Health inspection·March 12, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record and facility policy review, the facility failed to recognize and report a change in condition to the physician, conduct weekly skin wound evaluations as their policy directed, and carry out physician's orders for antibiotic (medication for treating infections), for one of three residents sampled for wound care (Resident 1) when: Residents Affected - Few 1. Resident 1 had a surgical wound to her upper left leg that had worsened on 3/29/24, and her physician was not notified. 2. Resident 1's weekly skin evaluations of her wounds, were not performed weekly. 3. Resident 1 had orders from her vascular surgeon (a doctor who specializes in treatment of blocked arteries and veins), to begin taking an antibiotic on 4/10/24, that were never carried out. These failures had the potential to delay the healing process of Resident 1's wounds and contribute to Resident 1's hospital readmission. Findings: 1. A review of the facility's policy titled, Change in a Resident's Condition or Status revised October 2024, indicated, The nurse will notify the resident's Attending Physician .when there has been .d. significant change in the resident's condition. A review of the Centers for Disease Control and Prevention (CDC) newsletter titled, Know the Signs and Symptoms of Infection dated 11/4/24, indicated, call the doctor right away if you notice any of the following signs and symptoms of an infection; redness, soreness, or swelling in any area including surgical wounds A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included orthopedic aftercare following surgical amputation (removal of toes), diabetes, kidney disease stage 3 (kidneys have moderate damage and decreased ability to filter waste products), heart failure, chronic obstructive pulmonary disease (COPD, a lung disease), peripheral vascular disease (impaired or blocked blood flow to arms and legs), non-pressure chronic ulcer of left heel and midfoot (a wound), dementia, bipolar disorder (form of depression and anxiety), and lung cancer. Resident 1 was made her own healthcare decisions. A review of Resident 1's admission Minimum Data Set (MDS, a data driven clinical assessment) dated 3/28/24, indicated Resident 1's Brief Interview of Mental Status (BIMS, an evaluation of cognition Page 1 of 4 555304 555304 03/12/2025 Arbor Post Acute 1200 Springfield Drive Chico, CA 95928

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few level, thinking, reasoning and memory recall with range 00 to 15), score was 15 out of 15, which indicated no problems. A review of Resident 1's hospital, Discharge Summary dated 3/25/24, indicated Resident 1's hospital course included left lower extremity (left leg) peripheral vascular disease (blockage of blood vessels) complicated by osteomyelitis (bone infection) of the left great toe, second left toe ulceration which were amputated, left heel wound, and cellulitis (an infection and swelling caused by bacteria) of the left foot. On 3/21/24, Resident 1 had a surgical procedure called a Fem-Pop Bypass (a surgery that creates a new pathway for blood to flow through the lower leg), and the surgical incisions were intact. A review of Resident 1's, Nursing-Admission/readmission Evaluation/Assessment dated 3/25/24, indicated Resident 1 was admitted to the facility with three surgical incisions on her left leg; a. Left inner upper thigh which measured 2.5 centimeters long (cm- 2.5 cm equals approximately one inch). b. A mid-thigh incision which measured 2.8 cm long by 0.5 cm wide, and described the wound as beefy red. c. A third incision that was near the bottom of the thigh above the knee. This incision was not measured, but indicated the incision wound was covered with steri-strips (a form of wound closure strips), and had a small amount of bloody drainage, but no signs of infection. A review of Resident 1's, Physician's Orders dated 3/25/24, indicated, Left Anterior [front] Leg Surgical Incisions: Cleanse with NS (normal saline), pat dry, apply TAO (triple antibiotic ointment), cover with dry dressing and wrap. Monitor for s/sx [signs and symptoms] of infection every day shift for 14 days. A review of Resident 1's Physician's Orders dated 3/26/24, included an order to, Monitor redness and swelling to LLE [left lower extremity], for increase in redness and pain notify MD [doctor] and an appointment with [the vascular surgeon] on 4/10/24 to recheck the left inner leg incisions status. A review of Resident 1's, Impaired Skin Integrity Care Plan, initiated on 3/25/24, reflected interventions to administer treatments as ordered and monitor for effectiveness. A review of Resident 1's, Skin Breakdown Care Plan, initiated on 3/25/24, reflected interventions, Check skin during daily care provisions. Notify physician of abnormal findings. A review of Resident 1's nursing Progress Notes titled, Skin/Wound Note reflected the following: On 3/27/24 at 2:07 pm, a nurse documented, No signs or symptoms of infection to the left leg. On 3/29/24 at 4:29 pm, a nurse documented, LLE edematous [swollen], hard to touch and red. There was no documentation that Resident 1's physician was notified of this change. On 3/30/24 at 2:53 pm, a nurse documented, Resident complained of pain to left medial [middle] leg surgical incision sites. Incision sites red/inflammed and warm to the touch doctor contacted and new order was received for Keflex [an antibiotic] 500 mg (milligrams a unit of measure), three times a day and topical Bactroban (antibiotic ointment) two times a day, for 7 days. 555304 Page 2 of 4 555304 03/12/2025 Arbor Post Acute 1200 Springfield Drive Chico, CA 95928

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review of Resident 1's nursing Progress Notes, with the Director of Nursing (DON) on 3/11/25 at 1:50 pm, Resident 1's progress note dated 3/29/24 at 4:29 pm, was reviewed. DON confirmed Resident 1 had a change in the condition of her wound and her physician was not notified and should have been. 2. A review of the facility's policy titled, Skin Assessment: Best Practice revised 9/8/22, indicated, A weekly skin assessment is completed once a week and describes the current condition of the patients skin. A review of the facility's policy titled, Pressure Injuries/Skin Breakdown-Clinical Protocol revised April 2018, indicated, If a skin issue is noted the nurse should describe and document/report the following: Anatomical [where on the body] location stage, size, (length, width and depth), sinus tracts (tunneling under the skin), undermining (wound edges separate from the wound), presence of drainage, necrotic tissue (dead tissue) A review of three weeks of Resident 1's, Weekly Skin and Wound Evaluations V7.0 from admission on [DATE] to discharge on [DATE], reflected one of three weeks of the Weekly Skin and Wound Evaluations had not been completed; On 3/25/24, documentation included descriptions and measurements for the three surgical sites on the left upper leg. The week of 4/1/24, had no documentation that Resident 1's surgical wounds had been evaluated. The week of 4/8/24, the evaluation was done on 4/11/24, and reflected that one of the incisions, left mid-thigh surgical site, had dehisced (broke open), the left leg was red, hard, swollen and warm to the touch. During a concurrent interview with the DON and record review on 3/11/25 at 1:50 pm, Resident 1's, Weekly Skin and Wound Evaluations V7.0 were reviewed. DON confirmed Resident 1's surgical wounds were not evaluated on 4/1/24, and should have been. 3. A review of the facility's policy titled, Physician Orders revised October 2023, indicated Prescribed medication and treatment orders will be carried out in accordance with the physician/nurse practitioner order. A review of Resident 1's Vascular Surgeon's VS), Physician's Visit Summary note, dated 4/10/24, indicated Resident 1 had seen her vascular surgeon that day for a follow-up visit. The vascular surgeon documented, I obtained a culture from one of the incisions that had dehisced. I started her [Resident 1] on Augmentin [an antibiotic] 500 mg 3 times daily. One of the small incisions in the medial thigh where I ligated a tributary [rerouted a blood vessel] has dehisced. There is no pus drainage, but I went ahead and cultured the wound. [Resident 1] has a lot of swelling and cellulitis appearance along the medial aspect of her thigh. She also has swelling of the leg. She needs to keep it elevated. A review of Resident 1's nursing Progress Notes dated 4/10/24, indicated there was no documentation to reflect that Resident 1 had left the facility to go to her appointment with her VS on 4/10/24. There was no documentation that Resident 1 returned from her appointment or whether or not she had new orders from the VS. 555304 Page 3 of 4 555304 03/12/2025 Arbor Post Acute 1200 Springfield Drive Chico, CA 95928

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 1's, Physician's Orders for the month of April 2024, reflected no order for the Augmentin that her vascular surgeon had ordered on 4/10/24. During a concurrent interview with the Administrator (Admin) and record review on 3/12/25 at 4:14 pm, Resident 1's Physician Visit Summary for the Vascular Surgery Clinic office visit on 4/10/24 was reviewed. Admin confirmed that Resident 1's VS had ordered Augmentin for Resident 1, and that was never started, nor was there any documentation by the facility that Resident 1 had left for, or returned from this appointment on 4/10/24, and there should have been documentation and follow-up by the nurses for any new orders. 555304 Page 4 of 4