Health inspection·August 28, 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 interview and record review the facility failed to prevent a pressure ulcer (damage to area of the skin due to pressure) from developing for one of three sampled residents (Resident 1). Residents Affected - Few This failure placed a clinically compromised Residents (Resident 1) health and safety at risk for potential infection and pain. When the facility failed to prevent the development of a stage 3 pressure ulcer on right trochanter (hip). Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: esophageal cancer (cancer of the tube from throat to stomach), tracheostomy (tube inserted to help oxygen reach lungs), (diabetes type II (body does not produce enough insulin, or resist insulin), hypertension (high blood pressure). During a review concurrent interview and record review of Resident 1's Medical Record with the Assistant Director of Nurses (ADON and Treatment Nurse (TXT Nurse), reviewed as follows: 1. Skin Pressure Injury Evaluation- Dated June 06, 2024, at 1307: Right Knee Stage 4, measuring 0.5x0.8, depth 0.2. (on admission). 2. Skin non pressure injury evaluation dated June 15, 2024: Right trochanter hip blanchable redness, length 5x4, depth none .Doctor notified, encourage patient to reposition as tolerated, pain management . 3. Skin Pressure Injury Evaluation dated June 19, 2024, at 1430: Right trochanter stage 3, measuring 1.5x1.5, 0.1 depth .Reported by staff of resident with skin break down, noted the following. Right trochanter stage 3 pressure injury, tissue quality 100% granulation, scant serosanguinous drainage noted, wound edges well defined peri wound clean and intact. Resident noted to be noncompliant and is also noted to be favoring right side . 4. Carplan: The resident has pressure ulcer or potential for pressure ulcer development related to, unavoidable factors .Date initiated August 27, 2024. INTERVENTIONS: If the refuses treatment .Interdisciplinary Team (IDT) meeting and family to determine why and try alternative methods to gain compliance. Document alternative methods. (No Careplan regarding resident refusal for repositioning; facility acquired wound started June 19, 2024, no careplan documentation for June 2024, NO IDT meeting in June 2024 regaining wound and repositing refusals). (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: 555350 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 555350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373 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)