Health inspection·April 25, 2025

§483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing 72315 - Nursing Service--Patient Care. (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures, and deformities. Such care shall include: (1) Changing position of bedfast and chairfast patients with preventive skin care in accordance with the needs of the patient. (4) Using pressure-reducing devices where indicated. (7) Carrying out of physician's orders for treatment of decubitus ulcers. The facility shall notify the physician, when a decubitus ulcer first occurs, as well as when treatment is not effective, and shall document such notification as required in Section 72311(b). 72523 - Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 3/11/2025 during a standard annual recertification survey the California Department of Health (CDPH) identified that the facility failed to ensure Resident 154, who was assessed at a high risk for developing a pressure injury did not develop a deep tissue skin injury ([DTI] (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) on the right lateral (side) foot and the right buttock. The facility failed to: 1.Ensure Resident 154 was turned and repositioned every two hours per physician order and a care plan titled, "Risk for Skin breakdown" dated 1/27/25 2. Ensure Resident 154 skin assessment was done during shower days and/or bed bath (a wash that you give to someone who cannot leave their bed). 3. Ensure Certified Nursing Assistant (CNA- in general) inspected Resident 154's skin daily and the licensed nurses assessed the resident 's skin weekly as indicated in the resident's care plan titled, "Risk for Skin Breakdown" dated 1/2025. As a result, Resident 154 developed a DTI on 2/25/25 measured 2.5 centimeter (cm) in length by 2.0 cm in width, on the right lateral foot and on 3/11/25 developed DTI on a right buttock measured 3.5 cm in length by 1.5 cm in width with undetermined depth. A review of Resident 154's Admission Record, indicated Resident 154 was admitted to the facility on 1/25/25, with diagnoses of cerebral infarction (damage to the brain from interruption of its blood supply), chronic respiratory failure (a long-term condition where there is not enough oxygen in your body), and functional quadriplegia (complete immobility due to severe disability requiring total assistance with daily activities). A review of Resident 154's History and Physical (H&P), dated 1/28/25, indicated, Resident 154 did not have the capacity to understand and make decisions. A review of Resident 154's Minimum Data Set ([MDS], resident assessment tool), dated 2/1/25, indicated, Resident 154 was dependent (helper does all the effort. Resident does none of the effort to complete the activity) on staff for toileting hygiene, shower/bath self, and personal hygiene. The MDS indicated Resident 154 was always incontinent of bowel (no episodes of continent bowel movements) The MDS indicated Resident 154 was at risk of developing pressure injuries. A review of Resident 154's Braden Scale (tool used to assess a patient's risk of developing pressure injury) dated 1/25/25, indicated, Resident 154's total score was 10 (High Risk: Total Score 10-12) which indicated Resident 154 was a high risk for developing a pressure injury. A review of Resident 154's care plan titled, "Risk for Skin breakdown," dated 1/27/25 indicated the goal for Resident 154's was to have an intact skin as evidence by no redness over bony prominences (areas where bones are close to the skin's surface) and other pressure area. The care plan interventions included to turn and reposition resident at least every two hours, reassess skin daily by CNA and weekly by licensed nurses/treatment nurse and notify a physician and resident or resident representative for significant change in skin condition. A review of Resident 154's Physician Order Summary, dated 1/27/25, indicated to elevate the resident's left and right lower extremity with a pillow when in bed daily for 14 days. A review of Resident 154's Interdisciplinary Team ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) Conference, dated 1/29/25, indicated interventions for skin breakdown included repositioning the resident as often as needed. A review of Resident 154's undated IDT Notes for Pressure Ulcer and Other Wounds Recommendations/Comments, indicated, "Resident at risk for further skin breakdown from multiple medical contributing factors; severely contracted, generalized edema (swelling), limited positioning, total dependent with two persons assist in bed mobility and positioning." A review of Resident 154's Skin Inspection dated 2/7/25 Resident 154's right buttock and right lateral foot had intact skin. A review of Resident 154's Physician Order Summary dated 2/25/25, indicated to apply Prevalon Boots (help reduce the risk of pressure injury by keeping the heel floated) to bilateral feet while in bed to reduce/prevent further pressure damage every day and night shift. A review of Resident 154's Skin Integrity Report, dated 2/25/25, indicated the resident had a DTI to a right buttock measured 3.5 cm in length, 1.5 cm in width, with undetermined depth and DTI to a right lateral foot measured l 2.5 cm in length, 2.0 cm in width with undetermined depth. A review of Resident 154's Treatment administration Record (TAR) dated 2/25/25, indicated a physician's order dated 2/25/25 to apply Prevalon Boots, to relieve pressure to bilateral feet while in bed to reduce/prevent further damaged due to pressure, on day shift (7a.m. to 7 p.m.) and on night shift (7 p.m. to 7 a.m.). A review of Resident 154's undated shower record, titled "Subacute Shower," the record indicated, Resident 154's shower days were Tuesday and Friday. During an observation on 3/12/25 at 8:39 a.m. in Resident 154's room, Resident 154 was observed in bed lying on a left side with eyes open, non-verbal (unable to communicate using spoken words), and non-responsive to verbal and tactile stimuli (any form of touch or physical contact that is perceived by the skin). During a concurrent observation and interview on 3/12/25 at 1:21 p.m. with Treatment Nurse (TN) 1, in Resident 154's room, Resident 154 was observed in bed lying on a left side with open eyes and non-verbal. Resident 154 was observed lying on a low loss air mattress ([LAL] a type of medical mattress designed to prevent and treat pressure injury by constantly circulating air through tiny holes, keeping the skin cool and dry and reducing moisture buildup) with a sheet under the resident. During the observation Resident 154's was observed to have a pressure injury located on her right lateral foot which appeared with intact skin and black discolored area without a drainage. Resident 154 was also observed to have an open skin on the right buttock, red in color and without a drainage. TN 1 stated the Registered Nurse (RN), and TN were responsible for performing skin assessments upon admission, weekly, and as needed. TN 1 stated CNA's will inform TN of any changes in residents skin condition. TN 1 stated during shower and resident bed bath, CNAs would do a residents (in general) skin inspections and document on the Skin Inspection sheet of any changes to a residents' skin. TN 1 stated any changes to a residents' skin will be reported immediately to the charge nurses and TN. TN 1 stated residents were showered twice weekly and received bed baths on remaining days of the week. TN 1 stated CNA 3 reported to TN 1 Resident 154's newly developed pressure injury to the right buttock on 3/11/25 (documented 2/25/25). TN 1 stated it started as a blister that progressed to a DTI. TN 1 stated Resident 154 also developed a DTI to her right lateral (side) foot that was observed on 2/25/25 during TN 1 weekly wound assessment. TN 1 stated Resident 154 should be turned and repositioned every two hours and as needed in order to prevent development and deterioration of existing pressure injuries. TN 1 stated turning and repositioning residents helps with blood circulation (the movement of blood throughout the body) and helps to decrease the chances of developing a pressure injury. TN 1 stated Resident 154's pressure injury to the right lateral foot and right buttock could have been avoided if the resident was turned every two hours and if Prevalon boots were applied sooner, right upon admission on 1/25/25. TN 1 stated he did not order Prevalon boots to Resident 154 until 2/25/25, and instead he used pillows to help relieve the pressure from Resident 154's heels. During a concurrent interview and record review on 3/12/25 at 1:30 p.m. with TN 1, Resident 154's Turn and Reposition Turning Schedule for the month of 2/2025, was reviewed. The Turn and Reposition Turning Schedule indicated Resident 154 had not been turned and repositioned every two hours per Resident 154's care plan. TN 1 stated that Resident 154 had not been turned and repositioned every two hours from 2/11/25 through 2/28/25. During an observation on 3/12/25 at 3:30 pm in Resident 154's room, Resident 154 remained in bed lying on her left side from the last observation on 3/12/25 at 8:39 a.m. and 1:21 p.m. During a concurrent interview and record review on 3/13/25 at 9:20 a.m. CNA 3 stated that he was responsible for assisting residents with their activities of daily living and turning and repositioning the residents in bed. Resident 154's Skin Inspection Sheets dated 2/7/25 and 2/11/25 were reviewed with CNA 3. CNA 3 stated Resident 154 right buttock and right heel skin was intact. CNA 3 stated Resident 154 did not have Skin Inspection Sheets for the month of 1/25 and 3/25. CNA 3 stated missing Resident 154's Skin Inspection Sheets indicated Resident 154 did not receive a shower on her scheduled shower days (Tuesdays and Fridays) and the resident's skin was not inspected. CNA 3 stated that he was responsible for doing skin inspection when Resident 154 received a shower or a bed bath. CNA 3 stated he must report any observed skin changes to the charge nurse or treatment nurse immediately. CNA 3 stated on the days that residents (in general) were not scheduled for shower; residents should receive a bed bath. CNA 3 stated skin changes would be considered open areas, redness, blisters, discoloration, and swelling of the skin. CNA 3 stated after resident shower or bed bath he documents on the Skin Inspection Sheets. CNA 3 stated the treatment nurse reviews the Skin Inspection Sheets and signs the sheet after it was reviewed. CNA 3 stated residents should be turned and repositioned every two hours and as needed. CNA 3 stated when the residents were turned and repositioned it should be documented on the residents Turn and Reposition Turning Schedule form. CNA 3 stated if there was no documentation on the Turn and Reposition Turning Schedule form it means that Resident 154 was not turned and repositioned. CNA 3 stated if residents were not turned and repositioned every two hours it had the potential to result in pressure injury. During a concurrent interview and record review on 3/13/25 at 9:44 a.m. with the Director of Staff Development (DSD), Resident 154's Skin Inspection Sheets for the month of 1/25, 2/25, and 3/25 were reviewed. The Skin Inspection Sheets indicated Resident 154 did not receive a shower and her skin was not inspected on the following days: On 1/28/2025 (Tuesday) On 1/31/2025 (Friday) On 2/7/2025 (Friday) On 2/14/2025(Friday) On 2/25/2025 (Tuesday) On 2/28/2025 (Friday) On 3/4/2025 (Tuesday) On 3/7/2025 (Friday) The DSD stated that CNAs were responsible for checking the residents' skin on the residents' shower days and to document it on the Skin Inspection Sheet. The DSD stated the purpose of the Skin Inspection Sheet was to document any skin changes including open areas, redness, blisters, discoloration, and swelling and inform the charge nurse and treatment nurse, so that charge nurse and or TN could intervene in a timely manner and implement the necessary interventions. The DSD stated that according to the reviewed Skin Inspection Sheets, Resident 154 was only showered on 2/7/2025 and 2/11/2025 since her admission on 1/25/2025. The DSD stated residents (in general) should be showered according to their shower schedule and if the residents do not receive a shower they should receive a bed bath instead. The DSD stated showering residents that have pressure injuries helps maintain healthy skin by keeping the area clean and dry, and removing potential irritants (is a substance that directly damages the skin's surface when it comes into contact) like stool and urine which could cause pressure injuries. During a concurrent interview and record review on 3/13/25 at 10:30 a.m. with CNA 3, Resident 154's Turn and Reposition Turning Schedule, dated February 2025 was reviewed. CNA 3 stated there was no documentation that indicated Resident 154 was turned every two hours as ordered by Resident 154 physician. The Turn and Reposition Schedule indicated Resident 1 was turned and repositioned on r the following dates and times as follows: On 2/11/2025 6:02 a.m.,14:20 p.m., and 9:23 p.m. On 2/12/2025 6:00 a.m.,12:24 p.m.,1:01 p.m., and 8:38 p.m. On 2/13/2025 6:59 a.m., 12:10 p.m.,1:15 p.m.,3:51 p.m., and 9:54 p.m. On 2/14/2025 1:05 a.m.,6:36 a.m.,1:50 p.m.,3:54 p.m., and10:11 p.m. On 2/15/2025 3:11 a.m., and 6:57 a.m. On 2/16/2025 2:30 a.m.,6:50 a.m.,2:50 p.m.,4:20 p.m., and 9:37 p.m. On 2/17/2025 2:31 a.m.,6:37 a.m.,12:34 p.m.,1:56 p.m., 4:20 p.m., and 10:06 p.m. On 2/18/2025 6:00 a.m.,12:51 p.m.,1:44 p.m.,6:20 p.m., and 9:13 p.m. On 2/19/2025 6:00 a.m.1:26 p.m.6:34 p.m., and 9:25 p.m. On 2/20/2025 6:00 a.m.,12:42 p.m.,1:57 p.m.,4:15 p.m., and 10:18 p.m. On 2/21/2025 6:00 a.m., 2:40 p.m.,5:40 p.m., and 10:00 p.m. On 2/22/2025 6:00 a.m., 1:46 p.m., 3:57 p.m., and 10:35 p.m. On 2/23/2025 1:16 p.m.4:21 p.m.9:48 p.m. On 2/24/2025 3:26 a.m.6:09 a.m.2:44 p.m. 6:43 p.m.10:16 p.m. On 2/25/2025 6:44 a.m.,11:40 a.m.,2:04 p.m.10:10 p.m. On 2/26/2025 2:00 p.m.7:52 p.m. On 2/27/2025 5:32 a.m.10:39 a.m.11:38 a.m.1:48 p.m., and 7:57 p.m. On 2/28/2025 6:00 a.m.,2:37 p.m., and 8:53 p.m. CNA 3 stated, Resident 154 should have been turned and repositioned every two hours and as needed to prevent pressure injuries from developing new and prevent deterioration of Resident 154's current pressure injuries. CNA 3 stated Resident 154 could have developed the pressure injuries on her right lateral foot and right buttocks from not being turned every two hours. CNA 3 stated that he discovered Resident 154's right buttock pressure injury on 3/11/2025 and informed the License Vocational Nurse (LVN) 2 and the TN (unknown) about Resident 154's pressure injury on right buttock. CNA 3 stated Resident 154 had not been turned and repositioned every two hours as ordered from 2/11/25 through 2/28/25. During a concurrent interview and record review on 3/13/25 at 11:39 a.m. LVN 2 stated CNAs were responsible to provide residents a shower and bed baths. LVN 2 stated CNAs were responsible for doing skin inspections when giving a shower and bed baths and to report any skin changes to the charge nurse and treatment nurse. LVN 2 stated the RN (in general), and the TN (in general) were responsible for assessing the residents' skin upon admission and weekly. LVN 2 stated skin changes would be considered open wounds,