Inspection·December 9, 2022

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 adequate pressure ulcer management was provided for one resident (Resident 9), for a census of 25 when: Residents Affected - Few 1. The low air loss mattress (LAL, designed to distribute the body weight and help prevent skin breakdown) was not provided as ordered; and 2. There was missing and incomplete wound assessments. These failures increased the risk for wound deterioration. Findings: A review of the medical records indicated Resident 9 was admitted with diagnoses including heart failure (the heart cannot pump enough blood and oxygen to support other organs in the body). A Minimum Data Set (MDS, an assessment tool) dated 10/11/22 indicated Resident 9 was cognitively intact with a score of 13/15 in the Brief Interview of Mental Status (BIMS, test of cognition). Resident 9's Braden Scale for Predicting Pressure Sore Risk indicated he was at risk. Resident 9's physician order dated 10/6/22 indicated, May have LAL mattress for pressure ulcer and skin management every shift. Resident 9's progress note dated 10/21/22 indicated a new pressure ulcer/injury on the left heel. Resident 9's Wound evaluation dated 10/21/22 indicated an unstageable (the stage is not clear, wound bed covered by slough or dead tissue) pressure ulcer on left heel measuring 1.47 cm (centimeters, unit of measure) for the length and 1.26 cm for the width. The wound bed with 60% slough. A progress note dated 10/28/22 indicated, IDT [Interdisciplinary] Review for Skin dated 10/21/22 [Resident 9] reported to have an open are [sic] to left heel .[Resident 9] is alert and independent with transfer and ambulation. Root cause: [Resident 9] is self transfer and ambulation and is wearing improper footwear that put pressure to the heel .medical condition related. A concurrent observation and interview was conducted on 12/7/22 starting at 2:08 p.m. inside Resident 9's room with the Director of Nursing (DON), Licensed Nurse 2 (LN 2) and a Certified Nursing Assistant. Resident 9 was lying in bed with his left foot elevated with a pillow and a regular mattress. Resident stated he had no pain when his left foot was examined by the LN 2. The LN 2 stated Resident 9's wound was unstageable, identified on 10/21/22 due to his footwear and his preference to lay on (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 4 Event ID: 555769 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 555769 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE University Retirement Community at Davis 1515 Shasta Drive Davis, CA 95616 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)