Health inspection·May 30, 2025

CFR §483.25 Quality of Care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: (b) Skin Integrity (1) Pressure injuries. 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 injuries and does not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure injuries receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new injuries from developing. CFR §483.10 Resident's Rights (14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is - ... (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); T22 CCR § 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. ... (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). T22 CCR § 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. (2) Encouraging, assisting, and training in self-care and activities of daily living. (3) Maintaining proper body alignment and joint movement to prevent contractures and deformities. (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). CCR § 72523(a) 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 4/14/2025, at 8 a.m., the California Department of Public Health (CDPH) conducted an unannounced standard annual recertification survey. CDPH identified that the facility failed to ensure Resident 35's right heel suspected deep tissue pressure injury (SDTI, suspected pressure injury where damage is occurring beneath the skin, but the surface skin may still appear intact. It's characterized by a purple or maroon localized area of discolored skin or a blood-filled blister due to damage to underlying soft tissues from pressure) and left heel blister did not progress to unstageable (actual pressure injury covered by slough (pale yellow, thick, tissue with fiber) and/or eschar (a piece of dead tissue that is cast off from the surface of the skin) pressure injuries by failing to: 1. Ensure Resident 35's right heel SDTI did not decline to an unstageable pressure injury. 2. Monitor and document the presence of a left heel SDTI upon Resident 35's admission. 3. Document weekly left heel SDTI wound assessments in Resident 35's medical record. 4. Refer Resident 35 to a wound care practitioner. 5. Provide Resident 35 with offload (minimizing or removing weight placed on the foot to help prevent and heal ulcer) measures including low air loss (LAL -medical-grade mattress designed to prevent and treat pressure injuries by reducing moisture and heat buildup) mattress and elevate heels over a pillow or heel protector boots, and provide supplements such as additional protein, Zinc (mineral for wound healing), Vitamin C and a Multivitamin to promote left heel SDTI wound healing. 6. Notify Resident 35's physician when the left heel "blister" was reclassified as a left heel SDTI on 3/26/2025. 7. Notify Resident 35's physician and complete a change of condition (COC) assessment when Resident 35's left heel SDTI was noted to have a foul (bad) odor (indicating infection), an area of eschar, and slough on 4/14/2025. 8. Ensure the interdisciplinary team (IDT) including the Director of Nursing (DON), the treatment nurse (TXN) 1, and the registered dietician (RD) met and discussed interventions to promote Resident 35's left heel SDTI and right heel SDTI wound healing. These deficient practices resulted in Resident 35's left heel blister and right heel SDTI progressing to unstageable pressure injuries on 4/14/2025 and causing Resident 35 pain. Resident 35 was admitted to a general acute care hospital (GACH 2) on 4/17/2025 with a chief complaint of heel pain and a primary diagnosis of a left heel unstageable pressure injury. Resident 35 was treated with Vancomycin (medication to treat infection) intravenously (IV) for bacterial wound infections, Morphine for pain, and was given one liter of Normal Saline (NS, medical grade hydrating solution) solution for hydration in the emergency department (ED) on 4/17/2025. These deficient practices placed the resident at high risk for sepsis, amputations, and a decline in physical and psychosocial wellbeing. A review of Resident 35's Admission Record indicated Resident 35 (an 84-year old-woman) was admitted to the facility on 3/23/2025, from GACH 1 with diagnoses of left femur fracture (broken thigh bone), fall, muscle weakness, difficulty in walking, joint replacement surgery, and type 2 diabetes (a condition in which the body cannot use insulin correctly, and sugar builds up in the blood). A review of Resident 35's GACH 1 Wound Care Consult Notes dated 3/23/2025, indicated Resident 35 had a left heel Stage II (when the wound extends into the bottom layers of the skin or may present as an intact blister)/ DTI with an intact fluid filled blister which measured 6.0 centimeters (cm) in length by 6.0 cm in width and a right heel SDTI with erythema (redness) which measured 3.0 cm in length by 3.0 cm in width. The Wound Care Consult Notes indicated Resident 35 required Pressure Injury Prevention Protocol including a waffle seat cushion (an air pressure redistribution cushion), or a low air loss mattress, turning and repositioning every two hours, and offloading the heels over a pillow or heel protector boots. A review of Resident 35's Initial Admission Record dated 3/23/2025, indicated treatment nurse (TXN) 2 conducted a skin integrity check. The Admission Record indicated TXN 2 notified the physician (unspecified) of Resident 35's left heel blister and right heel SDTI. Resident 35's Initial Admission Record did not include a description, including the appearance and measurements of the left heel blister and the right heel SDTI upon admission. A review of the undated Admission Report- Skin Check, indicated Resident 35 had a right heel SDTI measured at 1.5 cm in length by 0.5 cm in width and a 3.0 cm by 6.0 cm left heel blister. A review of Resident 35's history and physical (H&P) dated 3/24/2025, indicated Resident 35 was able to make her own medical decisions. The H&P indicated Resident 35 was sent to the facility after left hip surgery due to a left hip fracture. The H&P indicated Resident 35 did not have any concerning rashes or lesions (wounds) at the time but did have a left hip surgical wound site. The H&P included a plan to monitor the surgical wound per facility protocol and obtain a wound care evaluation as needed. The H&P indicated the facility's care staff was instructed to call the physician for any change of condition (COC). A review of Resident 35's care plan titled, "Actual impairment to skin integrity related to left heel blister and left heel protector boot (cushioned boot that floats the heel to aid in healing of pressure injuries)" dated 3/25/2025, indicated the goal for Resident 35 included reducing the risk for impairment to skin integrity by (body) positioning techniques, and adaptive equipment (heel protector boots). The care plan interventions included avoiding scratching, keeping body parts from excessive moisture, keeping fingernails short, educating resident, family, and caregivers of causative factors and measures to prevent skin injury, and encouraging good nutrition and hydration to promote healthier skin. On 4/15/2025, the care plan for the left heel blister was updated and included, "On 3/26/2025 patient was reassessed by TXN 1, the left heel blister was classified as SDTI with purple tissue (can indicate impaired blood flow or tissue damage)." On 4/15/2025, the care plan interventions were updated to include left heel SDTI treatment as ordered, monitor/ document location, size and treatment of the skin injury, report abnormalities, failure to heal and signs and symptoms of infection to the physician, monitor for skin breakdown and off-load (minimizing or removing weight placed on the foot to help prevent and heal ulcers) as tolerated. A review of Resident 35's Order Summary indicated the following physician's wound care orders: - On 3/25/2025, for left heel blister, cleanse with NS, pat dry, apply antibacterial ointment then apply gauze and wrap with Kerlix every day (7 a.m. to 3 p.m.) shift. The order was discontinued on 3/26/2025. - On 3/25/2025, for right heel SDTI cleanse with NS, pat dry, apply oil emulsion dressing wrap, wrap with Kerlix, every day shift. The order was discontinued on 4/16/2025. - On 3/25/2025, for bilateral (both) heels apply protector boots as tolerated or as patient allows. Every day shift. - On 3/26/2025, for left heel SDTI: cleanse with NS, pat dry, apply Sure-Prep (skin barrier ointment), apply abdominal (ABD) pad and cover with rolled gauze. Offloading as tolerated, monitor for skin breakdown and notify the physician of any changes; every day shift. The order was discontinued on 4/14/2025. - On 4/14/2025, for left heel SDTI: cleanse with NS, pat dry, apply Medihoney Calcium alginate dressing and cover with rolled gauze. Offloading as tolerated, monitor for skin breakdown and notify the physician of any changes; every day shift. The order was discontinued 4/16/2025. - On 4/14/2025, wound culture the left heel, one time only. - On 4/16/2025, wound care consult for SDTI. - On 4/16/2025, for left heel unstageable pressure injury: cleanse with NS, pat dry, apply Medihoney, Calcium Alginate dry dressing and cover with rolled gauze. Offloading as tolerated, monitor for any signs for skin breakdown and notify the physician of any changes. - On 4/16/2025, for right heel unstageable pressure injury: cleanse with NS, pat dry, apply Medihoney, Calcium Alginate, dry dressing and cover with rolled gauze. Offloading as tolerated, monitor for any signs for skin breakdown and notify the physician of any changes. A review of Resident 35's Skin/ Wound Note dated 3/26/2025, (three days after admission), indicated Resident 35 was reassessed by TXN 1 and the left heel blister was classified as an SDTI with purple tissue. The Skin/Wound Note did not indicate measurements or a complete wound assessment describing the characteristics of the wound, including the color, if it was blanchable or not, the texture (boggy or mushy), temperature (to touch), swelling, pain. The note did not indicate the facility staff notified the physician of the new wound type classification (from blister to SDTI) and asked for new treatment orders. Resident 35 did not have weekly Skin/Wound assessments documented in her medical record including all wounds and their progress status. A review of Resident 35's MDS, dated 3/28/2025, indicated Resident 35 had moderate cognitive impairment and required substantial/ maximal assistance (helper does more than half the effort) for bed mobility including rolling from left to right. The MDS indicated Resident 35 was at risk for pressure injuries and had two deep tissue injuries (one on the left foot and one on the right foot) and zero unstageable pressure injuries with slough or eschar. During an observation on 4/14/2025, at 10 a.m., Resident 35 was lying in bed with her feet elevated on one pillow. Resident 35 did not have heel protector boots on, Resident 35 was not lying on a low air loss mattress. During an interview on 4/14/2025, at 10:11 a.m., Family Member (FM) 2 stated she was upset because Resident 35's left heel wound was getting worse. During an observation on 4/14/2025, at 1:44 p.m., TXN 1 was in Resident 35's room speaking to FM 3 at the bedside. Resident 35 was observed lying in bed crying in pain, saying her left foot hurt. Resident 35 was informing FM 3 she had chills. TXN 1 was observed obtaining a wound culture swab from Resident 35's left foot wound as ordered due to the foul odor of the wound. Resident 35's left heel was observed with the following and described by TXN 1 as: a large area of dark purple or black appearing eschar, surrounded by a pinkish red area of granulation tissue, and a small amount of yellowish white slough. A review of Resident 35's wound culture results, obtained from the left foot on 4/14/2025, indicated Resident 35 had moderate growth of Proteus Mirabilis, a gram-negative bacteria that causes wound infections. During an interview on 4/15/2025, at 9:03 a.m., TXN 1 stated Resident 35's wounds were not being treated by a wound care specialist. TXN 1 stated she noticed a change in appearance on 4/14/2025 to Resident 35's left heel wound and an odor, so she obtained the wound culture on 4/14/2025. TXN 1 reviewed her wound care binder at the nurse's station where she tracked residents' wound progress but there was no information about Resident 35 in her wound care binder. TXN 1 reviewed Resident 35's medical record and stated there was no weekly skin/wound documentation in Resident 35's medical record including measurements and appearance of the wounds. TXN 1 reviewed Resident 35's Licensed Nurse (LN)-Initial Admission Assessment dated 3/23/