Health inspection·June 11, 2025

Code of Federal Regulations 42 CFR §483.21(b)(1), F656, Comprehensive Care Plan §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following — (i)The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii)Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). F686  42 CFR §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.   Cal. Code Regs., Tit. 22, § 72311. Nursing Service – General.  § 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: (A) The admission of a patient. (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (C) An unusual occurrence, as provided in Section 72541, involving a patient.  Cal. Code Regs., Tit. 22, § 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.  (5) Providing care to maintain clean, dry skin free from feces and urine.  (6) Changing of linens and other items in contact with the patient, as necessary, to maintain a 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).  Cal. Code Regs., Tit. 22, § 72313. Nursing Service--Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. Cal. Code Regs., Tit. 22, § 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. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (1) Physician services policies and procedures which include: (B) Patient evaluation visits by the attending physician and documentation of alternate schedules for such visits. (2) Nursing services policies and procedures which include: (D) Notification of the licensed healthcare practitioner acting within the scope of his or her professional licensure regarding sudden or marked adverse change in a patient's condition. On 4/28/2025 at 8:30 AM, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding neglect, quality of care, and death of Resident 1.  CDPH determined the facility failed to provide the necessary care and services for Resident 1 who was at risk for developing pressure ulcer ([PU] a skin damage or injury due to poor circulation or prolonged unrelieved pressure) and had a diagnosis of peripheral vascular disease (PVD- also known as peripheral arterial disease [PAD], a circulatory problem where narrowed arteries reduce blood flow to the legs, arms, or other parts of the body, often due to plaque buildup) prevent complications from PU, in accordance with the facility's policy and procedure, care plan and the physician's order. The facility failed to: 1. Ensure the facility's licensed staff and administration followed through on Nurse Practitioner (NP) 1's recommendation on 9/24/2024 to refer Resident 1 to a vascular physician (a doctor who specializes in the blood vessels) and NP 1’s recommendation on 12/25/2024 to refer Resident 1 to a wound specialist. Resident 1 was not evaluated by a vascular physician, and a wound specialist did not evaluate Resident 1 until 1/17/2025. 2. Implement Resident 1’s care plans to report improvements and declines to the physician and failed to notify Physician 1, NP 1, and/or the Director of Nursing of Resident 1’s worsening right and left foot changes in condition. There was no documented evidence in the progress notes that licensed staff reported Resident 1’s right foot SDTI (Suspected Deep Tissue Injury – discolored intact skin in which the extent of tissue damage is not fully visible at the skin surface) worsening condition to Physician 1 or NP 1 between 12/28/2024 and 1/12/2025. 3. Identify, develop, and implement a care plan for Resident 1's diagnosis of Peripheral Vascular Disease (PVD), also known as Peripheral Artery Disease (PAD) when the Podiatrist evaluation dated 10/22/2024 indicated a diagnosis of Type II Diabetes with PVD (PAD) without gangrene and again when the facility received an arterial doppler (a non-invasive diagnostic test that uses sound waves to visualize and measure blood flow in the arteries, typically of the arms and legs) result dated 12/18/2024 indicating the findings were consistent with moderate PVD of the bilateral lower extremities, to ensure licensed nurses assessed and monitored Resident 1 for the signs and symptoms of PVD and provided appropriate treatment measures for PVD. 4. Provide treatment as prescribed when licensed staff did not refer Resident 1 to a wound specialist to assess Resident 1's right foot wound, in accordance with NP 1's verbal order to the Treatment Nurse (TXN) on 12/25/2024. Facility staff did not place an order for a referral until 1/13/2025 (19 days from NP 1's verbal order to refer Resident 1 to a wound specialist) and Resident 1 was not seen by the wound specialist for an outpatient appointment until 1/17/2025. At that appointment, the wound specialist immediately ordered Resident 1 transferred to the General Acute Care Hospital (GACH) 1 ER due to infection and gangrenous changes to the right heel and left second toe. 5. Implement policies and procedures titled “Change of Condition Reporting”, “Comprehensive Person-Centered Care Planning,” “Skin Management System,” and “Physician Services.” As a result of these failings, Resident 1 was transferred to GACH 1 on 1/17/2025 where she was found to have worsening lower extremity gangrene that included a malodorous (an unpleasant or offensive odor, often associated with rotting or decaying matter) dry gangrenous right heel ulcer with surrounding erythema (abnormal redness) and tenderness to palpation and left second toe with dry gangrene. On 1/22/2025, GACH 1 performed an angiogram (a medical imaging technique that uses X-rays to visualize blood vessels) of Resident 1’s right foot for revascularization (a medical procedure aimed at restoring blood flow to a body part or organ, typically by surgical or minimally invasive methods, to address a blockage or narrowing of blood vessels) and angioplasty (surgical repair or unblocking of a blood vessel). Resident 1 was discharged from GACH 1 on 1/29/2025 to a Long-Term Acute Care Hospital (LTACH – specialized level of care focusing on patients with complex and prolonged medical needs) and was then admitted to hospice care (a specialized form of end-of-life care that provides comfort, support, and medical assistance to terminally ill patients and their families) on 2/12/2025. Resident 1 passed away on 2/18/2025 in hospice, due to diagnoses that included sepsis (a life-threatening emergency that happens when your body's response to an infection damages vital organs and, often, causes death) secondary to osteomyelitis (infection in the bone that can cause inflammation, pain and damage to the bone) and PAD. A review of Resident 1's Admission Record (AR), indicated Resident 1 was a 75 year old female resident who was originally admitted to the facility on 3/14/2024 and readmitted on 6/3/2024 with diagnoses including pneumonia (a severe infection and inflammation of the lungs), chronic kidney disease, diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing) Type II, and Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). A review of Resident 1’s Initial Admission Record- Skin Integrity – dated 6/3/2024, indicated “[Resident 1] had bilateral upper extremities scattered skin discoloration.” The record did not indicate Resident 1 had any pressure ulcers, wounds, and other skin problems upon readmission on 6/3/2024. A review of Resident 1's Braden Scale for Predicting Pressure Injury Risk (a Braden Scale used to predict the risk of developing pressure sores/injuries. Early identification allows for preventative measure to be taken, such as repositioning, pressure relief measures, and nutritional support) dated 6/3/2024, the total score indicated was 12 (categorized at high risk for pressure injury). A review of Resident 1’s Skin Evaluation PRN (as needed) /Weekly dated 6/10/2024, authored by the TXN, indicated “Skin check assessment done, no new findings to report… Patient [Resident 1] has existing abdominal fold MASD (moisture associated skin damage) improving, no bleeding or discomfort. Patient [Resident 1] has trace edema on lower extremities. Patient [Resident 1] is noted with existing left heel non-blanchable redness. Resolved right foot.” A review of Resident 1’s Minimal Data Sheet (MDS- a resident assessment tool) dated 6/10/2024, the MDS indicated Resident 1 had severe cognitive impairment (a condition that makes it very difficult for a person to think, learn, and remember). The MDS indicated Resident 1 was dependent to staff on rolling left and right, sitting to lying, lying on side of bed, and chair/bed-to-chair transfer and personal hygiene. The MDS indicated Resident 1 was at risk for developing pressure ulcers and had two Stage 1 (intact skin with non-blanchable redness of localized area, usually over a bony prominence) pressure injuries (also called pressure ulcers). The MDS did not indicate the location of the two Stage 1 pressure injuries. A review of Resident 1's Care Plan dated 6/30/2024, indicated Resident 1 was at risk for developing PU related to UTI (urinary tract infection- an infection in the bladder/urinary tract), ESRD (End Stage Renal Disease-irreversible kidney failure) on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). The care plan interventions included: the facility will assess/record/monitor wound healing, assess and document the wound perimeter (around the wound), report improvements and declines to the physician; administer treatment as ordered and monitor for effectiveness; provide pressure relieving/reducing device; and weekly head to toe skin at risk assessment. A review of Resident 1's Podiatry (a medical care and treatment of the human foot) Evaluation and Treatment dated 8/19/2024, indicated Resident 1 had absent hair growth on the foot and skin temperature was cool to touch. The evaluation indicated Resident 1 was assessed having onychomycosis (a fungal infection of the nails). A review of Resident 1’s Braden Scale for Predicting Pressure Injury Risk dated 9/16/2024, indicated the total score was 14 (categorized at moderate risk for pressure injury). A review of Resident 1’s Physician Progress Notes dated 9/24/2024, authored by NP 1 indicated “[Follow up] vascular surgeon, pending date.” A review of Resident 1's Podiatry Evaluation and Treatment dated 10/22/2024, indicated Resident 1 had absent hair growth on the foot with skin temperature cool to touch. The evaluation indicated Resident 1 was assessed having onychomycosis, The Podiatry evaluation added another diagnosis during this assessment and indicated Resident 1 had "Type II Diabetes with PVD without gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection)." Resident 1’s records did not indicate any other follow up Podiatry Evaluations after this visit on 10/22/2024. A review of the Progress Notes dated 11/21/2024 indicated Resident 1 had a change in skin condition of the right heel which was noted with cracked skin, scant (small amount) bleeding and redness. The Progress Notes did not indicate the type of wound and/or measurement of the wound. A review of Resident 1’s Care Plan, dated 11/21/2024 indicated Resident 1 had PU on right heel related to history of ulcers and immobility. The care plan interventions included placing heel protectors, assessing/recording/monitoring wound healing, wound perimeter, measure length, width, and depth of the wound. wound bed, and healing progress. The interventions also included reporting improvements and declines of the skin condition to the physician. A review of Resident 1’s Care Plan, dated 11/29/2024 indicated Resident 1 has pressure ulcer (right heel Suspected Deep Tissue Injury) related to immobility. The care plan interventions included to administer treatments as ordered and monitor for effectiveness, assessing/recording/monitoring wound healing, wound perimeter, measure length, width, and depth of the wound. wound bed, and healing progress. The interventions indicated “Right heel open wound – clean with NS, pat dry and paint with betadine and cover with dry dressing and off load from pressure.” A review of Resident 1’s Skin Evaluation PRN /Weekly dated 11/25/2024 indicated, Resident 1’s right heel was noted with a pressure wound measuring 1 centimeter (cm) x 1 cm with no staging (no documentation of the stage or depth of the wound/ulcer). Additional comments indicated Resident 1’s right heel had cracked skin. A review of Resident 1’s Skin PU Weekly Assessment dated 11/29/2024 indicated, Resident 1's right heel PU was reclassified to SDTI measuring 3 cm x 4 cm, with 100% maroon/purple discoloration and pain, the wound bed was assessed to have normal skin. The intervention was to clean with normal saline, pat dry, paint with