Health inspection·November 1, 2023

F 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Minimal harm or potential for actual harm Based on interview, clinical record and policy and procedure review, the facility failed to ensure wound care teaching was done in preparation for discharge for 1 of 2 sampled residents (Resident 1) when the wound nurses were not aware of the discharge plan and the discharge paperwork did not include wound care instructions. Residents Affected - Few This failure had the risk potential for deterioration of the wounds upon discharge. Additionally, Resident 1 was reported to have been admitted to the hospital with wound infection. Findings: According to the 'admission Record,' the facility admitted Resident 1 on 9/19/23, with multiple diagnoses which included, diabetes, pneumonia, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), Parkinson's disease (a disorder of the nervous system that affects movement, often including tremors, stiffness or slowing movement), heart failure, muscle weakness among other comorbidities (medical issues). Resident 1's Minimum Data Set (MDS, an assessment tool), dated 9/25/23, indicated he was totally dependent on staff for assistance in bathing, wheelchair locomotion, transition between bed and wheelchair and, required extensive assistance of staff for toileting needs, personal hygiene, and bed mobility. The resident scored 8 out of 15 in a Brief Interview For Mental Status (BIMS, a test for cognitive status) contained in the MDS which indicated he had moderate cognitive impairment. The MDS indicated Resident 1 was at risk of pressure ulcer development (bed sores) and had 2 DTI's and one stage 1 pressure ulcer (PU stage 1 is intact skin with non-blanchable redness of a localized area) to the buttocks. According to the 'Intake Information' report received by the Department on 10/23/23, Resident 1 developed bed sores during his stay at the facility and he was improperly discharged . During an interview with Resident 1's family member on 10/27/23, at 9:47 a.m., she stated she did not receive teaching on wound care from the facility and had to hire people to help her. The family member stated Resident 1 was currently admitted in the hospital and was receiving antibiotics for wound infection. A review of Resident 1's 'Discharge Information .' on 10/27/23, at 12:15 p.m., concurrently with the Director of Nursing, the 'Skin Condition on Discharge' portion was not completed. The DON stated the wound nurse or the nurse who discharged Resident 1 should have completed the section and provided wound care discharge teaching to the resident or family. Page 1 of 5 555164 555164 11/01/2023 Arbor Rehabilitation & Nursing Center 900 North Church Street Lodi, CA 95240

F 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview and concurrent record review with the facility's wound nurse (Licensed Nurse, LN 3), she stated the Social Services department that coordinates discharges did not notify her Resident 1 was to discharge home. LN 3 stated the discharge teaching should have been done 3 days prior to discharge with the family so they can demonstrate the ability to provide wound care at home. LN 3 further stated the communication about the discharge would also have helped her to determine if it was safe to discharge the resident. LN 3 stated she was not aware she had the responsibility to complete the condition of the skin on the discharge information document as she always used narrative progress notes. The facility' policy and procedure titled 'Discharge/Transfer of the Resident,' dated 2006 indicated, the Licensed Nurse (LN) was to complete the post discharge plan of care form and include instructions for post discharge care and explanations to the resident and /or representative. The LN was to document the condition of the resident on discharge. 555164 Page 2 of 5 555164 11/01/2023 Arbor Rehabilitation & Nursing Center 900 North Church Street Lodi, CA 95240

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, clinical record and the facility's policy and procedure review, the facility failed to ensure one of 2 sampled residents (Resident 1) received care consistent with professional standards of practice to prevent pressure ulcers (PUs) when risks were not comprehensively identified, and appropriate preventative measures were not implemented in a timely and consistent manner. Residents Affected - Few This failure resulted in Resident 1 sustaining deep tissue injury (DTI, pressure ulcers that appear as purple localized areas of discolored intact skin or blister due to damage of underlying soft tissue from pressure and /or shear) to bilateral heels within 5 days of admission to the facility. Findings: According to the 'admission Record,' the facility admitted Resident 1 on 9/19/23, with multiple diagnoses which included, diabetes, pneumonia, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), Parkinson's disease (a disorder of the nervous system that affects movement, often including tremors, stiffness or slowing movement), heart failure, muscle weakness among other comorbidities. Resident 1's Minimum Data Set (MDS, an assessment tool), dated 9/25/23, indicated he was totally dependent on staff for assistance in bathing, wheelchair locomotion, transition between bed and wheelchair and, required extensive assistance of staff for toileting needs, personal hygiene, and bed mobility. The resident scored 8 out of 15 in a Brief Interview For Mental Status (BIMS, a test to determine cognitive status) contained in the MDS which indicated he had moderate cognitive impairment. The MDS indicated Resident 1 was at risk of pressure ulcer development and had 2 DTI's and one stage 1 pressure ulcer (PU stage 1 is intact skin with non-blanchable redness of a localized area) to the buttocks. The MDS indicated Resident 1 would have a pressure reducing device to wheelchair and bed. The MDS did not include turning and repositioning of the resident as an intervention. According to the 'Intake Information' report received by the Department on 10/23/23 indicated, Resident 1 developed bed sores during their stay at the facility and he was improperly discharged . During an interview with Resident 1's family member on 10/27/23, at 9:47 a.m., she stated she did not receive teaching on wound care from the facility and had to hire people to help her. The family member stated Resident 1 was currently admitted in the hospital and was receiving antibiotics for wound infection. According to a 'Skin/Wound Evaluation,' dated 10/3/23, Resident 1 was noted with two DTIs (DTI, deep tissue injury, damage to underlying layers of skin), to bilateral heels on 9/25/23, five days after admission to the facility. Resident 1's 'Care Plans,' initiated on 9/25/23, was reviewed and indicated he had a skin tear to bilateral heels instead of DTI's. The Care plan did not include the interventions that were identified in the MDS assessment and did not include turning and repositioning the Resident. Another Care plan initiated on 9/28/23, was reviewed and indicated Resident 1 had a skin tear to the left ankle. A review of Resident 1's 'Actual Pressure Ulcer' to left and right heel indicated it was not initiated until 10/1/23 by the wound nurse. The care plan did not include the interventions identified by 555164 Page 3 of 5 555164 11/01/2023 Arbor Rehabilitation & Nursing Center 900 North Church Street Lodi, CA 95240

F 0686 the MDS assessment; pressure reducing device to wheelchair and bed. Level of Harm - Minimal harm or potential for actual harm During a concurrent record review and interview with the Director of Nursing (DON) on 10/27/23 at 12:15 p.m., the DON validated Resident 1's admission assessment indicated he had skin discoloration to the buttocks and had no pressure ulcers. The DON validated the admission risk for skin breakdown assessment indicated the resident was at moderate risk for skin breakdown. The DON validated a nurse documented Resident 1 had skin tears to bilateral heels on the care plan dated 9/25/23, instead of DTIs and stated the nurse should have edited the care plan to read 'DTIs.' The DON validated an order to float Resident 1's heel was initiated on 9/25/23, and was not documented as done by the Certified Nursing Assistant (CNAs) every shift under the tasks. The DON stated she was not sure Resident 1 had pressure reducing devices to the wheelchair and bed as per the MDS assessment. Residents Affected - Few In an interview conducted with Licensed Nurse (LN 1) on 10/27/23, at 1:23 p.m., she stated Resident 1 had skin discoloration to buttocks area, bilateral heel DTIs and left ankle blister. LN 1 stated she provided wound care to Resident 1 on 10/3/23 and 10/4/23 and the left outer heel blister had not popped open. LN 1 stated Resident 1 did not have a pressure reducing device to wheelchair or to bed. During an interview with LN 2 on 10/27/23, at 2:27 p.m., he stated he was the regularly assigned nurse to the section. LN 2 stated the wound nurse took care of Resident 1's wounds and he recalls her telling him the Resident had bilateral heels DTI that developed while at the facility and a blister in one of the heels had popped open. LN 2 stated the resident had no pressure reducing device to wheelchair or bed. LN 2 stated the resident had limited mobility and needed extensive assistance of staff for most of his Activities of Daily Living (ADLs) including bed mobility and repositioning and the use of pressure reducing devices would have been appropriate for his condition and comorbidities. An interview conducted with CNA 1 on 10/27/23, at 2:36 p.m., she stated she had no recall of Resident 1. The CNA stated the care that CNAs provided to each resident, was included, and documented under the tasks and included turning in bed, repositioning, and floating heels. On 10/30/23 at 12:31 p.m., the DON indicated in writing, Float heal documentation was on the [NAME] only for CNAs, they were not documenting each shift on that task. During a telephone interview with LN 3 on 10/31/23, at 11:25 a.m. she stated her responsibility was to provide wound care to all residents with wounds during her shift. LN 3 reported that the admission nurse completed the skin assessment on admission and if a major skin issue was identified, she would be notified to check on the resident. LN 3 stated she was informed of Resident 1's heel DTI's and on 10/1/23 she noted the left heel blister had popped open and revised the care plans and the treatment. LN 3 stated Resident 1 had bilateral heels DTI's not skin tears. LN 3 stated Resident 1 had incontinent associated dermatitis (IAD, inflammation of the skin due to exposure to urine/feces) to the buttocks. LN 3 stated Resident 1 had no pressure reducing devices to bed or wheelchair because he had no pressure ulcers to the back or buttocks, he did not meet the criteria to have an air mattress or wheelchair cushion. A review of the facility's Policy and Procedure titled ' Pressure Ulcer, Prevention of' dated 2006 indicated the facility was to, Assess for risk of pressure ulcer development . identify high and low risk residents . Assess and identify complicating conditions that may contribute to pressure ulcer development . Develop a care plan to eliminate or minimize risk factors . Pressure relief . Use appropriate support surface in the resident's bed or chair . Use pressure reducing or relieving devices 555164 Page 4 of 5 555164 11/01/2023 Arbor Rehabilitation & Nursing Center 900 North Church Street Lodi, CA 95240

F 0686 Level of Harm - Minimal harm or potential for actual harm as necessary . Establish a turning and positioning schedule in bed and chair . Position with appropriate support surfaces to protect bony prominences . CARE PLAN DOCUMENTATION GUIDELINES . Identify the appropriate problem under which to list the pressure ulcer care as an approach . Identify and treat the underlying cause of the pressure ulcer . Consider listing complicating conditions, as well as possible risks and complications . Residents Affected - Few According to Lippincott Manual of Nursing Practice (2010, 9th edition), Pressure ulcers (decubitus ulcers) are localized ulcerations of the skin or deeper structure. The most commonly result from prolonged periods of bed rest in acute or long-term care facilities; however, they can develop within hours of compromised individual .[areas identified in a picture diagram included areas at the back of the body e.g. heel, ankle, sacrum (located above tailbone), tailbone, elbow] . Pressure . applied for longer than 2 hours can produce tissue destruction; healing cannot occur without relieving the pressure . Friction contributes to pressure ulcer development by causing abrasion [scraped area] . Shearing force, produced by sliding of adjacent surfaces . Moisture on the skin results to maceration. Risk Factors for Pressure Ulcers . Bowel or bladder incontinence .hypoxia [low oxygen in the tissues] . Neurologic impairment or immobility . dementia . Prevent Pressure Ulcer Development . positioning for immobile patients . inspect skin several times daily . bowel and bladder program . Relieve the Pressure . Avoid elevation of head of bed . Reposition every 2 hours . Use special devices to cushion specific areas . Use an alternating -pressure mattress .frequent shifting of weight . 555164 Page 5 of 5