Health inspection·June 15, 2023

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 and record review, the facility failed to input the correct setting on the Low Air Loss Mattress (LAL Mattress; an air mattress designed to prevent and treat pressure ulcer [an injury that breaks down the skin and underlying tissue]) for one of three sampled residents (Resident 1). Residents Affected - Few This deficient practice has the potential for Resident 1 to develop a pressure ulcer. Findings: A review of Resident 1's admission record, indicated Resident 1 was admitted on [DATE] with the diagnosis of disorientation (a state of mental confusion), muscle weakness and difficulty in walking. A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care planning tool), dated 3/1/2023, indicated Resident 1's cognitive skills for daily decision making is moderately impaired (decisions poor; cues/ supervision required). The MDS also indicated Resident 1 required one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) for bed mobility, dressing, and personal hygiene. The MDS also indicated the resident required one-person total dependence during transfer, and toilet use. The MDS indicated Resident 1 was 123 pounds (lbs- pounds, unit of measurement). A review of Resident 1's History and Physical, dated 11/29/2022, indicated Resident 1 does not have the capacity to understand and make decisions. A review of Resident 1's Braden Scale for Predicting Pressure Sore Risk, dated 12/12/2023, indicated Resident 1 was at risk for pressure ulcer development. A review of Resident 1's physician orders, dated 5/6/2023, indicated LAL Mattress: Monitor setting/Placement - Every Shift. The physician's order did not specify the LAL Mattress needs to be adjusted according to the resident's weight. A review of Resident 1's treatment administration record (TAR, the report that serves as a legal record of the treatment administered to a patient) for May 2023, indicated LAL mattress: Monitor setting placement Type TX- Treatment - Every Shift. The TAR did not specify the LAL Mattress setting would need to be adjusted according to the resident's weight. A review of Resident 1's Care Plan for right inner buttock skin abrasion, initiated on 5/9/2022, indicated LAL mattress to maintain skin integrity and promote right inner buttock skin lesion. The (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: 555432 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. Los Angeles, CA 90041 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)