Health inspection·September 26, 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. California Code of Regulations, Title 22, Section 72301. Required Services. (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. 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 72313 Nursing Service - Administration of Medications and Treatments (a) Medications and treatments shall be administered as follows: (1) No medication or treatment shall be administered except on the order of a person lawfully authorized to give such order. (2) Medications and treatments shall be administered as prescribed. 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 8/11/2025, 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 on 8/12/2025 a resident (Resident 10) who developed pressure ulcers after arriving at the facility. Based on observation, interview, and record review, the facility failed to ensure Resident 10 who had intact skin upon admission on 6/2/2025, was assessed as at risk for developing pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence), required assistance with turning while in bed and in a chair, and was incontinent of bowel and bladder (having no or insufficient voluntary control over urination or defecation) did not develop multiple pressure ulcers while in the facility and received appropriate treatment and services to maintain skin integrity (the condition of the skin being intact, healthy and free from damage). The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN) 2 and Treatment Nurse (TN) 1 assessed and reported to the Director of Nursing (DON) that Resident 10 developed skin peeling and redness between the buttocks on 7/24/2025 and to the physician for treatment on the same date. 2. Assess Resident 10 promptly upon Certified Nurse Assistant (CNA) 2’s identification of an open sacrococcyx (tailbone) wound as indicated in the Daily Body Check Report, dated 7/28/2025. 3. Conduct a timely Wound Risk Assessment (also known as Braden Scale - an assessment tool used to predict the risk of a resident developing pressure ulcers) for Resident 10 upon the development of Moisture Associated Skin Damage (MASD - inflammation or skin erosion caused by prolonged exposure to moisture like urine, stool, and sweat) on 7/31/2025 and the subsequent identification of wounds to the sacrococcyx and left buttock on 8/12/2025. 4. Ensure Certified Nurse Assistant 9 (CNA 9) completed body checks for Resident 10 on 8/8/2025, 8/9/2025 and 8/10/2025.  5. Ensure TN 1 removed Resident 10’s incontinence brief on 8/11/2025 to assess the skin underneath during the administration of MASD treatment to the right and left buttocks. 6. Ensure TN 1 reported and obtained a physician’s order prior to providing wound treatment to Resident 10 on 8/12/2025, when TN 1 applied a bordered gauze dressing (a wound care product designed to absorb wound drainage and protect the wound) to Resident 10’s left buttock and sacrococcyx.   7. Administer Acetaminophen (also known as Tylenol, a medication used to relieve pain) as ordered to Resident 10 on 8/13/2025 prior to the administration of wound treatment. 8. Implement the facility’s policy and procedure (P&P) titled “Care and Prevention of Pressure Sores (also known as Pressure Ulcers),” last reviewed on 4/16/2025 that indicated to provide appropriate facility interventions to manage and prevent pressure sores. As a result, Resident 10 developed two facility-acquired pressure ulcers, as identified by Physician Assistant 1 (PA 1) on 8/13/2025. On 8/13/2025, PA 1 identified a stage two pressure ulcer (partial thickness loss of skin, presenting as a shallow open sore or wound) on the left buttock and a stage three pressure ulcer (full-thickness skin loss that extends through the skin into deeper tissue and fat but does not reach muscle, tendon or bone) on the sacrococcyx. A review of Resident 10’s Admission Record (AR) indicated that the facility admitted Resident 10, a 67-year-old female, on 6/2/2025 with diagnoses including unspecified sequelae (the long-term conditions that happen because of an illness or injury) cerebral infarction (stroke - loss of blood flow to a part of the brain ), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), myocardial infarction type two (heart attack- occurs when the heart muscle doesn't get enough oxygen due to an imbalance between oxygen supply and demand, not caused by a blockage in the coronary arteries) generalized muscle weakness, and abnormalities of gait (manner of walking) and mobility. A review of Resident 10’s History and Physical (H&P – comprehensive assessment conducted by a healthcare provider 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 6/2/2025, indicated Resident 10 did not have the capacity to understand and make decisions. The H&P indicated that Resident 10’s integumentary (skin) was intact. A review of Resident 10's Admission Re-assessment, dated 6/3/2025, indicated Resident 10 had left axilla (armpit) mass, and calluses on the right and left feet. A review of Resident 10’s Minimum Data Set (MDS - a resident assessment tool), dated 6/9/2025, indicated that Resident 10 has the ability to make self understood and has the ability to understand others. The MDS indicated Resident 10 required partial/moderate assistance from staff for bed mobility including rolling to the left and right. The MDS indicated Resident 10 was always incontinent of bowel and bladder. The MDS indicated Resident 10 had no unhealed pressure ulcer but was identified as being at risk for developing pressure ulcers. A review of Resident 10’s Braden Scale (a scoring tool used to predict resident’s risk of developing a pressure ulcer, total score ranges from zero [0] to 18 with a lower score indicating a higher risk of developing a pressure ulcer), dated 6/3/2025, timed at 2:18 p.m., indicated a score of 17, which signifies that Resident 10 is at risk for developing pressure ulcer. A review of Resident 10’s Physician Orders dated 7/31/2025, indicated treatment for Resident 10’s MASD to the right and left buttocks extending to the perianal (around the anal area). The Physician Order indicated to cleanse with normal saline (a mixture of water and salt), pat dry, apply a skin barrier cream, leave open to air every day shift for 30 days. A review of Resident 10’s Physician Orders dated 8/12/2025, indicated to administer Acetaminophen tablet 325 milligrams (mg - a unit of measurement), give two tablets by mouth every day shift prior to wound care and treatment. During an interview on 8/12/2025 at 2:26 p.m., with Resident 10, Resident 10 stated she has a “wound” on her (Resident 10) back. Resident 10 stated that she (Resident 10) did not have this “wound” upon admission to the facility. Resident 10 stated that the “wound” on her (Resident 10) back is starting to hurt, and that she (Resident 10) is in pain. Resident 10 further stated that a staff member (name unknown) applied something to the “wound” the previous day, but she (Resident 10) was unsure of what was applied. During an interview on 8/12/2025 at 2:30 p.m., with TN 1, TN 1 stated that Resident 10 does not have a wound treatment in place, because Resident 10 only has MASD. TN 1 stated that she (TN 1) has not yet performed the MASD treatment ordered for Resident 10. During a concurrent observation and interview on 8/12/2025 at 2:32 p.m., with TN 1, Certified Nurse Assistant 1 (CNA 1), and Certified Nurse Assistant 2 (CNA 2), at Resident 10’s bedside, CNA 1 and CNA 2 repositioned Resident 10 onto her (Resident 10) right side to change her incontinence briefs. Two bordered gauze dressings were observed, one on Resident 10’s left buttock and one on Resident 10’s sacrococcyx area both without dates and staff initial. TN 1 removed the two bordered gauze dressings and stated Resident 10 has two open wounds. TN 1 stated that she (TN 1) does not know who applied the dressings on Resident 10. TN 1 then exited Resident 10’s room. During a concurrent observation and interview on 8/12/2025 at 2:41 p.m., with CNA 1 and CNA 2, at Resident 10’s bedside, CNA 1 stated that she (CNA 1) provided care for Resident 10 yesterday (8/11/2025), during the 3 p.m. to 11 p.m. shift, and observed bordered gauze dressings already in place on Resident 10’s left buttock and sacrococcyx. CNA 1 stated that she (CNA 1) did not touch or remove the dressings. CNA 2 stated that she (CNA 2) cared for Resident 10 yesterday (8/11/2025), during the 7 a.m. to 3 p.m. shift, and observed a large open wound on Resident 10’s sacrococcyx. CNA 2 stated that she (CNA 2) then documented the wound on Resident 10’s Daily Body Check Report and notified the charge nurse (Licensed Vocational Nurse 1 [LVN 1]). During a concurrent observation and interview on 8/12/2025 at 2:43 p.m., with TN 1, at Resident 10’s bedside, TN 1 measured Resident 10’s wounds and stated that Resident 10’s sacrococcyx wound measured 4.5 centimeters (cm- a unit of measurement) in length by (x) three (3) cm in width, 80% wound bed granulation (the formation of new connective tissue and blood vessels that fill in a wound bed during the proliferative phase of healing), and 20% slough (dead tissue that is usually yellow, tan, gray, or green in color, usually moist and stringy in texture, that may be found in wounds). TN 1 stated that the wound edges were attached, with no signs of undermining (the destruction of tissue or ulcer extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface). TN 1 stated that the wound on Resident 10’s left buttock measured two (2) cm in length x 0.4 cm in width and depth would be considered unstageable (a type of wound that occurs when pressure on the skin causes tissue damage that cannot be accurately assessed or staged due to the presence of necrotic [dead or dying] tissue) because the depth could not be determined. During an observation on 8/13/2025 at 8 a.m., Physician Assistant 1 (PA 1) and TN 1 were at Resident 10’s bedside. During an interview on 8/13/2025 at 8:15 a.m., with TN 1, TN 1 stated that PA 1 evaluated Resident 10’s wounds and performed excisional debridement (a surgical procedure involving the sharp removal of dead, damaged, or infected tissue from a wound to promote healing) on Resident 10’s sacrococcyx wound. TN 1 stated that she (TN 1) then applied Santyl (also known as collagenase, a topical ointment that removes dead tissue from wounds so they can start to heal) to Resident 10’s sacrococcyx wound as ordered. TN 1 further stated that she (TN 1) was the staff member who applied the bordered gauze dressings to Resident 10’s left buttock and sacrococcyx area yesterday (8/12/2025). A review of Resident 10’s Wound Care Consultation Notes (WCCN) dated 8/13/2025, the WCCN indicated Resident 10 had the following wounds: 1. Sacral, Stage three pressure ulcer, size 4 cm x 2.7 cm x 0.2 cm, wound base granular (a wound in the process of healing) with exposed subcutaneous (under or beneath the skin), 40% slough, 60% granular, and excisional debridement. 2. Left buttock, Stage two pressure ulcer, size 1 cm x 0.4 cm x 0.1 cm, wound base granular with exposed dermis (middle layer of skin in your body). The WCCN indicated the following recommendations: 1. Wound #1, Sacral: to monitor/offload (removing or minimizing the pressure, weight, and force from a specific area of the body, such as a wound or a body part at risk of injury), foam, and Santyl. 2. Wound #2, Left Buttock: to monitor/offload and foam; Zinc cream (medication used to treat and prevent skin irritation) for moisture control, Vitamin A and Vitamin D ointment (A&D – a skin protectant used to treat and prevent diaper rash and minor skin irritations) for skin maintenance, every two hours turning at all times while in bed; and apply heel protectors (device used to protect the heel of a resident’s foot from pressure ulcers or pain caused by impact and friction) or keep heels floating or with pillows under legs at all times while in bed. During an interview on 8/13/2025 at 8:17 a.m., with LVN 2, LVN 2 stated that she (LVN 2) has not yet started medication administration. She (LVN 2) has not given any medications to Resident 10. LVN 2 further stated that she (LVN 2) plans to administer Resident 10’s medications after Resident 10 has eaten and been changed. During an interview on 8/13/2025 at 9:15 a.m., with Resident 10, at Resident 10’s bedside, Resident 10 stated that she (Resident 10) is able to move her (Resident 10) legs but is unable to roll her (Resident 10) body to the right or left on her (Resident 10) own. She (Resident 10) requires staff assistance to turn while in bed. Resident 10 further stated that she (Resident 10) can assist slightly but not significantly. During an interview on 8/13/2025 at 9:18 a.m., with Resident 10 and LVN 2, at Resident 10’s bedside, Resident 10 stated that she (Resident 10) has pain rated eight out of 10 pain on the pain scale (a tool used to measure and describe the intensity of pain, ranging from 0 [no pain] to 10 [worst possible pain]) in both hands. During a concurrent interview and record review on 8/13/2025 at 9:18 a.m., with LVN 2, Resident 10’s Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 8/2025 was reviewed. LVN 2 stated that tramadol (a pain medication used to treat moderate to severe pain) was administered to Resident 10 on 8/13/2025 at 3:08 a.m., and the last dose of Acetaminophen was given to Resident 10 in 6/2025. LVN 2 stated that she (LVN 2) has not administered any pain medication to Resident 10 during her shift. During a concurrent interview and record review on 8/13/2025 at 11:30 a.m., with Restorative Nursing Assistant 1