Health inspection·October 10, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 provide services in accordance with professional standards of practice for one of three sampled residents (Resident 1) when license nurses did not accurately complete Resident 1's Skin Assessments. This failure had the potential to compromise the facility's ability to provide resident-centered interventions based on assessment data. Residents Affected - Few Findings: Review of Resident 1's medical record indicated he was admitted on [DATE] and had the diagnoses including hypoxic ischemic encephalopathy (a type of brain damage that occurs when the brain has decreased oxygen or blood flow). Review of Resident 1's Nursing Notes, dated 8/15/24, indicated a license nurse checked on Resident 1's skin and noted dryness on left breast. Resident 1's weekly Skin Assessments, dated 8/16/24, were reviewed. There was a section asking if Resident 1 had impaired skin, and it was marked on No. Review of Resident 1's IDT: Special Issue, dated 8/19/24, indicated a licensed nurse checked on Resident 1's skin and noted swelling and discharge on the left nipple. Review of Resident 1's physician's order, dated 8/19/24, indicated to clean the affected site with NS (normal saline), put on Xeroform (topical medicated gauze used to cover wound), and cover it with Mepilex (topical foam dressing used to treat wound) every shift for 7 days on the left nipple. Review of Resident 1's physician's order dated 8/19/24 indicated, Amoxicillin-Pot Clavulanate (antibiotics, a medication to treat infections) Suspension reconstituted 400-57 milligram (mg, a type of unit measurement)/5 millimeter (ml, a type of unit measurement), give 3.1 ml two times a day for cellulitis for 7 days. Resident 1's weekly Skin Assessments, dated 8/22/24, were reviewed. There was a section asking if Resident 1 had impaired skin, and it was marked on No. During an interview and concurrent record review on 9/3/24 at 3 p.m. with the director of nursing (DON), she reviewed the above Skin Assessments and confirmed Resident 1's dryness on the left breast, and swelling and discharge on left nipple wound were not documented in the designated sections. The DON acknowledged Resident 1's Skin Assessments on 8/16/24 and 8/22/24 were not accurate. (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: 555734 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 555734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Hc Org No CA -Pediatric Hospital D/P Snf 3777 South Bascom Avenue Campbell, CA 95008 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)