Health inspection·April 2, 2025

F686 §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 2/11/2025 during a standard annual recertification survey the California Department of Health (CDPH) identified that the facility failed to ensure Resident 36, who was assessed at a high risk for developing a pressure injury did not develop a Stage II (partial-thickness loss of skin, presenting as a shallow open sore or wound) pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on sacrococcyx area which progressed to a Stage IV (wound that penetrate all layers of skin exposing muscles, tendons [tissue that unites a muscle with a bone] cartilage {tissue that lines a joint}, and bones caused by prolonged pressure on the skin) pressure injury. The facility failed to: 1. Ensure Resident 36 received wound treatment to Stage II sacrococcyx pressure injury for 14 days from 11/8/2024-11/21/2024 as ordered by the physician on. 2. Ensure Treatment Nurse (TX) assessed and documented Resident 36's sacrococcyx pressure injury weekly after 10/13/2024 until 12/12/2024 and evaluated the progression of Resident 36's pressure injury from Stage II to Stage IV. 3. Ensure nursing staff implemented Resident 36's Care plan titled, "Resident 36 has the potential for pressure injury development" dated 1/28/2022 and last revised on 1/7/25, with indicated to conduct weekly skin inspections by licensed nurse, inspect skin during activities of daily living (ADL's), and report any abnormal findings to Resident 36's medical doctor. 4. Ensure the facility's policy and procedure (P&P) titled Wound Care Suggestions and Documentation dated 10/2021 were followed which indicated, that wounds should be measured and reviewed weekly for improvement or decline. The wound will be observed for improvement or decline with dressing changes and treatment orders will be changed accordingly. As a result, Resident 36 developed sacrococcyx Stage II pressure injury that progressed to a Stage IV pressure injury measured 4.0-centimeter (cm) in length by 1.5 cm in width with 0.2 cm. depth in the sacrococcyx (bones at the base of the spine) area. A review of Resident 36 Admission Record indicated Resident 36, a 55 year old female, was admitted to the facility on 5/1/2024 with diagnoses including persistent vegetative state (severe brain damage), chronic respiratory failure (condition where lungs cannot adequately exchange oxygen and carbon dioxide leading to low blood oxygen level), malignant neoplasm of the trachea (cancer of the tube-like structure that connects your voice box to your airway), tracheostomy ( surgical procedure that creates an opening in the trachea( windpipe) and inserts a tube to provide an airway) and gastrostomy tube ([G-tube] a soft flexible tube surgically inserted into the stomach for administration of nutrition and medication). A review of Resident 36's History and Physical (H&P) dated 5/4/2024, indicated Resident 36 did not have the capacity to understand and make decisions. A review of Resident 36's, Change of Condition Evaluation ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) dated 8/21/2024, indicated Resident 36 developed a Stage II pressure injury on the sacrococcyx measuring 5.0 cm by 0.5 cm with superficial surrounding skin was discolored, moist and slightly macerated (prolonged exposure to moisture). A review of Resident 36's, Minimum Data Set ([MDS] - a resident assessment tool) dated 10/6/2024, indicated Resident 36 was in a persistent vegetative state (a condition in which a person is awake but lacks awareness of themselves or their surroundings) /no discernible consciousness (shows evidence of consciousness). The MDS also indicated Resident 36 was totally dependent (helper does all the effort) on staff assistance with Activities of Daily Living ([ADLs]- activities such as hygiene, dressing and toileting a person performs daily). A review of Resident 36's Braden Scale Assessment dated 10/8/2024, indicated Resident 36 had a score of eleven (10-12 high risk of developing pressure injury). A review of Resident 36's Skin and Wound Evaluation dated 10/13/2024 indicated Resident 36 had developed a Stage II pressure injury in- house (facility acquired) on the coccyx started on 8/21/2024 measured 2.5 cm by 2 cm with 0.2 cm in depth, with100% granulation tissue (pink fleshy tissue that forms in the healing process of wounds) and with light serosanguinous (clear watery fluid and blood) drainage. A review of Resident 36's, Physician Order Summary Report dated 8/22/2024, indicated Resident 36 had orders to clean Stage II pressure injury coccyx with normal saline ([NS]-cleansing solution), pat dry and apply Medi-honey (used to treat a variety of wounds) cover with foam dressing (type of dressing) every day for 21 days. A review of Resident 36's IDT Conference Record Skin dated 10/13/2024 indicated Resident 36 had a Stage II Sacrococcyx pressure injury. The IDT's recommendations include to turn and reposition the resident, provide wound treatment by cleansing it with NS, pat dry, apply Collagen powder (wound therapy agent used to accelerate the healing process) then apply Silvadene cream (wound treatment), cover with dry dressing. A review of resident 36's Skin and Wound Evaluation dated 10/13/24 indicated Resident 36 had a sacrococcyx stage II pressure injury measuring 5.0 cm in length by 2.0 cm in width x 0.2 in depth. A review of Resident 36's, Physician Order Summary Report dated 11/4/2024 indicated Resident 36 had a treatment order for Stage II pressure injury on sacrococcyx to cleanse with NS, pat dry, apply Collagen powder then apply Silvadene cream and cover with dry dressing daily for 21 days with a start date 11/5/24 and end date 11/26/2024. There also was a physician's order to apply Zinc Oxide to sacrococcyx daily started on 11/22/24. A review of Treatment Administration Record (TAR) for November 2024, indicated the physician order for the treatment to a Stage II pressure injury on sacrococcyx was discontinued on 11/7/24 without documentation as to why it was discontinued. The TAR indicated Resident 36 was not receiving any type of treatment to a Stage II pressure injury on sacrococcyx area. A review of Resident 36's, Treatment Administration Record (TAR) for the month of 11/2024, indicated Resident 36 stopped receiving wound treatment (TX) to her Stage II pressure injury on sacrococcyx on 11/8/2024 with no medical doctor (MD) notification or documentation as to why wound treatment was discontinued. The TAR indicated the treatment with Zinc Oxide (medication used to treat wound) was started on 11/22/24. A review of Resident 36's Care plan titled, "Resident 36 has the potential for pressure injury development" related to incontinence and dependent on staff for repositioning due to persistent vegetative state dated 1/28/2022 and last revised 1/7/25, the Care Plan indicated the goal for Resident 36 was not to have avoidable Stage III (full-thickness loss of skin, dead and black tissue may be visible) or a Stage IV pressure injury. The Care Plan's interventions included to do weekly skin inspections by a licensed nurse, inspect skin during ADL's, report any abnormal findings to MD and to have a Registered Dietician consult if indicated for nutritional review to promote wound healing (interventions revised on 11/08/2024). A review of Resident 36's medical record indicated there was no documentation to indicate the residents' skin was assessed on weekly basis as care planned after 10/13/2024 until 12/12/2024. A review of Resident 36's Care plan titled ,"Resident 36 has an actual Stage IV pressure injury to coccyx" dated 5/31/2022 (revised 1/9/2025), the Care Plan indicated the goal for Resident 36 was to show evidence of responding to wound treatment. The Care Plan interventions indicated to administer wound treatments as ordered and observe for effectiveness, report to MD as needed any changes in skin status appearance, color, odor, wound healing, signs and symptoms of infection, wound size, and stage of the wound. A review of Resident 36's, COC dated 12/12/2024, indicated Resident 36 had a sacrococcyx unstageable pressure injury (a full thickness skin loss where the base of the wound is covered in dead tissue) measuring 3.0 cm in length by 1.0 cm in width with undetermined UTD a measurement of wound depth used when it is not possible to determine the exact depth of a wound) tissue damage. A review of Resident 36's IDT Conference Record Skin dated 12/12/2024, indicated Resident 36 had an unstageable pressure injury to sacrococcyx area on 12/12/2024. The IDT Conference Record indicated a current wound treatment was to cleanse sacrococcyx pressure injury with NS, pat dry, apply Collagen powder then apply Silvadene cream and cover with dry dressing. A review of Resident 36's Skin and Wound Evaluation dated 12/14/2024 (two months after Skin and Wound Assessment on 10/13/2024), the Skin and Wound Evaluation indicated Resident 36 had a facility acquired unstageable pressure injury on the sacrococcyx started on 12/12/2024 measuring 4.5 cm in length by 3.0 cm in width with 1.5 cm in depth, re-staged to Stage III pressure injury on 12/19/2024 by in-house nurse (unknown). A review of Resident 36's Physician Order Summary Report dated 12/17/2024, indicated Resident 36 had a physician's order for a treatment to sacrococcyx unstageable pressure injury, cleanse with NS, pat dry, apply Collagen powder then apply Silvadene cream cover with dry dressing daily for 21 days with a start date of 12/18/2024 until 1/8/2025. A review of Resident 36's Physician Order Summary Report on 12/19/24 indicated Resident 36 had an order to clean sacrococcyx unstageable pressure injury with NS, pat dry, apply Silvadene cream, Collagen powder and Calcium Alginate (absorbs moisture and promotes healing) then cover with dry dressing daily for 21 days, discontinued on 12/26/24. A review of Resident 36's the Physician Order Summary Report on 12/27/24 indicated an order for wound consult for Resident 36's unstageable pressure injury to the sacrococcyx and an order to cleanse sacrococcyx unstageable pressure injury with NS, pat dry, apply Medi-honey then cover with dry dressing daily for 21 days. A review of Resident 36's Wound Consultant Progress note dated 1/1/2025, indicated Resident 36 had a sacrococcyx Stage IV pressure injury measuring 4.0 cm in length by 1.5 cm in width with 0.2 cm in depth. The Wound Consultant Progress note indicated wound debridement (a medical procedure that involves removing dead or infected tissue from a wound) was done at bedside. Wound Consultant Progress note indicated "removed necrotic (dead tissue) subcutaneous (under the skin) tissue, muscle tissue and viable surrounding tissue to the point of bleeding." A review of Resident 36's Nutritional Risk Review dated 1/6/2025 indicated Resident 36 had a Stage IV pressure injury to the sacrococcyx with recommendations to start Resident 36 on Prostat SF (Liquid protein supplement) 30 milliliter (ml ) two times a day and Juven (promotes wound healing) one packet two times a day to aid in wound healing. A review of Resident 36's Wound Consultant Progress note dated 1/30/2025, indicated Resident 36 had a sacrococcyx Stage IV pressure injury measuring 1.1 cm in length by 0.7 cm in width with 0.2 cm in depth with 100 % granulation tissue. During an observation on 2/14/2025 at 7:25 a.m. in Resident 36's room, Treatment Nurse (TX) 1 was observed providing wound dressing to Resident 36's Stage IV sacrococcyx pressure injury. Resident 36's sacrococcyx wound appeared as 1.1 cm in length by 0.7 cm in width 0.2 cm in depth with 100 % granulation tissue on wound base. During a concurrent interview and record review on 2/15/2025 at 1:40 p.m. with TX 1, Resident 36's Skin and Wound Evaluations dated 10/13/2024 and 12/14/2024 and Change of Conditions (COC) dated 8/21/2024 and 12/12/2024 were reviewed. TX 1 stated that on 8/21/2024 Resident 36 was identified to have on her sacrococcyx a Stage II pressure injury and was measuring 5.0 cm by 0.5 cm and was superficial. TX 1 stated on 10/13/2024 Resident 36 had a weekly skin and wound evaluation done. TX 1 stated Resident 36 sacrococcyx pressure injury measured 2.5 cm in length by 2.0 cm in width with 0.2 cm in depth and with 100% granulation tissue. TX 1 stated on 12/12/2024 Resident 36 had a COC done identifying an unstageable pressure injury on the sacrococcyx. TX 1 stated the next time Resident 36's skin and wound evaluation was done on 12/14/2024. TX 1 stated Resident 36 had an unstageable pressure injury to the sacrococcyx with slough (dead tissue) and was measuring 3.0 cm in length by 1.5 cm in depth with UTD depth and stage. TX 1 stated there was no weekly skin and wound evaluation documentation from 10/13/24 until 12/4/2024 for Resident 36 to track the progression of Resident 36's pressure injury. TX 1 stated it is important to assess Resident 36's pressure injury to assess wound size as it could change, and wound could deteriorate. During a concurrent interview and record review on 2/15/2025 at 10:38 a.m. with Unit 2 Director of Nurses (UDON 2), Resident 36's Skin and Wound Evaluations, and Treatment Administration Record (TAR) were reviewed. UDON 2 stated that on 11/7/2024 treatment for the sacrococcyx Stage II pressure injury was discontinued with no documentation of the reason for discontinuance. UDON 2 stated on 11/22/2024 an order to apply Zinc Oxide ointment to sacrococcyx daily for 21 days for skin maintenance as ordered. UDON 2 stated the last skin and wound evaluation for Resident 36 was on 10/13/2024 which indicated Resident 36 had a sacrococcyx pressure injury measured 2.5 cm by 2.0 cm by 2 cm with 100% granulation tissue. UDON 2 stated the next skin and wound evaluation was done on 12/14/2024. UDON 2 stated Resident 36 had developed a sacrococcyx unstageable pressure injury measured 3.0 cm in length by 1.5 cm in depth with UTD depth and precense of slough (dead tissue). UDON 2 stated pressure injury needs to have a weekly assessment and documentation to track the progress of a pressure injury. UDON 2 stated Resident 36's pressure injury was avoidable if Resident 36 sacrococcyx pressure injury was assessed for appropriate wound treatment and implemented timely. During a phone interview on 2/15/2024 at 12:06 p.m. TX 2 stated Resident 36 had a scar (date unknown) on her sacrum that started as moisture associated skin damage ([MASD] caused by prolonged exposure to moisture). TX 2 stated the wound coordinator was responsible for assessing and documenting Resident 36's p