Health inspection·June 10, 2025

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 one of five sampled residents (Resident 1) received wound preventative measures as ordered to prevent skin breakdown, promote circulation, and provide pressure relief. Residents Affected - Few This failure resulted in Resident 1 sustaining a stage 2 pressure ulcer (partial-thickness skin loss, where the epidermis (outer layer) and part of the dermis (second layer) are damaged caused by prolonged pressure) to their coccyx (tailbone), which had the potential to lead to complications including pain, discomfort, and infection. Findings: During a record review of the facility policy titled Skin Integrity Management Protocol dated 1/2019, it was indicated that staff were to relieve the underlying cause, addressing pressure, shear, other physical friction, and maceration/moisture factors. The facility policy indicated to keep local areas clean, dry, and free of body wastes such as urine, feces, perspiration, and wound drainage. The policy indicated to inspect skin frequently for indications of hyperemia (redness, swelling, and warmth), non-blanchable erythema (redness of the skin or mucous membranes), or disruption of skin integrity .sacrum/coccyx, and buttocks and to apply skin A&D ointment (zinc oxide) as indicated for skin maintenance. During a record review of the facility job description for Certified Nursing Assistants (CNAs) undated, it was indicated that facility CNAs were to observe and report the presence of pressure areas and skin breakdowns to prevent bedsores. A record review of Resident 1's admission record indicated they were admitted to the facility on [DATE] with diagnoses that included an intertrochanteric fracture of the right femur (a break in the upper part of the thigh bone) after a fall at home with Open Reduction Internal Fixation (ORIF - a surgical procedure used to repair broken bones, particularly in cases where the bone is displaced or comminuted), protein-calorie malnutrition (nutritional status with reduced availability of nutrients leads to changes in body composition and function), panic disorder (frequent and unexpected panic attacks), and hypokalemia (a low potassium level in blood). Resident 1 was their own responsible party (made their own financial and medical decisions). During a record review of Resident 1's Minimum Data Set (MDS - a standard assessment tool used in nursing homes and other long-term care facilities to collect data on residents' health and functional status) Section H Bowel and Bladder dated 9/26/24, Resident 1 was assessed as occasionally incontinent for urine and always incontinent for bowel. Page 1 of 3 555802 555802 06/10/2025 Country Crest Post-Acute 50 Concordia Lane Oroville, CA 95966

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a record review of Resident 1's MDS Section M Skin Conditions dated 9/26/24, Resident 1 was assessed as at risk for developing pressure ulcers. During a record review of Interdisciplinary Team (IDT - team of professionals from different disciplines to work collaboratively towards a resident's treatment plan) Notes dated 11/4/24, the Director of Nursing (DON) indicated that Resident 1 had a Braden score (a tool used to predict the risk of developing pressure ulcers) risk of 14 (a score of 18 or less indicates at-risk status) and indicated they were a moderate risk. During a record review of Resident 1's admission Baseline Care Plan dated 9/26/24, Resident 1's skin was assessed with surgical staples to the right hip and scattered purple discoloration to bilateral upper extremities, and moisture-associated skin damage (MASD - skin inflammation and erosion caused by prolonged exposure to moisture, like urine, stool, perspiration, or wound drainage) to buttocks and groin. During a record review of Resident 1's care plan dated 9/27/24, staff were to observe for skin redness and report accordingly. Resident 1 was at risk for skin breakdown or pressure ulcer formation. The care plan further indicated that staff were to observe for the presence of skin breakdown during care. During a record review of Resident 1's Physician Orders dated 9/26/24, it was indicated that zinc oxide was to be applied to the buttocks and groin as needed for skin maintenance. During a record review of the Situation-Background-Assessment-Recommendation (SBAR - a structured communication tool used to improve communication between healthcare professionals, especially when discussing critical patient information) dated 10/28/24, Resident 1 had a wound to their coccyx evaluated by nursing staff. Nursing staff concluded that Resident 1 had a stage 2 pressure ulcer (a partial-thickness skin loss due to unrelieved pressure) to their coccyx, and Resident 1 verbalized pain. During a record review of Resident 1's Physician Orders dated 10/28/24, it was indicated that the coccyx area was to be cleaned with normal saline, zinc oxide applied and covered with comfort foam dressing every shift for wound care. During a record review of Resident 1's shower sheets dated 10/1/24, 10/5/24, 10/8/24, 10/12/24, 10/15/24, 10/19/24, 10/22/24, 10/26/24, 11/2/24, 11/5/24, 11/9/24, 11/12/24, 11/15/24, and 11/16/24, CNAs did not indicate any reddened areas or rashes on Resident 1. During a record review of Skilled Services Documentation dated 9/29/24 through 10/27/24, nursing staff documented no skin issues for Resident 1 every day. During an interview with Licensed Vocational Nurse (LVN) A on 6/10/25 at 9:54 am, LVN A stated that the facility expectation was for CNAs to document on shower sheets when they noted skin issues. LVN A stated that CNAs should have documented rash for Resident 1's coccyx area and notified facility nursing staff. LVN A stated that it was difficult to get CNAs to complete skin assessments on facility residents. LVN A stated that they had voiced their concerns to the Director of Staff Development (DSD) but did not receive feedback. During an interview with the DSD on 6/10/25 at 10:21 am, the DSD stated that they faced challenges with newer CNAs and resident skin assessments. The DSD stated that CNAs did not know how to assess 555802 Page 2 of 3 555802 06/10/2025 Country Crest Post-Acute 50 Concordia Lane Oroville, CA 95966

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents' skin and how to determine if a change had occurred. The DSD stated that they were aware that nursing staff complained about CNAs and how they did not know how to properly document skin assessments. The DSD confirmed that staff did not follow the facility skin assessment policy for Resident 1. During an interview with the Administrator (Admin) on 6/10/25 at 11:30 am, the Admin confirmed that CNAs and nursing staff did not assess and document per facility policy to prevent and treat Resident 1's pressure ulcer. The Admin confirmed that the lack of assessment and documentation contributed to the breakdown of communication and care that could have prevented a stage 2 pressure ulcer for Resident 1. 555802 Page 3 of 3