Inspection·September 12, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1's clinical record was accurately documented when Resident 1's right heel ulcer was documented in the Treatment Administration Record (TAR) as a right lower leg ulcer. This failure had the potential to result in uncoordinated care. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses that included pressure ulcer (localized damage to one or more layers of the skin and/or underlying soft tissue usually over a bony prominence) of the right heel. During a review of Podiatry (branch of medicine devoted to the study, diagnosis and treatment of foot and ankle) Progress Notes dated 8/8/23, the Podiatry Progress Notes indicated Resident 1 presented to the podiatry clinic for follow-up visit for right medial (towards the middle/center) heel wound. The Progress Notes indicated current wound care as wet to dry, posterior splint, and heel wedge. During a concurrent interview and review with Treatment Nurse (TN) 1 on 9/12/23 at 12:10 p.m., Resident 1's TAR for July 2023 was reviewed , the TAR indicated Resident 1's right heel wound treatment as: cleanse right heel wound with normal saline (NS, a solution used to cleanse wounds during wound dressing changes), gently pat dry, pack wound with black foam, cover with drape, change every Monday, Wednesday and Friday and as needed if soiled or dressing is displaced. TN 1 stated Resident 1's right heel received Negative Pressure Wound Therapy (NPWT, a therapeutic technique using suction pump, tubing, and dressing to remove excess drainage and promote healing in acute or chronic wounds). During a review of Resident 1's TAR for August 2023, the TAR indicated the same treatment with NPWT was provided on the right heel until 8/4/23. The TAR for August 2023 also indicated the NPWT was discontinued on 8/5/23. Resident 1's TAR did not indicate a wound treatment for the right heel, after NPWT was discontinued, from 8/6/23 to 8/9/23. During a concurrent interview and review with Director of Nursing (DON) on 9/12/23 at 1 p.m., Resident 1's Order Summary Report and TAR for August 2023 were reviewed. DON stated the wound that was indicated in Resident 1's August 2023 TAR as right lower leg (everything between the knee and the ankle) was incorrect. DON stated the wound care was meant for Resident 1's right heel because Resident 1 did not have any wound on the right lower leg. Resident 1's August 2023 indicated body audit was done daily in the morning for skin observation. DON stated the licensed staff who did the body audit (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: 555710 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 555710 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tice Valley Post Acute 1975 Tice Valley Blvd. 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)