Health inspection·March 5, 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 ensure one resident (Resident 1) of three sampled residents received care to prevent the development of a pressure injury (damage to skin because of continuous pressure) when Resident 1 developed a Stage 3 pressure injury on the sacrococcygeal (the area between the hip bone on person ' s back and the tailbone) region. Residents Affected - Few This failure resulted in Resident 1 obtaining a facility acquired Stage 3 pressure injury (the loss of skin which extends to the tissue beneath the skin). Findings: A review of an admission record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses which included rheumatic tricuspid insufficiency (a heart condition in which the valve between two heart chambers does not close properly resulting in the heart working harder than it should), chronic combined systolic and diastolic heart failure (a condition in which the heart does not pump blood as well as it should) , and pulmonary hypertension (high blood pressure in the arteries and lungs). A review of Resident 1's order summary report indicated the physician ' s order, [All] Care plan read and approved by MD [physician] .[ordered on] 6/27/23 . A review of Resident 1's progress note dated 6/28/23 at 3:54 p.m. indicated, admission Braden Scale [a tool used to predict pressure injury risk] of 11 [a score of 10-12 is high risk of developing a pressure injury]. A review of Resident 1's care plan for, Bowel/bladder incontinence [unable to control bowel/bladder] related to cognitive loss [the thought process], decreased awareness of urge was initiated on 6/28/23. Staff were to provide, .perineal care [area between the anus and the vulva] care AM [in the morning], PM [in the afternoon/evening], and after each incontinence .[to assist Resident 1 to meet the goal of] .free of skin breakdown x 90 days [by] 10/1/23 . A review of Resident 1's care plan for, Potential for skin breakdown related to history of skin breakdown, [history] of bruises or skin tears due to fragile skin, incontinence, others was initiated 6/28/23. Staff were to provide, .incontinence care as needed .monitor for discoloration, bruises, swelling, skin tears or redness and report promptly .pressure relieving mattress as needed .treatment as ordered .turn and reposition frequently as needed .[to assist Resident 1 to meet the goal of] Have less skin tears or bruises x90 days .will be healed .no bruises or skin tears x90 days by [10/1/23] . (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: 555421 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 555421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonebrook Post Acute 4367 Concord Boulevard Concord, CA 94521 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)