Other·March 13, 2026

§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. California Code of Regulations, Title 22, Section 72311 Nursing Service – General (a) Nursing service shall include, but not be limited to, the following: (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. California Code of Regulations, Title 22, Section 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: (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). California Code of Regulations, Title 22, Section 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 1/26/2026, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct its annual health recertification survey. During the survey, CDPH identified Resident 18 had Moisture Associated Skin Damage (MASD - inflammation [becomes reddened, swollen or hot] or skin erosion [breakdown of outer layers of skin] caused by prolonged exposure to moisture-like urine, stool, sweat) on 10/28/2025, was assessed as at risk for developing pressure ulcers (also known as pressure sores and decubitus ulcers, localized damage to the skin and/or underlying tissue caused by prolonged pressure or friction, often over bony areas), required assistance with turning while in bed and while seated in a chair, and was incontinent of bowel and bladder (having no or insufficient voluntary control over urination or defecation) function. The facility failed to ensure that Resident 18 did not develop a pressure ulcer while in the facility and failed to provide appropriate treatment and services to maintain skin integrity (the condition of the skin being intact, healthy and free from damage) by failing to: 1. Ensure licensed nurses, Licensed Vocational Nurses (LVNs), and Treatment Nurses (TNs) completed at least weekly evaluations of Resident 18’s MASD skin breakdown and documented the findings, including a description of the MASD. 2. Ensure that Treatment Nurse 1 (TN 1) reported Resident 18’s wounds to Medical Doctor 1 (MD 1 – Resident 1’s physician) and Medical Doctor 2 (MD 2 - a wound care specialist physician), upon Resident 18’s readmission on 10/28/2025. 3. Ensure TN 1 followed up and obtained treatment orders from MD 1 and MD 2 on 10/28/2025 when MASD was identified on Resident 18’s left buttock. 4. Ensure Certified Nurse Assistants (CNAs) repositioned Resident 18 every two (2) hours (hrs) and as needed. 5. Implement the facility’s policy and procedure (P&P) titled, “Decubitus Ulcer Prevention,” last reviewed on 1/21/2025, which indicates the implementation of preventative measures and regular assessments to identify the presence of any pressure ulcers. As a result, Resident 18 developed one facility-acquired pressure ulcer (a new, preventable skin injury that develops after a resident is admitted or readmitted, typically caused by unrelieved pressure or friction) as identified by MD 2 on 1/20/2026. On 1/27/2026, MD 2 identified that it had progressed to a stage 2 (partial thickness loss of skin, presenting as a shallow open sore or wound) pressure ulcer on Resident 18’s left buttock. A review of Resident 18’s Admission Record (AR), indicated that the facility originally admitted Resident 18 on 12/7/2023 with diagnoses including chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood), nontraumatic intracerebral hemorrhage (bleeding into the substance of the brain in the absence of trauma or surgery) in hemisphere (sides of the cerebrum [area that controls movement, sensation, language, and thinking]), dysphagia (difficulty swallowing) following cerebral infarction (also known as stroke, loss of blood flow to a part of the brain), and hydrocephalus (the buildup of fluid in cavities deep within the brain called ventricles). A review of Resident 18’s Minimum Data Set (MDS - a resident assessment tool), dated 10/2/2025, indicated Resident 18 had the ability to understand others sometimes and rarely or never makes self understood. The MDS indicated Resident 18 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 18 was dependent on staff for bed mobility including rolling to the left and right. The MDS indicated Resident 18 had no unhealed pressure ulcer but was identified as being at risk for developing pressure ulcers. A review of Resident 18’s Clinical Admission Screener (CAS – a pre-admission document used to evaluate a prospective resident’s medical and physical needs to ensure the facility can provide appropriate care) form, dated 10/28/2025, indicated Resident 18 had left buttock MASD. A review of Resident 18’s Admission Progress Notes (APN - a comprehensive, written, or electronic document created by a provider upon a resident’s entry into an inpatient facility that includes gathering a thorough medical history from the resident and performing a physical examination to assess their overall health and identify any potential medical concern), dated 10/29/2025, indicated Resident 18 did not have the capacity to understand and make decisions. The APN indicated that Resident 18’s skin had no erythema (superficial reddening of the skin as a result of injury or irritation). A review of Resident 18’s Assessment of Decubitus Ulcer Potential (ADUP - a scoring tool used to predict a resident’s risk of developing pressure ulcer, the higher the score, the greater the potential to develop decubitus ulcers), dated 12/24/2025, indicated residents with a score above 12 should be considered at risk for developing pressure ulcers. The ADUP indicated Resident 18 scored 23. A review of Resident 18’s ADUP, dated 12/26/2025, indicated Resident 18 scored 25. A review of Resident 18’s Physician Order, dated 1/19/2026, indicated the following treatment: Cleanse the Left Buttock open blister (bubble on the skin filled with clear, watery liquid or blood, usually caused by friction, rubbing, or burns) with normal saline (NS - sterile water used to cleanse and moisten wounds), apply moist gauze (a wound care product designed to absorb wound drainage and protect the wound), pat dry with dry gauze, apply xeroform (a moist yellow dressing that covers the wound and promotes wound healing) and cover with a foam dressing every day shift for one (1) Day, with the Wound Doctor to reassess on 1/20/2026. A review of Resident 18’s wound care Progress Note Details (PND), dated 1/20/2026, indicated that Resident 18 had the following wound: Left buttock open blister, measuring 1.6 centimeters (cm - a unit of measure) in length x (by) 1.5 cm in width x 0.1 cm in depth, with a small amount of serous (clear, thin, watery fluid that's typically pale yellow in color) drainage noted. A review of Resident 18’s Physician Order, dated 1/20/2026, indicated the following treatment: Cleanse the left buttock open blister with NS, apply moist gauze, pat dry with dry gauze, apply xeroform and cover with a foam dressing every day shift for 14 Days. A review of Resident 18’s wound care PND, dated 1/27/2026, indicated that Resident 18 had the following wound: Left buttock stage 2 pressure ulcer, measuring 1.2 cm in length x 0.8 cm in width x 0.2 cm in depth, with a moderate amount of serous drainage, and a wound bed (exposed tissue surface within a wound) 76 to 100 percent (%). A review of Resident 18’s Physician Order, dated 1/27/2026, indicated the following treatment: Cleanse the Left Buttock Stage 2 Pressure Ulcer with NS, apply moist gauze, pat dry, apply xeroform and cover with a foam dressing every day and as needed for 30 days.” During a concurrent interview and record review on 1/27/2026 at 1:08 p.m., with TN 1, Resident 18’s Physician Orders and Nursing Progress Notes from 10/28/2025 to 1/27/2026 were reviewed. TN 1 stated that there were no treatment orders and no monitoring for Resident 18’s MASD on the left buttock during this period (10/28/2025 to 1/27/2026). Resident 18’s progress notes indicated Resident 18’s open blister on the left buttock was first identified on 1/19/2026 during perineal care (peri-care – gently washing the genitals [male or female reproductive organ] and anal [opening at the end of the digestive tract, where stool leaves the body] area to maintain hygiene, comfort, and prevent infection or skin irritation) provided by the CNAs. A one-time wound treatment order was placed on 1/19/2026. Resident 18 had an order to be evaluated by MD 2, a wound specialist physician, on 1/20/2026. TN 1 further stated that the open blister was classified as a stage 2 pressure ulcer. During a concurrent interview and record review on 1/27/2026 at 1:41 p.m., with TN 1, Resident 18’s care plans, in effect as of 1/27/2026, were reviewed. TN 1 stated there was no care plan developed for Resident 18’s MASD on the left buttock identified on 10/28/2025. The care plan titled, “Wound Management,” last revised on 1/20/2026, did not include Resident 18’s stage 2 pressure ulcer on the left buttock. She (TN 1) forgot to add the pressure ulcer to the care plan and should have been added on the day it was identified. TN 1 stated repositioning and turning the resident every 2 hours and as needed should be included in the care plan. The purpose of the care plan is to manage the wound and ensure the resident does not develop an infection.  She (TN 1), along with the LVNs, and Registered Nurses (RNs) taking care of Resident 18, review the care plan interventions. During an interview on 1/27/2026 at 1:49 p.m. with Certified Nurse Assistant 2 (CNA 2), CNA 2 stated she (CNA 2) is the assigned CNA for Resident 18 today, 1/27/2026. She (CNA 2) and another CNA (did not specify) reposition Resident 18. CNA 2 stated Resident 18 does not have any wounds on her (Resident 18) buttocks. CNA 2 stated she (CNA 2) usually repositions Resident 18 every two hours. She (CNA 2) sometimes does not reposition Resident 18 every two hours. CNA 2 stated it sometimes takes more than two hours to reposition Resident 18 because it is not possible. Turning residents requires two people. During a concurrent interview and record review on 1/27/2026 at 2:10 p.m., with Registered Nurse 8 (RN 8), Resident 18’s Physician Orders and Care Plans from 10/28/2025 to 1/27/2026 were reviewed. RN 8 stated that upon Resident 18’s readmission on 10/28/2025, she (RN 8), Treatment Nurse 2 (TN 2), and Licensed Vocational Nurse 4 (LVN 4) assessed Resident 18’s skin. RN 8 stated TN 2 is responsible for measuring wounds, developing care plans related to skin and wound issues, contacting the wound care physician (referring to MD 2), and initiating wound treatment orders, if indicated. RN 8 further stated TN 2 should have developed a care plan for Resident 18’s MASD on the left buttock and initiated the appropriate treatment orders. During a concurrent interview and record review on 1/27/2026 at 4:56 p.m., with TN 2, Resident 18’s Physician Orders, Care Plans, and Nursing Progress Notes from 10/28/2025 to 1/27/2026 were reviewed. TN 2 stated that when she (TN 2) identifies wounds, redness, skin discoloration (any change in your natural skin tone) on residents, the charge nurse (RN) and the primary nurse (LVN), document the findings in the Admission Notes, and the charge nurse enters orders for any identified skin issues. She (TN 2) is not responsible for documenting findings in the Admission Notes and that only the primary nurse and the charge nurse complete admission documentation. She (TN 2) assists with wound measurements and wound treatments, depending on the Physician’s Orders. TN 2 further stated that the charge nurse or whoever enters the order, is responsible for developing the care plan. TN 2 stated that only charge nurses are allowed to enter physician orders and that the charge nurse would contact the resident’s primary physician or the wound care physician, who visits weekly. TN 2 stated when Resident 18 was readmitted on 10/28/2025, she (TN 2) worked with the primary nurse (LVN 4), and the charge nurse (RN 8). She (TN 2) did not document her (TN 2) findings because RN 8 and LVN 4 documented in their (RN 8 and LVN 4) notes. She (TN 2) provided RN 8 and LVN 4 with the wound measurements and related details. TN 2 stated she (TN 2) did not call the wound care physician (MD 2) on 10/28/2025 for Resident 18. During a concurrent observation and interview on 1/28/2026 at 10:08 a.m., with TN 2, at Resident 18’s bed side, observed TN 2 measured Resident 18’s wounds. TN 2 stated Resident 18’s stage 2 pressure ulcer on the left buttock measured at 1.5 cm in length x 1.2 cm in width x 0.2 cm in depth with a small amount of yellow drainage and granulation (the formation of new connective tissue and blood vessels [a network of hollow, elastic tubes that circulate blood throughout the body] that fill in a wound bed during the proliferative [rapid growth] phase of healing) with pinkish red wound edges. During a concurrent interview and record review on 1/28/2026 at 3:51 p.m., with TN 1, Resident 18’s Wound Assessments and Nursing Progress Notes from 10/28/2025 to 1/28/2026 were reviewed. TN 1 stated there were no weekly skin assessments done prior to 1/20/2026. Weekly skin assessments should have been performed to monitor the left buttock’s wound progress, determine whether it was improving or worsening, and because assessments are part of the facility’s monitoring process. During a concurrent interview and record review on 1/29/2026 at 8:27 a.m., with LVN 4, Resident 18’s Admission Summary, dated 10/28/2025, timed at 3:10 p.m. was reviewed. The Admission Summary indicated “[MD 1] went to assess [Resident 18], new order of labs in [morning] and to continue previous orders and treatment. Orders noted and carried out. [Responsible party] … at bed side." LVN 4 stated she (LVN 4) did not communicate with MD 1 regarding Resident 18’s admission orders. LVN 4 stated that RN 8 was the one who communicated with MD 1 regarding Resident 18's admission orders. During an interview on 1/28/2026 at 10:35 a.m., with MD 2, MD 2 stated that during rounds on 1/20/2026, he (MD 2) was notified of Resident 18’s wounds. He (MD 2) did not have any documentation or notes for Resident 18 prior to 1/20/2026. Resident 18 is contracted (a condition in which a joint or body part becomes fixed in a bent or twisted position and cannot move through its full, normal range of motion). MD 2 stated that blisters located over pressure points that do not heal can progress to stage 2 pressure ulcers. Treatments he (MD 2) would have recommended for Resident 18 included turning and repositioning while in bed. Residents should not remain on one side for prol