Health inspection·December 29, 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.  483.25(b)(1)(i)(ii)   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 Patient 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 Patient 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 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 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, § 72301 - Required Services  (a) Skilled nursing facilities shall provide, but shall not be limited to, the following required services: physician, skilled nursing, dietary, pharmaceutical and an activity program.    (f) The facility shall ensure that all orders written by a person lawfully authorized to prescribe shall be carried out unless contraindicated.    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).    On 11/3/2025 at 9:35 AM, the California Department of Health (CDPH) conducted an unannounced visit to investigate a facility reported incident and complaint regarding quality of care and treatment for a resident who developed a pressure ulcer   Based on observation, interview, and record review, the facility failed to ensure Patient 1, who was assessed as a high risk for pressure injuries, was provided with care and services, consistent with professional standards of practice, to promote healing and prevent new pressure ulcers from developing and/or worsening by failing to:   1. Identify and implement individualized care plan interventions for Patient 1 to prevent a further decline in pressure ulcers as required by the regulations and policies and procedures.     2. Revise Care Plans as needed consistent with Patient 1’s skin care needs, when Patient 1 continued to have declining pressure injuries in accordance with the facility’s policy and procedure for their Care plan.   3. Monitor and inspect Patient 1’s skin on a daily basis when performing or assisting with personal care or ADLs in accordance with the policy and procedure titled Prevention of Pressure Injuries.     4. Ensure Patient 1 was turned and repositioned as indicated on Patient 1’s Care plan and in accordance with the policy and procedure titled Prevention of Pressure Injuries.  5. Recognize or address the potential for developing a pressure ulcer, resulting in the facility failing to identify the risks of pressure ulcers, developing a comprehensive plan of care and consistently implementing a plan that has been developed to prevent pressure ulcers for Patient 1.   As a result, Patient 1 was transferred to the General Acute Care Hospital (GACH) via 911 and Emergency Medical Services and admitted to emergency room (ER) on 10/21/25, with left buttock wound infections with foul odor drainage, pressure ulcer on the left toe and right heel, dehydration and hypotension (low blood pressure). Upon transfer Patient 1received intravenous fluids (fluids given into the vein) and was transferred to the Intensive Care Unit (ICU a unit in the hospital with life threatening condition), where Patient 1 was diagnosed with septic shock (a life-threatening medical emergency where a severe infection causes low oxygen in the cell and leads to death) and a gluteal (buttock) large wound and abscess that was debrided (surgical procedure to remove dead tissue).  Findings: A review of Patient 1’s Admission Record (AR) indicated Patient 1 was an 85 year old male who was initially admitted to the facility on 4/2/2022 and readmitted on 8/29/2025 with diagnoses of contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) to the right and left knee, muscle weakness, cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body).    A review of Patient 1’s Care Plan for at Risk for Pressure Ulcer, initiated on 1/6/2023, indicated the goal was to minimize the risk of skin breakdown/pressure sore daily. The Care Plan interventions indicated assisting skin integrity during care, turn and position as needed while in bed or wheelchair, and for weekly body check.     A review of the Minimum Data Set (MDS – a patient assessment tool) dated 10/4/2025, indicated Patient 1 had severe cognitive impairment (ability to think and reason) for daily decision making, and totally dependent on staff (helper does all of the effort, patient does none of the effort to complete the activity) for bed mobility, transfers, dressing, personal hygiene, requiring two or more persons to assist, and with eating. The MDS indicated Patient 1 had a total of one unstageable slough/eschar (dead tissue covering the wound) pressure ulcer that was present, the MDS indicated Patient 1’s treatment was pressure ulcer care and nutrition or hydration intervention to manage skin problems.  A review of Patient 1’s SNF Wound Evaluation (Skilled Nursing Facility) dated 8/29/25,  conducted by Treatment Nurse (TN) indicated Patient 1’s left great toe had suspected Deep Tissue Injury (DTI a wound that develops beneath the skin's surface, originating in the muscle and deeper tissues), undetermined or unstageable tissue (UTD- wound depth cannot be identified due to dead tissue covering the wound) measuring 3.9 x 1.5 centimeter (cm) with purple discoloration and swelling to the left toe.      A review of a care plan, initiated on 8/29/25, indicated Patient 1 had an unstageable wound to the left great toe with interventions to assess the resident’s skin care, apply pressure relieving device as needed and turn and reposition as needed when in bed and wheelchair.  A review of Patient’s 1 “Braden Scale for Predicting Pressure Score Risk” completed on 9/5/2025 indicated a score of 10 (a score of 10-12 was considered a high risk for developing pressure ulcers) due to respond only to painful stimuli, exposed to moisture, bedfast, completely immobile requires moderate to maximum assistance with movement, nutrition probably inadequate and with friction & shear problem.  A review of the “SNF Skin Wound Evaluation Care” completed and signed by the Treatment Nurse (TN) indicated the following:  -On 9/2/2025, Patient 1 had left dorsum 1st digit (Hallux) medial (left great toe) pressure ulcer with suspected DTI measuring 3.9 x 1.3 cm described with blacken/blue discoloration. The treatment indicated to cleanse with normal saline (a sterile saltwater solution use to clean wounds), apply Betadine (a liquid medication applied to the wound to kill germs) and leave open to air.  -On 9/11/2025, Patient 1’s left great toe wound measured 2.9 x 1.0 cm with 100% eschar attached edge appears flush (reddened) with wound bed with black/blue discoloration treatment indicated to cleanse with normal saline apply Betadine and leave open to air.    -On 9/17/2025, Patient 1’s left great toe wound measured 2.9 cm x 1.0 cm with attached edge appears flush (with redness) with wound bed or as a slopping edge (edge gently slant inwards towards the center of the wound bed) described as maroon discoloration treatment indicated to cleanse with normal saline apply Betadine and leave open to air.    -On 9/24/2025, Patient 1’s medial left great toe wound measured 2.9 cm x 1.0 cm with 20% eschar attached edge appears flush with wound bed described flaky. Treatment indicated to cleanse with normal saline, apply Betadine and leave open to air.    -On 10/1/2025, Patient 1’s left medial great toe wound measured 3 cm x 1 cm with 70% eschar, light serous exudate (a clear, thin, and watery fluid that leaks from wounds) attached edge appears flush with wound bed described black/blue discoloration. Treatment indicated to cleanse with normal saline apply Betadine and leave open to air.      A review of the COC (Change of Condition)/Interact Assessment Form, dated 10/7/25 timed at 5:20 PM, indicated Patient 1's right heel and a newly developed Stage 1 to the left buttock with redness, no open wound, no drainage, no signs/symptoms (s/s) of infection noted, the family and medical doctor (MD) was made aware, with new orders for wound care, complete blood tests, and to provide a low air loss mattress, and wound consultant were updated.    A review of the “SNF Skin Wound Evaluation” dated 10/8/25 indicated Patient 1’s left great toe wound measured 3 x 1 cm, with treatment to cleanse wound with normal saline apply Santyl (ointment medication that removes dead tissue from wounds so they can start to heal), cover with calcium alginate dressing (special bandage that is use for wounds with a lot of fluid). The Evaluation indicated new pressure ulcers on left gluteus stage 1 that measured 3 x 3 cm treatment cleanse with soap and water apply Zinc Oxide (protective skin cream) leave open to air and right heel stage 1 measuring 4 x 4 cm treatment was to apply Betadine and leave open to air.     A review of Patient 1’s care plan initiated on 10/8/25, indicated the patient had a declining stage 1 right heel pressure injury, which was now unstageable, due to impaired mobility and joint limitation. To minimize the decline, the care plan interventions included assessing the skin integrity, applying pressure relieving device, notifying the physician as needed, turn and reposition when in bed and wheelchair. The Care Plan did not indicate new interventions specifically tailored to address Patient 1’s declining (worsening) pressure injury.      A review of the “SNF Skin Wound Evaluation” dated 10/13/25 indicated Patient 1’s left gluteus (buttocks) declined to a deep tissue injury (DTI -damage to skin and underlying soft tissues from intense or prolonged pressure) 3 x 3 cm purple marron discoloration with treatment to cleanse with soap and water and to apply Zinc Oxide. The Evaluation indicated the right heel developed to a DTI which measured 4 x 4 cm and indicated the DTI had purple discoloration with treatment to apply Betadine cover with bandage. (Left great toe not assessed).    A review of the COC/Interact Assessment Form, dated 10/13/2025 timed at 5:20 PM, indicated Patient 1’s right heel wound declining now with purple, maroon discoloration and left buttock with purple, maroon discoloration with updated orders for wound care. The COC Form indicated Patient 1’s family, MD and wound consultant were updated.       On 10/20/2025, timed at 8:49 PM, A further review of the SNF Skin Wound Evaluation dated 10/20/2025 timed at 8:49 PM, and completed by TN indicated new pressure ulcers on the right hip, left and right posterior (behind) knees. The Evaluation indicated the following:  1. Left great toe measured 3 x 2 cm unstageable treatment applied with Betadine.  2. Left gluteus measuring 3.3 x 3.5 cm undetermined depth unstageable treatment apply Santyl ointment and cover with calcium alginate bandage.  3. Right heel unstageable measuring 4.5 x 4.5 cm UTD treatment apply Santyl ointment and cover with calcium alginate and bandage.  4. Right trochanter (hip) DTI measuring 3.0 x 2.0 cm stage I treatment apply barrier cream and leave open to air.  5. Right lateral post knee measuring 2.5 x 2.5 cm suspected deep tissue injury treatment apply Betadine and leave open to air.  6. Left medial post knee measuring 3.0 x 4.0 cm suspected deep tissue injury maroon/purple tissue treatment apply Betadine and leave open to air.  7. Right medial post knee measuring 7 x 3 cm suspected deep tissue injury apply Betadine and leave open to air dry.  8. Left middle popliteal fossa (diamond-shaped area at the back of the left knee which contains vital structures artery, vein, and nerve) DTI measuring 12.0 cm x 3.0 cm x 4 cm.    A review of Patient 1’s Care Plan, dated 10/20/2025, indicated Patient 1 had right medial posterior knee DTI. The Care Plan indicated that the facility will assess risk using the Wound Risk Assessment on admission and as needed, assess skin integrity, apply pressure relieving device, notify the physician and consult with wound consultant as needed, turn and reposition when in bed and wheelchair. The Care Plan did not indicate new interventions specifically tailored to address Patient 1’s declining pressure injury.      A review of Patient 1’s Care Plan, dated 10/20/25 for actual pressure sore, stage 1 to the right hip, secondary to immobility, indicated the same general interventions, not specific to Patient 1’s needs, such as administer treatment as ordered, and do not massage directly over bony prominence in the presence of Stage 1.       A review of the COC/Interact Assessment Form, dated 10/20/2025 timed at 12:29 PM, indicated  Patient 1’s wound care noted with a decline to the right heel with open wound with 90% slough (soft, yellowish, dead tissue (fibrin, protein, cells, microbes) that covers the wound bed, acting as a barrier to healing by harboring bacteria and blocking new tissue growth), 10% granulation (red, bumpy tissue), left buttock with open wound noted with 90% slough with 10% granulation, with new DTI (damage to skin and underlying soft tissues from intense or prolonged pressure wounds) to left medial posterior knee, right medial posterior knee, right lateral posterior knee and right hip stage 1 PI. The form indicated wound care initiated, MD made aware, wound doctor made aware with new orders for wound care, family also updated.      A review of the COC/Interact Assessment Form dated 10/21/2025, timed at 8:21AM, indicated  Patient 1’s wound on the left buttock was noted with redness, surroun