Health inspection·September 23, 2025

§483.21-Comprehensive Person-Centered Care Planning  §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     § 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 achieve.    § 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.  female  (4) Using pressure-reducing devices where indicated.     From 8/12/2025 to 8/15/2025, the California Department of Health (CDPH) conducted a standard annual recertification survey.       The facility failed to:    1. Initiate a wound treatment for Resident 62 when a change of condition (COC) was identified as a Stage III pressure injury (injury that extends through the skin into deeper tissue and fat) on 6/26/2025.    2. Follow and implement the plan of care for repositioning every two (2) hours for Resident 62 and Resident 101.    3. Provide offloading measures (refer to strategies used to reduce or redistribute pressure on specific parts of the body to prevent pressure injuries), such as a low air loss mattress (LAL- minimizing or removing weight to help prevent and heal ulcer) upon identification of the pressure ulcer in Resident 62 and Resident 101.    4. Ensure the Registered Dietitian ([RD] nutrition specialist) reassessed and implemented nutritional interventions for Resident 62 and Resident 101.     5. Ensure the interdisciplinary team (IDT: group of healthcare teams consisting of various specialties that share and combine their knowledge and information to create the best possible care plan for the resident) met to discuss and develop appropriate wound healing interventions for Resident 62 and Resident 101.    These deficient practices resulted in Resident 62 and Resident 101’s preventable pressure injury (PI). Resident 62’s right buttock redness progressed to a Stage III PI on 6/26/2025 with measurements of 2 centimeters (cm: unit of length) by (x) 2 cm (width) x 0.2 cm (depth). Resident 101 skin redness on the coccyx ( tailbone area) identified on 6/25/2025 progressed to an unstageable PI (base of the wound is unable to be determined due to the base of the wound covered by a layer of dead tissue that may be yellow, grey, green, brown, or black) on 6/26/2025, measuring 0.5 cm long x 0.5cm width x 0 cm depth. Resident 101’s PI was reclassified as a Stage III PI, measuring 1 cm length x 1 cm width x 0.1 cm depth with 100 percent (%) granulation (new, red, bumpy, and moist connective tissue fills the wound bed).    A review of Resident 62’s Admission Record (Face Sheet), indicated the facility admitted Resident 62, a 76-year-old female, on 11/24/2019 and readmitted on 4/4/2025 with diagnoses of gastrostomy (g-tube: a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), type II diabetes mellitus (DM: a chronic disease that affects how the body processes sugar), and dementia (a progressive state of decline in mental abilities).    A review of Resident 62’s Minimum Data Set (MDS: a resident assessment tool), dated 6/25/2025, indicated Resident 62 was cognitively (mental action or process of acquiring knowledge and understanding ability) severely impaired. The MDS indicated Resident 62 was dependent on staff for chair/bed-to-chair transfer, shower transfer, toileting hygiene, bathing, upper (waist above) and lower (waist below) body dress, required moderate assistance (provides less than half the effort) for oral hygiene, and required supervision for eating. The MDS indicated Resident 62 was at risk for developing pressure ulcers/injuries with no indication of an active pressure ulcer/injury. The MDS indicated Resident 62 had other skin issues of Moisture Associated Skin Damage (MASD: moisture associated skin damage caused from prolonged exposure to moisture) and had skin and ulcer/injury treatments to provide nutrition or hydration intervention to manage skin problems and applications of ointments/medications other than to feet.     A review of Resident 62’s COC dated 6/25/2025 at 1:11 p.m., indicated a Certified Nursing Assistant (CNA) was changing and cleaning Resident 62 when there was redness on the right buttocks and reported to Treatment Nurse 2 (TXN 2). The recommendation was to follow the facility protocol treatment for redness.     A record review of Resident 62’s Braden Scale for Predicting Pressure Ulcer Risk evaluation (a tool designed to help healthcare providers assess the resident’s risk for developing pressure injury), dated 6/25/2025 timed 3:08 pm, indicated Resident 62 was at high risk (score range 10 to 12) for developing pressure ulcers with a score of 12.     A review of Resident 62’s progress note dated 6/26/2025 timed 3:09 pm, indicated Resident 62’s right buttock redness was re-classified to Stage III PI. The wound was acquired in-house (within the facility) on 6/26/2025 and the PI was staged by the Physician Assistant (PA) with measurements of 2 cm x 2 cm x 0.2 cm. The primary dressing is MediHoney gel with secondary dressing to offload pressure.     A review of Resident 62’s wound assessment and plan visit dated 6/26/2025 indicated a Stage III pressure injury measured at 2.0 cm length x 2.5 cm width x 0.2 cm depth.    A review of Resident 62’s Treatment Administration Record (TAR: document that indicates the administration of treatments for residents) for 6/2025, indicated starting on 6/28/2025, for Right buttock PI: cleanse with NS (normal saline solution-a mixture of water and salt concentrate of 0.9 percent [%]), pat dry, apply Medical Honey (MediHoney: promote healing in wounds by creating a moist environment offering antimicrobial and anti-inflammatory effect) gel, cover with specialized foam dressing, every day shift for 30 days.     A review of Resident 62’s care plan (CP) untitled dated 6/30/2025, indicated Stage III right buttocks PI with interventions to keep skin clean and dry, and moisturized, turn/reposition resident every 2 hours, and administer treatment per Medical Doctor (MD) order initiated on 6/30/2025.     A review of the Nutrition/Dietary Note dated 7/22/2025 at 10:34 am, the nutrition/dietary note indicated Resident 62 had a Stage II (Partial-thickness loss of skin, presenting as a shallow open sore or wound) PI on the right buttocks with measurements of 1 cm x 1 cm x 0.1 cm.      During an observation on 8/14/2025 at 8:52 am, Resident 62 was observed lying on her left side on a low air loss mattress (LAL) with a position pillow to her mid-back and buttocks area. Three linen sheets were placed under Resident 62’s buttocks reducing air circulation.    During an observation on 8/14/2025 at 9:50 am, Resident 62 was observed lying on her left side in the same position with the position pillow to the right buttock and three sheets underneath resident's buttocks.    During a concurrent observation, interview and record review on 8/14/2025 at 3:49 pm, Resident 62’s progress notes authored by Licensed Vocational Nurse (LVN) 5 were reviewed with LVN 4. LVN 4 stated, Resident 62’s right buttock had been re-classified as a Stage III pressure ulcer on 6/26/2025.  LVN 4 stated treatment was not implemented on the day the facility identified the acquired PI on 6/26/2025.  LVN 4 stated there was a change of condition (COC) on 6/25/2025, where redness to right buttock was identified, LVN 4 stated it was important to notify the wound doctor and Registered Dietitian (RD).  LVN 4 stated that staff should reposition residents every 2 hours to relieve pressure from the affected areas. LVN 4 stated CNA’s documentation of Resident 62’s repositioning could not be located in the Point of Care ([POC] section in the electronic medical records).     During an interview on 8/14/2024 at 3:49 pm, LVN 4 stated a Registered Dietitian did not address or re-assess Resident 62 until 7/22/2025 for the specified PI. LVN 4 stated the importance of RD   nutritional assessment in addressing the nutritional or hydration needs of Resident 62. LVN 4 stated Resident 62 should be on low air loss mattress and it was not implemented when Stage III was identified on 6/26/2025. LVN 4 stated that staff should have used a low air loss mattress for Resident 62 immediately after identifying the Stage III pressure injury, but the facility did not provide the LAL until 23 days later.    During an interview on 8/14/2024 at 3:49 pm, LVN 4 stated one sheet of linen should be used, and not 3 linens, as ample amounts of linen wound interfere with air circulation.  LVN 4 stated there were 3 sheets under Resident 62’s buttocks when she was pulled up (repositioned) in the morning. LVN 4 stated it is beneficial for residents to have low air mattresses and indicated it was not implemented as Resident 62 was combative and the facility should not have waited to provide the low air mattress despite Resident 62 being combative.     During an interview on 8/14/2024 at 3:49 pm, LVN 4 stated the IDT did not evaluate Resident 62’s PI until 7/20/2025, nearly a month after the PI was identified. LVN 4 stated IDT meetings are attended by the Director of Nursing (DON), TXN, Assistant Director of Nursing (ADON), and Social Service (SS), and the IDT meeting for Resident 62 should have been done within 48 hours of the identification of a new PI.  LVN 4 stated a Braden Scale reassessment was not completed for Resident 62 when the PI was identified on 6/26/2025.     During a concurrent interview and record review on 8/15/2025 at 8:21 am, CNA 4 stated staff should reposition residents every 2 hours. CNA 4 mentioned that there was no documentation of repositioning on paper or in the POC.    During an interview and record review on 8/15/2025 at 12:53 pm, with RD , RD  stated Resident 62 was at nutritional risk and the resident’s psychotropic medications (drugs that affect mental processes) could affect the weight and increased the risk of skin breakdown., RD  stated almost a month after the PI was identified on 6/26/2025 when RD assessed Resident 62 (on 7/22/2025).  On 6/25/2025, RD stated there was no mention of specific PI treatments in the care plan.  RD stated her involvement in Resident 62’s care was important to promote faster wound healing.   RD stated evaluation of the residents with PI should be conducted within 48 hours after the identification of a new PI for nutrition and hydration interventions.    During a concurrent interview and record review on 8/15/2025 at 2:12 pm, the DON stated that care plans should be individualized for each resident. The DON said they (the facility in general) informed the family and involved them (the family) in the IDT, and the IDT team created the plan of care. The DON stated that the RD should be involved within 48 hours, and the care plan should be initiated and reflect the intended care. DON stated the IDT should meet with the residents within 72 hours if there is a COC. The DON stated care plan interventions should include repositioning the resident every 2 hours, providing low air loss (LAL) mattress, and avoiding putting on multiple sheets to the mattress, as it defeats the purpose of the airflow mattress.     During an interview on 8/15/2025 at 2:12 pm, the DON stated a pressure injury is preventable if the residents’ care plans and assessments are done accordingly. The DON stated the facility cannot prove that Resident 62 was being repositioned since they do not document repositioning in the POC. The DON stated Resident 62 does not have a reassessment Braden Scale when it should have been done the day the pressure injury was discovered on 6/26/2025. The DON stated when a pressure injury was identified on 6/26/2025.  The DON stated the low air loss mattress was ordered on 7/22/2025, almost a month after the identification of pressure injury.     A review of the facility’s Policy & Procedure (P&P) titled, “Skin Integrity Management” revised on 6/27/2024, indicated “facility will identify, evaluate, and intervene to prevent further pressure injury and/or heal pressure ulcers and any other skin integrity conditions.”       A review of Resident 101’s Face Sheet, indicated the facility admitted Resident 101 was a 57-year-old female, on 9/5/2024 with diagnoses of hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infection (stroke-blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting left dominant side, g-tube, and type II DM.    A review of Resident 101’s History and Physical (H&P), dated 12/22/2024,  indicated Resident 101 does not have the capacity to understand and make decisions.    A review of Resident 101’s MDS dated 7/16/2025, indicated Resident 101’s cognition was severely impaired. The MDS indicated Resident 101 is dependent on all aspects of performing activities of daily living (ADLs: activities such as bathing, dressing, personal/oral hygiene, and toileting). The MDS indicated Resident 101 has impairment on both sides of the upper and lower extremity. The MDS indicated Resident 101 had a Stage III PI with skin and ulcer/injury treatments of pressure reducing devices for bed, nutrition or hydration intervention to manage skin problems, and pressure ulcer/injury care.    A review of Resident 101’s COC dated 6/25/2025 at 11 am, the COC indicated TXN noted redness on Resident 101’s coccyx (commonly referred to as the tailbone) initial treatment was rendered, and the Nurse Practitioner (NP) was notified.     A review of Resident 101’s COC dated 6/26/2025, indicated upon reassessment with the wound care team and PA, the  previously classified Stage I  (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness) PI (appears as redness caused by prolonged pressure, often on a bony area) on the coccyx was classified as unstageable PI on 6/26/2025.    A review of Resident 101’s CP titled “Unstageable Pressure Injury” dated 6/29/2025, indicated repositioned Resident 101 every two hours.    A review of Resident 101’s Wound Assessment and Plan dated 6/26/2025,  indicated it was an initial assessment, wound location: coccyx, unstageable PI (identified as Stage I in the COC) onset date 6/26/2025 with measurements of 0.5 cm x 0.5cm x 0 cm. The treatment order indicated to apply Medical Honey Gel-cleanse wound with normal saline or sterile water, apply to wound bed, and cover with dry clean dressing as instructed.     A review of Resident 101’s Wound Assessment and Plan dated 7/2/2025 and 7/9/2025, indicated wound location: sacrum (triangular bone at the base of the spine, just above the coccyx) and coccyx area, Stage III PI, onset date 9/11/2024, healing with measurements of 1 cm x 1 cm x 0.1 cm.  The comment section indicated the wound was a re-ulceration (re-opening) of a previously healed Stage III PI.    A review of Nutritional Risk Assessment dated 7/30/2025 timed at 4:06 pm,  indicated Resident 101 wound condition was reviewed with the wound IDT, the wound is a healing Stage III sacrum/coccyx PI, measuring 0.5 cm x 0.5 cm x 0.1 cm.     During a concurrent interview and record review on 8/15/2025 at 9:10 a.m.  with LVN 4, Resident 101’s Braden Scale for 4/10/2025 and 7/15/2025 were reviewed. LVN stated Resident 101 was high risk for developing PI. LVN 4 stated Resident 101 score was 13 on 4/10/2025 and 9 on 7/15/2025.