Health inspection·January 22, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure ongoing nursing assessments for one of three residents (Resident 1) involving: Residents Affected - Few 1. admission Evaluation did not include skin condition of buttock area that had Mepilex (absorbent foam dressing) for protection. 2. When pressure injury was evaluated, Pressure Ulcer Report was not completed until four days after admission and Skin and Wound Evaluation Report was completed after an additional three days. 3. Care plans for rashes and pain were not personalized for Resident 1. 4. Treatment Administration Record (TAR) did not have entries for nine tasks related to skin monitoring and wound care. This failure resulted in Resident 1 not receiving ongoing assessments and the delay in having updated status of pressure injury (a localized damage to the skin and underlying tissue usually over a bony prominence or related to a medical or other device) may potentially affect Resident 1's care and well-being. Findings: A review of Resident 1's face sheet, undated, indicated Resident 1 was admitted to the facility in July 2023 with diagnoses of muscle weakness and atrophy (decrease in size). A review of Resident 1's facility document Braden Scale For Predicting Pressure Risk, dated 7/14/23, indicated Resident 1's Braden score is 11 (score of 10–12 = High Risk). A review of Resident 1's facility document Minimum Data Set (MDS, an assessment tool used to guide care), dated 7/20/23, indicated Resident 1 required extensive assistance with bed mobility, toilet use, and personal hygiene including total dependence with bathing. MDS also indicated Resident 1 required substantial/maximal assistance to roll from lying on back to left and right side. MDS indicated Resident 1 had one Stage 2 (can be an intact blister or shallow open sore) pressure ulcer present upon admission. 1. During an interview on 10/3/23 at 8:15 a.m. with Assistant Director of Nursing (ADON), ADON stated Licensed Vocational Nurse (LVN) 1 received a discharge report from acute hospital that Resident 1 had a Mepilex dressing for buttock protection. Per ADON, Registered Nurse (RN) 1 did not have the buttock area skin condition on Resident 1's admission form. At 11:20 a.m., ADON stated having no (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: 555446 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 555446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rossmoor Post Acute 1226 Rossmoor Parkway Walnut Creek, CA 94595 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)