Health inspection·October 4, 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 observation, interview, medical record review and facility P&P review, the facility failed to provide the necessary care and services to prevent the development or worsening of pressure injuries for two of two sampled residents (Residents 1 and 2). Residents Affected - Few * The facility failed to assess Resident 1's skin when readmitted to the facility and failed to develop a care plan to address Resident 1's coccyx wound. * The facility failed to revise Resident 2's care plan to address Resident 2's Stage 3 pressure injury and failed to ensure Resident 2 received his wound treatment with his own wound medication supply. These failures had the potential for Residents 1 and 2 not to receive the appropriate care and services to promote healing of the pressure injury. Findings: 1. Review of the facility's P&P titled admission Notes (undated) showed should a resident be discharged from and readmitted to the facility, the new admission data must be recorded. Review of the facility's P&P titled Guidelines for Charting and Documentation revised 4/2012, under the section for Nursing Summaries and/or Assessment for skin-hair-scalp-nails, showed dry moist, scaly, etc., be descriptive of lesion, edema; etc., include location, size, depth, color, amount, consistency, odor of drainage, and status of tissue and surrounding area, and indicate the type of treatment and how often the treatment is administered. Medical record review for Resident 1 was initiated on 10/3/24. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. a. Review of Resident 1's Admission/readmission Evaluation/assessment dated [DATE], showed the question asking if the resident had wounds or skin integrity concern present upon admission, the documented answer was no. However, the Comment section showed per report coccyx wound. Review of Resident 1's Order Summary Reported showed a physician's order dated 9/29/24, to cleanse the coccyx wound with normal saline, pat dry, apply triad cream (skin treatment), and cover with a dry dressing once daily. Further review of Resident 1's medical record failed to show documented evidence Resident 1's skin (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 3 Event ID: 555328 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 555328 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountain Valley Post Acute 11680 Warner Avenue Fountain Valley, CA 92708 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)