Health inspection·September 18, 2023

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 observation, interview, and record review, the facility failed to ensure staff provide preventive care by consistently turning residents every 2 hours on two of two sampled residents (Resident 41 and Resident 42). Residents Affected - Few This failure had the potential to result in worsening of pressure injury (bed sore, injury to skin and underlying tissue resulting from prolonged pressure on skin) for Resident 41 and developing new pressure injury for Resident 42. Findings: During a review of Resident 41's History and Physical (H&P), dated 07/14/2023, the H&P indicated, Resident 41 was admitted to transitional care unit (where assists patients as they transition from a stay in the hospital to home or another level of care) for hypotension (low blood pressure). Patient had hemiparesis (weakness to move on side of body) affecting left side as late effect of cerebrovascular accident (damage to brain from interruption of its blood supply) and generalized weakness. During a review of Resident 41's care assessment dated 07/14/2023, the care assessment indicated, Resident 41 ' s Braden Scale (a tool to assess risk for developing pressure injury) Score was 12 (indicates high-risk for developing a pressure injury). During a review of Resident 42's History and Physical (H&P), dated 09/15/2023, the H&P indicated, Resident 42 was admitted to transitional care unit for rehabilitation. Patient had sepsis (a life-threatening complication of an infection), hypertension (high blood pressure), diabetes mellitus (high blood sugar), cellulitis (bacterial skin infection) and debility (physical weakness). During a review of Resident 42's PCS Open Chart dated 09/14/2023, the PCS Open Chart indicated, Resident 42's Braden Scale (a tool to assess risk for developing pressure injury) Score was 14 (indicates moderate-risk for developing a pressure injury). During an interview, on 09/19/2023 at 11:07 a.m., with Wound Care Ostomy Nurse (WCON) 1, WCON 1 stated with Braden Scale (a tool to assess risk for developing pressure injury) score of 18 or below, high risk turning protocol will be triggered to prompt nurses to document turning every 2 hours. During an interview, on 09/21/2023 at 11:16 a.m., with Resident 42, Resident 42 stated he could only turn a little and the staff turned him when changing him and when therapy comes once a day. During an interview on 09/21/2023 at 11:19 a.m., with director of TCU (DIR), DIR confirmed both Resident 41 and Resident 42 were on high risk turning protocol which required turning every 2 hours. (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: 555610 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 555610 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emanate Health Inter-Community Hospital- D/P Snf 210 W. San Bernardino Rd. Covina, CA 91723 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)