Health inspection·February 15, 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 observation, interview, and record review, the facility failed to provide the necessary care and treatment to a resident's (1) identified skin issues (redness of the buttocks), for one of three sampled residents, when Resident 1's physician was not informed of the resident's skin condition during admission to the facility. Residents Affected - Few The delayed care and treatment to Resident 1's skin issues had the potential to worsen Resident 1's skin condition. Findings: On 2/9/24, an unannounced onsite at the facility was conducted related to a complaint on quality of care. During a review of the facility's admission Record, dated 12/31/23, the admission Record indicated Resident 1 was admitted to the facility, with diagnoses which included generalized body weakness, dementia (inability to think, remember and reason), hemiplegia (paralysis that affect one side of the body), and hemiparesis (weakness or inability to move on one side of the body). During a review of Resident 1's minimum data set (MDS, an assessment tool), dated 1/2/24, indicated Resident 1's brief interview for mental status (BIMS, ability to recall) score was 7, which meant Resident 1's cognition was severely impaired. The functional abilities section of the MDS indicated Resident 1 required maximum assistance when repositioning in bed. During a review of Resident 1's undated acute care hospital (ACH) record, indicated Resident 1 had no skin issues [no rashes or ecchymosis - bruises]. During a review of Resident 1's skin measurement observation form completed by Licensed Nurse (LN) 1 dated 1/14/24, indicated LN 1 documented Resident 1 had moisture associated skin damage (MASD, caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents) at the buttocks. During a review of Resident 1's Treatment Administration Record (TAR) for January 2024, indicated Resident 1 started receiving treatment of her buttocks on 1/2/24. During a joint observation of Resident 1 and an interview with Resident 1's personal caregiver (PC) on 2/9/24 at 12:13 P.M., PC stated she came to the facility every day. PC stated Resident 1 had some redness on her buttocks. PC opened Resident 1's incontinence brief and showed Resident 1's Page 1 of 2 555870 555870 02/15/2024 Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945

F 0686 buttocks. Resident 1 had a red, open area at the buttocks, with dry flaky skin surrounding the open area. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview with LN 2 and a review of Resident 1's record on 2/9/24 at 4:17 P.M., LN 2 stated she admitted Resident 1 to the facility on [DATE]. LN 2 stated Resident 1 had redness on her groin and sacral area upon the initial skin assessment. LN 2 stated Resident 1 was diabetic and given her age was prone to skin issues. LN 2 stated if there was redness, there should be a barrier cream (protects the skin from external irritants) applied to the affected area. LN 2 stated she did not recall calling the physician. Residents Affected - Few During a telephone interview with LN 1 on 2/15/24 at 11 A.M., LN 1 stated he did a thorough skin assessment on Resident 1 on 1/2/24 and noted Resident 1's skin redness of her buttocks and was assessed as MASD. LN 1 stated Resident 1 started getting treatment of her buttocks on 1/2/24. LN 1 stated the facility's policy was, Upon identifying the resident's skin issues, the LN has to inform the physician to get an order for the barrier cream or triad paste because you don't want the skin condition to get worse and try to treat it right away. During a telephone interview with the Director of Nursing (DON) on 2/15/24 at 2:40 P.M., the DON stated the expectation was if there were skin issues, the LNs should notify the doctor and have initiated the treatment because the skin condition could worsen overnight. During a review of the facility's policy titled, Prevention of Pressure Injuries, revised April 2020, the policy indicated, Purpose - The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors .Prevention .Skin Care .4. Use a barrier product to protect skin from moisture .Monitoring, I. Evaluate, report and document potential changes in the skin . 555870 Page 2 of 2