Health inspection·April 11, 2025

F658 §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-(i) Meet professional standards of quality.

F686 §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.

F842 §483.70(h) Medical records. §483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(h)(5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. 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, § 72347. Nursing Service – § 725Content of Health Records. (a) A facility shall maintain for each patient a health record which shall include: (1) Admission record. (2) Current report of physical examination, and evidence of tuberculosis screening. (3) Current diagnoses. (4) The orders of a licensed health care practitioner acting within the scope of his or her professional licensure, including drugs, treatment and diet orders, progress notes, signed and dated on each visit. The orders of a licensed health care practitioner acting within the scope of his or her professional licensure shall be correctly recapitulated. (5) Nurses' notes which shall be signed and dated. Nurses' notes shall include: (A) Records made by nurse assistants, after proper instruction, which shall include: 1. Care and treatment of the patient. 2. Narrative notes of observation of how the patient looks, feels, eats, drinks, reacts, interacts and the degree of dependency and motivation toward improved health. 3. Notification to the licensed nurse of changes in the patient's condition. (B) Meaningful and informative nurses' progress notes written by licensed nurses as often as the patient's condition warrants. However, weekly nurses' progress notes shall be written by licensed nurses on each patient and shall be specific to the patient's needs, the patient care plan and the patient's response to care and treatments. On 2/25/2025 at 8:04 am, the California Department of Public Health (CDPH) conducted an unannounced visit for an annual recertification survey. As a result of the survey, CDPH determined that the facility failed to ensure Residents 1, 2, 3 and 4 received treatment and services to protect skin integrity (the state of skin being intact, healthy, and free from damage), promote healing, and prevent the development and worsening of pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) in accordance with the facility’s policy and procedures, residents care plans, and the physician’s orders by failing to: 1.Ensure that Resident 1, who did not have a pressure ulcer on admission to the facility, did not develop a Stage 2 (partial-thickness of skin, presenting as a shallow open sore or wound) coccyx (tailbone) pressure ulcer that worsened to a Stage 3 pressure ulcer (full-thickness loss of skin, dead and black tissue may be visible). In addition, the resident developed a left heel vascular ulcer (an open sore developed due to problems with poor blood circulation) while in the facility. 2. Ensure that Resident 1’s care plan was implemented, documented that the skin was monitored for skin breakdown. Resident 1’s skin assessment was not documented on 2/12/2025 to 2/14/2025, and 2/18/2025 to 2/21/2025 on the Daily Skin Assessments 3. Ensure that Resident 2 and 3’s Low Air loss Mattress (LAL, distributes the resident's body weight over a broad surface area and help prevent skin breakdown) was set based on the resident's weight of and was checked every shift for setting, connection, and functioning as ordered by the physician. Both Residents 2 and 3 had a healed Stage 4 pressure ulcer (skin damage due to unrelieved pressure of all layers of the skin, reaching the underlying muscle, tendon, or bone, often with exposed tissue and a high risk of infection) on the sacral, and a healed Deep Tissue Injury (DTI, skin damage due to unrelieved pressure beneath the skin that may appear purple or maroon, or with blood-filled blister) on the ischium (lower and back part of the hip), but was still at high risk for skin breakdown. 4. Obtain records from the wound specialist regarding the Resident 4’s, who had a Stage 4 pressure ulcer on the right ischium, wound condition and treatment recommendation since 1/23/2025. In addition, there was no weekly skin and wound assessment documentation in Nursing Progress Notes and Interdisciplinary Team report of the resident's wound condition after 1/23/25. These deficient practices resulted in the development of pressure ulcer for Resident 1 and the potential to result in the recurrent development of pressure ulcers and/or worsening of pressure that could lead to pain, discomfort and infection for Residents 2, 3 and 4. During a review of Resident 1's Admission Record, the record indicated the facility admitted Resident 1 on 1/31/2025 with diagnoses that included acute respiratory failure (ARF, when the lungs have trouble getting enough oxygen [odorless gas needed for plant and animal life] into the blood) with hypoxia (not enough oxygen in the body's tissues, muscle weakness, and peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 1's History and Physical (H&P, a comprehensive physician's note regarding the assessment of a resident's health status), dated 1/31/2025, the record indicated Resident 1 had the capacity to understand and make decisions. The H&P indicated Resident 1 had no skin breakdown and skin was intact. During a review of Resident 1's Body Check, dated 1/31/2025, the record indicated Resident 1 did not have any skin breakdown. During a review of Resident 1's Braden Scale for Predicting Pressure Sore Risk Original (a standardized and evidence-based assessment tool to assess a resident's risk of developing pressure ulcers), dated 1/31/2025, the record indicated Resident 1 was at mild risk for developing pressure ulcer because the resident's skin was occasionally moist, and the resident makes small frequent movement while confined to bed. During a review of the Nursing Progress Notes, dated 2/1/2025, Treatment Nurse (TXN) 2 indicated Resident 1 had a coccyx (tailbone) Stage 2 pressure ulcer (partial-thickness loss of skin, presented as a shallow open sore or wound) sized 2 centimeters (cm, unit of measure) by 2 cm by 0.1 cm, with 100% pink wound bed. During a review of Resident 1's Order Summary Report (physician's orders), dated 2/1/2025, the report indicated orders to clean Resident 1's coccyx pressure ulcer with normal saline (NS- fluid with a mixture of salt and water [0.9% sodium chloride]), pat dry, apply Thea-honey (sterile, medical grade honey dressing used to treat wounds), and cover with foam dressing every day, during every shift. During a review of Resident 1's care plan, date initiated on 2/1/2025, the care plan indicated Resident 1 had an actual skin breakdown on her coccyx area. The care plan interventions, dated 2/1/2025, included to turn or reposition the resident for comfort as tolerated, observe for signs and symptoms of skin breakdown such as redness, decreased sensation, and skin that does not blanche easily, and to observe for verbal and nonverbal signs of pain related to wound treatment. During a review of Resident 1's care plan, date initiated on 2/5/2025, the care plan indicated Resident 1 missed her treatment on 2/4/2025 that included cleansing coccyx pressure ulcer with NS, pat dry, apply Thea-honey, cover with foam dressing and for bilateral (both sides) lower extremity, apply A&D ointment x dry scaley skin every day for 30 days until finished. The care plan's interventions also included to monitor vital signs (measurement of the blood pressure, heart rate, respiratory rate and body temperature) every shift, provide treatment as ordered, and call the physician for any changes of condition (CoC). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment), dated 2/6/2025, the MDS indicated Resident 1's cognition (a person's mental process of thinking, learning, remembering, and using judgement) was intact. The MDS indicated Resident 1 was dependent (helper does all the effort, resident does none of the effort to complete the activity) for activities of daily living (ADLs, activities a person performs daily such as bathing, dressing, and toileting), and Resident 1 required substantial assistance (helper does more than half the effort) to turn from her back to the left or right side and to return to lying on her back on the bed. The MDS indicated Resident 1 was always incontinent (involuntary loss of bladder or bowel control) for urine and stool. The MDS indicated Resident 1 was at risk for developing pressure ulcers. The MDS indicated Resident 1's skin and pressure ulcer treatments included a pressure reducing device for the bed, pressure ulcer care, and the application of ointment or medication to the pressure ulcer. During a review of Resident 1's Order Summary Report, dated 2/6/2025 the physician ordered Resident 1 to be seen by wound consult (a physician specialized in wound care and pressure ulcers). During a review of Resident 1's Wound Assessment, dated 2/6/2025, evaluated by Physician Assistant (PA) 1, PA 1 indicated Resident 1 had a Stage 2 pressure ulcer on her coccyx measured 2.0 cm by 2.0 cm by 0.1 cm with light serosanguinous (thin watery fluid pink in color) drainage. PA 1 indicated Resident 1's pressure ulcer wound edges were macerated (a process where the skin becomes softened and breaks down due to prolonged exposure to moisture) and easily irritated. During a review of Resident 1's Wound Assessment, dated 2/13/2025, evaluated by PA 1, PA 1 indicated Resident 1's coccyx Stage 2 pressure ulcer measured 2.0 cm by 2.0 cm by 0.2 cm. PA 1 indicated Resident 1 had a serial surgical debridement (a medical procedure to clean a wound by removing the dead or damaged tissue). PA 1 indicated Resident 1's pressure ulcer remeasurement was 2 cm by 2 cm by 0.3 cm and reclassified as a Stage 3 pressure ulcer (full-thickness loss of skin. Dead and black tissue may be visible). PA 1 indicated Resident 1 had "multiple comorbidities (two or more conditions occurring at the same time) and a high Braden score resulting in high risk for wound decline and delayed wound healing." PA 1 indicated Resident 1's coccyx pressure ulcer wound edges were macerated and easily irritated with light serosanguinous drainage noted. During a review of Resident 1's CoC document, dated 2/13/2025, indicated the Physician Assistant (PA) 1 examined and reported Resident 1's coccyx pressure ulcer had declined due to comorbidities (medical conditions that you have in addition to a primary diagnosis). The Primary Care Physician (PCP) 1 recommendations included to continue following PA 1's treatment orders. During a review of Resident 1's care plan, date initiated 2/13/2025, the care plan indicated Resident 1 had been seen by the wound care physician for a decline of wounds related to her comorbidities. The care plan's interventions included continuing wound care treatment plan and to notify physician for any changes. During a review of Resident 1's Braden Scale document, dated 2/14/2025, the Braden Scale indicated Resident 1 was at high risk for developing pressure ulcers due to limited movement and required complete assistance with movement and skin was constantly damped with sweat or urine. During a review of Resident 1's Interdisciplinary Team (IDT, a group of health care professionals with various areas specialties who work together towards the goal of their resident) Care Conference note, dated 2/14/2025, the IDT note indicated Resident 1 had a Stage 3 coccyx pressure ulcer sized 2 cm by 2 cm by 0.3m cm, with 50% pink wound bed and 50% slough (dead tissue that is usually yellow, tan, grey, or green in color, usually moist and stringy in texture, that may be found in wounds), with "light serosanguinous drainage, no odor, macerated" and easily irritated wound edges. The IDT note wound status indicated Resident 1 Stage 3 pressure ulcer wound status was "worsening." The IDT note indicated Resident 1's risk factor included "exposure of skin to urinary and fecal incontinence." During a review of Resident 1's Order Summary Report, with an ordered date on 2/14/2025, Resident 1 had an order for a Low Air Loss