Health inspection·November 13, 2025

F 0686 Level of Harm - Actual harm Residents Affected - Few interventions for specific risk factors. 1. Repeat the risk assessment weekly and upon any changes in condition. Mobility/Repositioning 1. Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team (professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological needs) . Monitoring 1. Evaluate, report ad document potential changes in the skin. During a review of Resident 1's Order Summary Report, (OSR), contained current orders at time of transfer to the hospital, the OSR did not indicate a physician's order to reposition Resident 1 frequently and did not have physician's order for a pressure-relieving mattress or device for her chair as indicated in her care plan with a focus on Altered Skin Integrity, the facilities P&Ps titled Skin assessment and prevention of pressure injuries, and the MDS section M. During a phone interview with Resident 1's Responsible Party (RP, person in charge of decision making) on 11/5/25, at 9:43 a.m., the RP stated, Resident 1 was brought to the Emergency Department (ED, name of the hospital) on 8/17/25. She was unresponsive and had low blood pressure. The RP further stated the Emergency physician discovered Resident 1 had severe stage III (Full-thickness loss of skin. Dead and black tissue may be visible) wounds on her bottom, We were never told about the open wounds. The RP further stated he visited Resident 1 in the facility [name of the facility] every week and stayed for a couple of hours at Resident 1's bedside. RP also stated that his sister visited Resident 1, and she was not told by the facility that Resident 1 had stage III wounds on her bottom. RP also had indicated in the complaint that, She had been complaining about pain on her bottom for months. Additionally, when she had a doctor appointment on August 4, 2025, and was transferred to the medical transport, she was in extreme pain and distress, unable to sit up in her wheelchair, lying over the arm of her wheelchair, barely able to stay in it. During a review of Resident 1's record from [name of the hospital] ED (emergency department) titled Wound Care Note (WCN), dated 8/18/25, the WCN indicated thefollowing: . Location: Sacrum (triangular bone in the lower back between hip bones) . Wound Category: Pressure yes.Unstageable x (when unable to determine stage of ulcer due to physician being unable to see the base of the wound) . Additional wound: Location: Left ischium (above the back side of the thigh and beneath the buttocks. A pressure injury can develop here when you sit too long without shifting your weight) . Wound Category: Pressure yes. Stage 3 x. Non-pressure Additional wound: Location: Right ischium. Wound Category: Pressure yes. Pressure Injury: Stage 2 x (Partial-thickness loss of skin, presenting as ashallow open sore or wound) .Pain: Yes. During a review of Resident 1's record from [name of the hospital] ED titled Physician Note (PN), dated 8/19/25, the PN indicated, Unstageable pressure injury sacrum, stage II pressure injury right ischium, stage III pressure injury left ischium.This wound was present on admission. Category: Other Wounds. Location: Sacrum. Discovery Time: 08/17/2025 21:18. During an interview and record review with Medical Records Asst (MRA), and Licensed Nurse 1 (LN 1) on 11/6/25 at 11:44 a.m., MRA found Resident 1's Shower Day Skin Inspection, (SDSI, with a drawing of a naked human body, anteriorly and posteriorly to mark and label skin changes noted during a shower) sheets were dated 8/2/25, 8/7/25, 8/9/25, 8/11/25, 8/13/25, 8/14/25. LN 1 confirmed the SDSI sheets were Resident 1's shower sheets. LN 1 stated the Certified Nursing Assistant (CNAs) should mark (with an x or shading) and label the SDSI sheets of their observations during a shower. The process would then have the CNAs informing the nurse of any unusual or new redness or sores. The process then should be that the nurse would assess the resident's skin areas as identified by the CNAs. The LNs should then collaborate with the Treatment Nurse (TN). LN 1 confirmed this did not happen. During a continued interview and record review with LN 1 and MRA on 11/6/25 at 11:44 a.m., LN 1 stated Resident 1's SDSI sheet dated 8/11/25 was marked as open area at the posterior buttocks (back of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555083 If continuation sheet Page 2 of 4 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 555083 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manzanita Healthcare Center 5318 Manzanita Avenue Carmichael, CA 95608 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)

F 0686 Level of Harm - Actual harm Residents Affected - Few bottom) and SDSI sheet dated 8/16/25 was circled and marked Red at the posterior buttocks. LN 1 stated that the remainder of the SDSI sheets were all marked with shading at the posterior buttocks area but were not labeled with words such as open or red as it should have been. LN 1 stated that nurses should have assessed, documented and informed the Treatment Nurse (TN) of Resident 1's changes in her skin as indicated on the shower sheets. LN 1 further stated that if redness and open skin areas were left untreated, they could get infected and result in possible pressure sores. LN 1 continued to say that the nurses are also expected to complete Resident 1's Weekly Nursing Summary (WNS) assessments to evaluate skin changes, and other health status changes. LN 1 stated that the last completed WNS was 7/31/25, and that the nurses did not conduct the WNS for Resident 1 for the month of August 2025. LN 1 emphasized the importance of completing the WNS assessment to capture Resident 1's health decline or change of condition. The MRA confirmed that she did not have copies of the WNS assessment sheets. During an interview with LN 3 on 11/12/25 at 12:39 p.m., LN 3 acknowledged that she signed Resident 1's SDSI sheets however she cannot recall the dates. LN 3 said she doesn't perform skin assessments unless the CNA reported to her that there was a difference between resident's current skin condition from the previous skin assessment. LN 3 continued to say, CNA 2 wrote down open area on 8-11-25 in the SDSI sheet. LN 3 stated if there is an open skin on the sacrum area and it is not treated, it could get infected and may lead to a pressure sore as it was on the boney part of the human body. During an interview with LN 2 on 11/6/25 at 1:05 p.m., LN 2 stated Resident 1 was dependent on staff with her Activities of Daily Living (ADL, refers to basic self-care tasks like bathing, dressing, and eating) needs. Resident 1 was unable to turn to her side without the help from the staff, and the facility staff used the Hoyer lift (a mechanical device used to lift and/or transfer a person from place to place) to transfer Resident 1 to bed, wheelchair, and shower chair. LN 2 confirmed she signed Resident 1's SDSI sheets dated 8/9/25 and 8/14/25. LN 2 stated that although it was not labeled with words indicating the problem, the SDSI sheets were marked with black ink at the posterior buttocks which indicated an issue with that area. LN 2 verbalized, a signed SDSI sheet meant that she was aware of Resident 1's skin changes, and LN 2 should have assessed and documented her findings and informed the TN. However, LN 2 was not sure if she had assessed Resident 1's skin as the process (after identifying skin abnormality on the shower sheet) required. During an interview with CNA 1 on 11/6/25 at 1:33 p.m., CNA 1 acknowledged she gave showers to Resident 1 on 8/2/25, 8/7/25, 8/9/25, 8/13/25, 8/14/25. CNA 1 stated that Resident 1 was unable to turn to sides, recline on her bed without the assistance from the nursing staff. CNA 1 admitted that she saw redness and a rash on 8/2/25, 8/7/25, 8/9/25, 8/13/25, 8/14/25 to Resident 1's skin on her posterior buttocks as she marked on the SDSI sheet. However, CNA 1 stated she did not label with words her markings on the SDSI sheets, I should have labeled it, so they [nurses] know what I saw. During an interview with the Director of Nursing (DON) on 11/6/25 at 1:51 p.m., the DON acknowledged that CNA 1 and CNA 2 gave showers to Resident 1 as indicated on the SDSI sheets. The DON further acknowledged LN 2 and LN 3 signed the SDSI sheets acknowledging they received and reviewed the reports for Resident 1. The DON stated the facility's process was for the nurses to review the SDSI sheets, assess and document the resident's skin as reported by the CNA on the SDSI sheets, and then the nurse should collaborate with the TN for further physician order/treatments. The DON confirmed that all SDSI sheets (on 8/2/25, 8/7/25, 8/9/25, 8/13/25, 8/14/25) indicated an unusual finding on posterior buttocks of Resident 1. The DON further stated that these assessments/findings were not documented in the resident's chart such as on the Treatment Administration Record (TAR, tool nurses use to document and manage wound care treatments) and progress notes as the process indicated. The DON stated the expectation is for the nurses to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555083 If continuation sheet Page 3 of 4 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 555083 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manzanita Healthcare Center 5318 Manzanita Avenue Carmichael, CA 95608 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)

F 0686 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete physically check the resident's skin for any skin change as indicated on the SDSI sheets. The DON further confirmed that there were no WNS done for Resident 1 for August 2025, and said, there should be WNS completed by the nurses for Resident 1 every week. This tool would help nurses identify early signs of changes in skin condition. The DON stated that if the process was not followed when a sore or redness was identified then an open sore left untreated, could get worse and become infected. During an interview with CNA 2 on 11/12/25 at 1:18 p.m., CNA 2 stated Resident 1 was incontinent with urine and bowel, and needed help in changing her briefs, and assistance in taking a shower. CNA 2 further stated Resident 1 cannot walk, and needed assistance to turn to sides, CNA 2 used the Hoyer lift to bathe and transfer Resident 1. CNA 2 acknowledged that she noted an open skin tear and redness to Resident 1's posterior buttocks and indicated it on the SDSI sheets. CNA 2 continued to say that she informed LN 3 about her observations of Resident 1's skin condition as documented on SDSI sheets. During an interview with the TN on 11/12/25 at 1:41 p.m., the TN stated that she was familiar with Resident 1 and emphasized that if an open area or skin tear was left untreated, it could get infected, grow and may progress to a pressure sore or unstageable sore. The TN continued to say that Resident 1 should have been repositioned every two hours, checked her skin integrity regularly, placed a cushion on Resident 1's wheelchair to help prevent pressure, and placed a pressure-relieving mattress especially to bed bound or bedridden residents. During a review of Resident 1's TAR, dated 8/1/25 - 8/31/25, the TAR did not have documentation of treatments regarding wound care on the residents bottom or a repositioning or turning protocol. During the review of the facility's policy and procedures, titled Bath/Shower, dated 2001, indicated, The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition the resident's skin. During the review of the facility's policy and procedures, titled Care Plans, Comprehensive Person-Centered, (CPCPC), dated 2001, the CPCPC indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 9. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' condition change.10. The interdisciplinary team review and updates the care plan: a. when there has been a significant change in the resident's condition. Event ID: Facility ID: 555083 If continuation sheet Page 4 of 4