admission nursing assessment. Review of Resident 1's medical record dated 9/29/24 indicated, Resident 1 was noted to have stage 2 pressure ulcer (partial thickness loss of skin) to right hip (buttocks) measuring 3 cm (centimeter) X 3 cm X 0.1 cm. During a review of Resident 1's Wound Consultation (WC) notes dated 10/7/24 indicated, right buttocks pressure ulcer, Stage 3, deteriorating. During a review of Resident 1's care plan (CP (a document that summarizes care needs and treatment plans) dated 8/2/24, the CP indicated, Resident 1 was at risk for skin breakdown. And further indicated that Resident 1, be turned and repositioned every 2 hours. During an interview with Wound Care Nurse (WCN), on 11/18/24 at 1:59 p.m., WCN stated that a (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: 555066 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 555066 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenfield Care Center of Fillmore, LLC 118 B Street Fillmore, CA 93015 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)