Health inspection·November 13, 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 necessary treatment and services to promote healing of pressure injuries (a localized area of skin damage caused by prolonged or intense pressure on the skin, often over bony parts of the body) are provided in a timely manner, for one of three residents (Resident A), when: Residents Affected - Few - The pressure injury on the sacral area (lower portion of spinal column) was not identified on admission and treatment orders not initiated timely; and - Treatment orders were not administered as ordered by the physician. These failures had the potential in the delay in care and treatment of Resident A's pressure injury which could affect healing. Findings: On November 6, 2024, at 12: 30 p.m., an unannounced visit to the facility was conducted to investigate complaints and facility reported incident of quality of care and neglect. On November 6, 2024, at 1:30p.m., an interview and concurrent record review was conducted with the Treatment Nurse (TN). The TN stated when Resident A was admitted to the facility, it was hard to notice the wound on the resident's sacrum, due to the resident ' s dark skin tone. The TN stated Resident A came from the hospital with a scaral wound which was unable to stage because of presence of necrotic tissue (black dead tissue) and was difficult to see and took two people to examine her sacral area because the resident had loose skin around her bottom, it. The TN stated she forgot to document a description of the sacral wound bed on Resident A's skin assessment note, dated October 22, 2024. The TN stated Resident A's sacral wound bed had an eschar (dark colored leathery dead tissue) present when she assessed it on October 15, 2024. The TN stated the facility's protocol for prevention of pressure injury which includes a wound consult. The TN stated usually a wound consultant comes in and would document an assessment of the wound weekly and would give any treatment recommendations for the licensed nurse to implement, but there was no wound consult done. The TN stated she last worked on October 29, 2024, and returned to work on November 5, 2024. On November 6, 2024, at 4:00 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident A did not have an order for a wound care consult upon identification of the pressure injuries. The DON stated but Resident A did not see a wound care consultant. On November 6, 2024, a review of Resident A ' s medical record was conducted. Resident A was Page 1 of 4 555613 555613 11/13/2024 The Grove Care and Wellness 3401 Lemon Street Riverside, CA 92501

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few admitted to the facility on [DATE], with diagnoses which included a urinary tract infection (bladder infection) and dementia (problems with thinking and remembering). A review of Resident A's Initial admission Record, dated October 14, 2024, indicated, .Patient had dry skin on lower extremities and red heel, has edema (swelling) at both lower extremities and her left upper arm. Has pressure injury on sacrum .Signed date: 11/04/2024 (November 4, 2024) . A review of Resident A's Audit Report .admission Assessment, dated November 12, 2024, indicated documentation on the pressure injury on the sacrum was added on November 4, 2024, and not on admission on [DATE]. A review of Resident A's care plan, dated October 14, 2204, indicated, .has pressure ulcer development r/t (related to) poor mobility, requires assistance with adls (Activities of Daily Living) .pt (patient) admitted with left heel P/I .sacrum p/i .right heel p/i .Interventions .Administer treatments as ordered and monitor its effectivenesss .Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress . A review of Resident A's Order Summary Report, indicated the following physician's order: - .(L)(left) heel P/I (pressure injury): Cleanse with NS (normal saline) pat dry apint (sic) with betadine cover with DD (dry dressing) every day shift for 21 days ., date ordered October 15, 2024; - .(R)(right) heel P/I: with NS pat dry apint (sic) with betadine cover with DD (dry dressing) every day shift for 21 days ., date ordered October 15, 2024; - .Sacrum P/I: Cleanse with NS pat dry apply xeroform cover with DD every day shift for 21 days ., date ordered October 15, 2024; and - .Sacrum P/I: Cleanse with NS pat dry paint with beetadine cover with DD every day shift for 21 days ., date ordered October 19, 2024. A review of Resident A ' s Treatment Administration Records (TAR), indicated all treatment orders were completed on the day the treatment was scheduled for October 2024. A review of Resident A's Administration Audit Report, indicated the following: - Left heel treatment scheduled for October 15, 2024, was documented as administered on October 19, 2024; - Sacrum pressure injury treatment scheduled for October 16, 17, and 18, 2024, was documented as administered on October 19, 2024; - Right heel treatment scheduled for October 16, 17, 18, and 19, 2024, was documented as administered on October 22, 2024. - Sacrum P/I scheduled for October 19 and 21, 2024, was documented as administered on October 23, 2024; 555613 Page 2 of 4 555613 11/13/2024 The Grove Care and Wellness 3401 Lemon Street Riverside, CA 92501

F 0686 - Sacrum P/I scheduled for October 20, 2024, was documented as administered on October 24, 2024. Level of Harm - Minimal harm or potential for actual harm A review of Resident A's Skin Pressure Ulcer Weekly, dated October 29, 2024, indicated documentation of Resident A's pressure injuries completed by the TN on November 4, 2024. Residents Affected - Few A review of Resident A's Progress Notes, indicated the following: - November 3, 2024, at 9:44 a.m., indicated, .Foul odor wound at sacrum . - November 3, 2024, at 3:27 p.m., indicated, .Obtained order from (name of physician) to have Rocephin (brand of antibiotic) for wound infection and do wound culture (laboratory test to check presence of bacteria on the wound) . - November 3, 2024, at 5:34 p.m., indicated, .Resident continues to have malodor to the coccyx wound, large amount of purulent (containing pus) exudate (fluid that leaks out of blood vessels into nearby tissues) noted . - November 4, 2024, at 3:42 p.m., indicated, .patient was transferred to hospital . On November 12, 2024, at 1:05 p.m., an interview was conducted with the Licensed Vocational Nurse (LVN). The LVN stated the admission nurse was responsible for completing a head to toe assessment on admission. On November 12, 2024, at 1:55 p.m., an interview was conducted with the Minimal Data Set (MDS) nurse. The MDS stated she does fill in when needed as the treatment nurse. The MDS stated she performed a skin evaluation on Resident A on October 30, 2024, but did not complete the note. The MDS stated she did not feel confident with wound care notes and did not measure Resident A ' s sacral wound or document the wound description. The MDS stated she usually would leave that for the treatment nurse to complete. On November 12, 2024, at 2:30 p.m. an interview and concurrent record review was conducted with the TN. The TN stated the admission nurse was to complete the initial assessment on a new resident and one of the assessments to be completed including the skin. The TN stated she does not remember why she did not complete her initial skin assessment note for Resident A on October 15, 2024, she made changes to her documentation on October 18 and 22, 2024, but she should not have waited to complete her documentation. The TN sated she did Resident A's treatment to her heels and sacrum starting on October 15, 2024, and did not document consistently or daily as her audit report indicated, she should be signing off treatments the day they were completed not two or three days after. On November 12, 2024, at 4:30 p.m., an interview and concurrent record review was conducted with the Registered Nurse (RN). The RN stated the initial admission assessment included a full body skin check, and after the assessment, we notify the doctor with our findings, and ask for orders. The RN stated she forgot to put Resident A ' s sacral pressure injury on the initial assessment, she forgot to document it on October 14, 2024 and when she remembered she added it on November 4, 2024. A review of the facility ' s undated policy titled, Change of Condition Reporting, indicated, .all changes in resident condition will be communicated to the physician .timely notification of a change in resident condition .change in a resident ' s condition manifested by a marked change in physical 555613 Page 3 of 4 555613 11/13/2024 The Grove Care and Wellness 3401 Lemon Street Riverside, CA 92501

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few or mental behavior will be communicated to the physician with a request for physician visit .or acute care evaluation .document resident change of condition and response in nursing progress notes per policy and update resident care plan, as indicated . comprehensive care plan completed . A review of the facility ' s policy and procedures titled, Skin Management System, dated December 2023, indicated, .Residents will have a head to toe skin assessment by a licensed nurse at the time of admission. Any skin lesions will be documented on the Nursing admission Assessment. A treatment order will be obtained from the attending physician for areas requiring treatment .A plan of care will be initiated to address areas of actual skin breakdown. The plan of care will be reviewed and revised as needed. Resident will have ongoing head to toe assessment done weekly, incorporated into the LN Weekly Summary review .report of all wounds and their progress will be updated by the treatment nurse weekly . 555613 Page 4 of 4