Health inspection·April 30, 2025

The following reflects the finding of the California department of Public Health during Investigation of a complaint number: CA00950130 A Class A citation was issued. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations §483.25(b)(2) Foot care. To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must: (i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and (ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments. Title 22, California Code of Regulations § 72311. Nursing Service-General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the patient. (b) All attempts to notify licensed healthcare practitioners acting within the scope of his or her professional licensure shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending licensed healthcare practitioner acting within the scope of his or her professional licensure or his or her designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g). § 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: (4) Using pressure-reducing devices where indicated. (5) Providing care to maintain clean, dry skin free from feces and urine. (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. (a). Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 3/18/2025, the California Department of Public Health (CDPH, the Department) made an unannounced visit to the facility to investigate a complaint allegation regarding resident neglect related to wound care. As a result of the investigation, the Department determined the facility failed to provide foot care consistent with professional standards to maintain skin integrity for Resident 1. The facility failed to: 1. Ensure that the Magnetic Resonance Imaging (MRI - uses a strong magnetic field and radio waves to create detailed images of the inside of the body, aiding in the diagnosis and monitoring of various conditions) recommended by the Wound Physician Specialist (WPS) to rule out (R/O) osteomyelitis (a bone infection that can occur when bacteria spread to the bone, causing pain, swelling, and potentially leading to serious complications if left untreated) on 2/12/2025 after Resident 1's left plantar foot (located on the bottom of the foot) wound has reopened was followed through and completed 2.Implement the facility's policy and procedures (P&P) titled, "Wound Care" by failing to document the services provided on 2/7/2025 through 2/11/2025, 2/13/2025, 2/14/2025, 2/15/2025, 2/16/2025, 2/18/2025, and 2/19/2025 and following a professional standard practice of an accurate and thorough patient-centered assessment in Resident 1's medical record. 3. Develop an individualized care plan (CP) for Resident 1's left lower foot wound when Resident 1 was readmitted on 1/19/2024. As a result of these failures, Resident 1 was transferred to the general acute care hospital 1 (GACH 1) on 2/19/2025 with admitting diagnosis of sepsis (a life-threatening blood infection) due to necrotizing soft tissue infection (a rare but life-threatening bacterial infection that rapidly destroys the skin, muscle, and fascia [connective tissue]) of left lower extremity (LLE) and a left ankle disarticulation (a type of limb amputation that is performed by separating the limb through a joint instead of cutting through a bone) was performed on 2/20/2025. Then on 2/27/2025, an incision and drainage (I&D - a medical procedure used to treat abscesses) and left below the knee amputation (BKA - a surgical procedure where the lower leg and foot are removed below the knee joint) was performed on 2/27/2025 on Resident 1. During a review of Resident 1's Admission Record indicated Resident 1, a 70 years-old male was admitted to the facility on 7/25/2022 and readmitted on 1/19/2024 with diagnosis including epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures, [a sudden, temporary disruption of the brain's normal electrical activity, potentially causing changes in behavior, movements, feelings, or awareness]), chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), chronic congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and a past medical history of type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 2/1/2025, it indicated Resident 1's cognitive skill for daily decisions were moderately impaired. The MDS indicated Resident 1 required maximum assistance to totally dependence on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's Physician History and Physical (H&P), dated 1/28/2025, the H&P indicated, Resident 1 can make needs known but cannot make medical decisions. During a review of Resident 1's Braden Scale (a tool used in healthcare to assess a patient's risk of developing pressure injuries [areas of skin damage caused by prolonged pressure, often over bony areas, leading to reduced blood flow and tissue damage] by evaluating six key areas: sensory perception, moisture, activity, mobility, nutrition, and friction/shear) dated 1/19/2024, it indicated, Resident 1's score was 13 (a score of 13 indicates a moderate risk of developing a pressure injury). During a review of Resident 1's WPS progress notes, it indicated the following: i. Dated 1/24/2024, "This patient (Resident 1) was readmitted with a left lower leg wound." ii. Dated 7/17/2024, "This patient (Resident 1) was reconsulted for the evaluation and treatment for a blister (a small, fluid-filled pocket that forms on the upper layers of the skin) located on the left plantar foot. iii. Dated 9/4/2024, "The left foot wound is shrinking and is expected to heal within the next few weeks. The wound has been reclassified from a blister to arterial ulcer (open wounds that develop when there is inadequate blood flow to the affected area)." iv. Dated 2/12/2025, "This patient (Resident 1) left plantar foot wound has reopened [according to the facility's SBAR dated 2/7/2025], and treatment is being resumed. Due to the depth extension of the side, it is warranted to have the patient undergo an MRI to rule out osteomyelitis. v. Dated 2/19/2025, "This patient (Resident 1) was evaluated today, and it was noted that he developed a boggy (abnormal texture of tissues characterized by sponginess, usually because of high fluid content) necrotic (dead or dying tissue in the body, often caused by a lack of blood supply or other injuries) area on the dorsal aspect of the foot (refers to the top or upper side of the foot, opposite the sole or bottom) which is suspected to be communicating with the lateral (to the side) metatarsal (long bones that form the main part of the foot) wound. There is suspicion for osteomyelitis and possible wet gangrene (a serious condition where tissue dies due to a bacterial infection). Current measurements: 4.5-centimeter (cm, unit of measurement) (length) by (x) 3.5 cm (width) x UTD (undetermined [depth]). During a review of Resident 1's CP indicated the following Resident 1 was: i. At risk for hyperglycemia (high blood sugar, occurs when there's too much glucose [sugar] in the bloodstream) / hypoglycemia (low blood sugar) due to diagnosis of DM initiated on 9/29/2022, the CP had a goal of, "will be free from signs and symptoms (s/s) of hypo/hyperglycemia daily", with interventions including, "monitor skin for redness and circulatory problems, report to medical doctor any abnormal findings." ii. At risk for skin breakdown related to Braden risk score: 13, date initiated 6/17/2024, the CP had a goal of, "(Resident 1) will prevent or delay skin breakdown to the extent possible given risk factors; and (Resident 1) will be compliant with treatments and intervention measures to prevent skin breakdown." iii. At risk for skin breakdown related to open wound to left outer foot, initiated on 2/7/2025, the CP had a goal of, "(Resident 1) will be compliant with treatments and intervention measures to prevent skin breakdown and will prevent or delay skin breakdown to the extent possible given risk factors". During a concurrent interview with Registered Nurse (RN) 1 and record review of Resident 1's CP on 3/20/2025 at 12:53 p.m., RN 1 stated, there was no CP developed regarding Resident 1's left foot wound when Resident 1 was readmitted on 1/19/2024. RN 1 further stated, there was also no CP developed for Resident 1's blister on the left plantar foot which reopened on 7/17/2024. RN 1 stated, when the blister was reclassified to arterial ulcer on 9/4/2024, there was also CP developed. RN 1 stated, an individualized CP should be developed with interventions so that all staff are on the same page to manage residents' care. During a review of Resident 1's Physician Order Summary Report (POSR) indicated: i. Dated 2/7/2025, "Treatment - left foot open wound - cleanse with normal saline (NS - a mixture of salt and water that can be applied directly to the wound site) pat dry, apply Medi-honey (a brand of medical-grade honey-based dressings used for wound and burn management, promoting a moist environment for healing and debridement), dress with cushion dressing (Cushion dressing [a type of wound dressing, like a soft, padded bandage, designed to protect and cushion a wound, often made of foam or similar materials, and can absorb fluid.]) every shift." (order was discontinued on 2/10/2025) ii. Dated 2/10/2025, "Treatment- left foot open wound- Cleanse with NS, Pat Dry, Apply Santyl (used to remove dead tissue from wound) and Mupirocin (a medication that treats skin infections caused by bacteria) two percent ointment, dress with cushion dressing every shift." (order was discontinued on 2/12/2025) iii. Dated 2/12/2025, "Treatment- left foot open wound- Cleanse with NS, Pat Dry, Apply Santyl and Mupirocin due to specific bacteria) used to treat secondarily infected traumatic skin lesions due to specific bacteria) 2% ointment, Dress with Gentell super absorbent dressing (offers excellent absorbent capacity for the treatment of moderate or heavy exuding [discharge] wound) every shift." During a review of Resident 1's situation, background, assessment, recommendation (SBAR - a communication tool used by healthcare workers when there is a change of condition among the residents), dated 2/7/2025, indicated, "Resident (1) is noted with Moisture-Associated Skin Damage (MASD - a type of skin inflammation and erosion caused by prolonged exposure to moisture) to sacrum (the large, triangle-shaped bone in the lower spine that forms part of the pelvis) and left outer foot open wound. The left foot open wound appears approximately 1 centimeter (cm - unit of measurement) in size, skin open, area reddened." During a review of Resident 1's Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) Wound Note on 2/13/2025, wound note indicated, "Resident (1) was seen and assessed by WPS and noted with left plantar foot ulcer 2.0 cm (length) x 1.5 cm (width) x 0.9 cm (depth). During a review of Resident 1's medical record in GACH 1, indicated: i. Admission diagnosis of sepsis due to necrotizing soft tissue infection of LLE. ii. Date of Admission: 2/20/2025 at 12:21 a.m.: Emergency Room physical exam upon admission indicated, "Musculoskeletal (the system comprising muscles, bones, joints, and connective tissues like tendons and ligaments that work together to enable movement and provide structure to the body): Bilateral (both) Lower Extremity (BLE): swelling and tenderness present, BLE edema (a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body), thrombotic thrombocytopenic purpura (TTP - a rare, life-threatening blood disorder) to left foot, ankle to calf, copious purulent drainage (a large or excessive amount of fluid or discharge) noted coming from the left dorsum of foot (the upper surface or top of the foot) Sacral decubitus ulcer (a localized area of skin damage that develops over a bony prominence) noted. Skin: wound to lateral plantar surface of left foot. Active purulent and watery gaseous, foul-smelling discharge." iii. Operative report dated 2/20/2025 indicated, "Procedure performed: ankle disarticulation, left side. The necrotic area was large over the dorsum of the foot (the upper surface or top of the foot). The leg was edematous, and it was difficult to tell if the infection spread proximally." Surgical pathology (the study of tissues and fluids removed during surgery to help diagnose diseases and guide treatment decisions, using both visual inspection and microscopic examination) report dated 2/21/2025 indicated, "gangrenous ulcer (acute necrotizing inflammation) a sudden, severe inflammation that causes tissue death, often due to bacterial infection, and requires immediate medical attention) of the left ankle (a severe infection where dead tissue (necrosis) forms in an open wound or ulcer) with underlying abscess (a localized collection of pus that forms in the body's tissues due to a bacterial infection) formation with acute necrotizing inflammation, fat necrosis (a condition where fat cells die and break down), and fibrosis (the scarring or thickening of tissue, often occurring as a body's response to injury or chronic inflammation, leading to stiffening and potentially affecting organ function); iv. Operative report date 2/27/2025 indicated, "Procedure performed: below knee amputation, through tibia and fibula (the two long bones in the lower leg), left side. v. Pathology report dated 2/27/2025 indicated, "