Health inspection·May 23, 2025

Code of Federal Regulations, Title 42, § 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 residents’ choices, including but not limited to the following: Code of Federal Regulations, Title 42, Section 483.21(b) Comprehensive Care Plans §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 Code of Federal Regulations, Title 42, Section 483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.71. §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents’ needs, as identified through resident assessments, and described in the plan of care. §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident’s needs. California Code of Regulations, Title 22, Section 72311. Nursing Service-General. (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 72315. Nursing Service - Patient Care. (d) Each patient shall be provided care which shows evidence of good personal hygiene, including care of the skin, shampooing and grooming of hair, oral hygiene, shaving or beard trimming, cleaning and cutting of fingernails and toenails. The patient shall be free of offensive odors. California Code of Regulations, Title 22, Section 72501. Licensee – General Duties. (e)The licensee shall employ an adequate number of qualified personnel to carry out all the functions of the facility and shall provide for initial orientation of all new employees, a continuing in-service training program and competent supervision. California Code of Regulations, Title 22, Section 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. On 4/7/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding quality of care of Resident 1. As a result of the investigation, the CDPH determined the facility failed to ensure Licensed Vocational Nurse (LVN) 1 and Registered Nurse (RN) 1 assessed/checked Resident 1's body on 3/20/2025 and 3/21/2025 to prevent injury/wound from embedded (implanted, an object fixed firmly and deeply in a surrounding mass) bracelets as indicated in Resident 1’s care plan and the facility’s policies and procedures (P&P) titled, “Comprehensive Care Plans,” and “Skin Assessment.” This failure resulted in Resident 1 developing an infected wound to Resident 1's left wrist. A review of Resident 1's Admission Record indicated the facility initially admitted Resident 1, a 58-year-old male, on 4/30/2015 with diagnoses including mild intellectual disabilities (limitations on intelligence, learning and everyday abilities) and abnormalities of gait (walk) and mobility. A review of Resident 1's Care Plan (CP) titled, "Care Plan Report," dated 12/11/2024, indicated Resident 1 was at risk for development of pressure ulcers secondary to multiple health conditions, limited mobility, effects of medication, impaired cognition. The CP's goal indicated staff will minimize the risk of development of pressure ulcers every day. The CP's interventions indicated for staff to perform daily body check of Resident 1 for redness and open areas, keep Resident 1’s skin clean and dry, and protect Resident 1’s skin from moisture. A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 1/26/2025, indicated Resident 1's cognition was moderately impaired. The MDS indicated Resident 1 required partial/moderate assistance with showering/bathing and upper body dressing. The MDS indicated Resident 1 did not have any skin condition. A review of Resident 1's Nursing Weekly Assessment (NWA) dated 3/19/2025, the NWA indicated Resident 1’s skin was intact. A review of Resident 1's History and Physical dated 3/28/2025, indicated Resident 1 was able to make needs known but could not make medical decisions. A review of Resident 1's Emergency Medical Services (EMS) Run Report dated 3/21/2025, and timed at 11:25 a.m., indicated the emergency medical technicians (EMTs) arrived at the facility on 3/21/2025 at 11:30 a.m., and was at Resident 1's bedside to evaluate Resident 1 at 11:31 a.m. The EMS Run Report indicated the EMTs noticed swelling to Resident 1’s (left) arm and upon exposing Resident 1’s (left) arm, the EMTs noted a hospital bracelet and personal bracelet cutting into Resident 1's skin and showing signs and smell of infection with discharge coming from the wound (on the left wrist). A review of Resident 1's General Acute Care Hospital (GACH) 1's Emergency Department Provider Notes (EDPN), dated 3/21/2025, timed at 12:01 p.m., indicated "Skin: Rubber band embedded in the left wrist that appears infected." A review of Resident 1’s GACH 1 History of Present Illness (HPI), dated 3/21/2025, timed at 1:04 p.m., indicated Resident 1 had an infection (on Resident 1's left wrist) related to embedded bracelets. During an interview on 4/9/2025 at 1 PM with LVN 1, LVN 1 stated LVN 1 was assigned to Resident 1 on 3/20/2025. LVN 1 stated LVN 1 noticed a foul smell coming from Resident 1's body (on 3/20/2025), but did not know where the smell was coming from. LVN 1 stated a full body assessment of a resident was not within LVN 1's scope of practice. LVN 1 stated LVN 1 did not check/assess other areas on Resident 1's body nor notify LVN 1's supervisor, RN 1, about Resident 1's foul smell. LVN 1 stated Resident 1 was given a shower on 3/20/2025. LVN 1 stated LVN 1 noticed the smell from Resident 1 the following day (3/21/2025). LVN 1 stated LVN 1 notified RN 1 of the smell, so LVN 1 and RN 1 went to Resident 1's room. LVN 1 stated RN 1 instructed LVN 1 to give Resident 1 another shower (on 3/21/2025). LVN 1 stated LVN 1 notified RN 1 that a shower was given to Resident 1 on 3/20/2025 but the foul smell did not go away. During a concurrent interview and record review on 4/9/2025 at 2:20 p.m. with the Director of Nursing (DON), the facility’s P&P titled, "Skin Assessment," was reviewed. The P&P indicated the procedural guidelines in performing the full body skin assessment. The P&P explanation and compliance guidelines indicated a full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and as needed. The P&P indicated the assessment may also be performed after a change of condition or after any newly identified pressure ulcer (localized damage to the skin and underlying tissue caused by sustained pressure) and/or wound. The DON stated the facility’s P&P indicated it was the facility's policy for staff (LVNs and RNs) to perform a full body skin assessment as part of its systematic approach for pressure ulcer and/or wound prevention and for the promotion of healing of various skin conditions. The DON stated LVN 1, and RN 1 did not assess/check Resident 1's skin condition as indicated in the facility's policy. The DON stated the facility had LVNs who performed weekly body checks. The DON stated when the LVN (in general) noticed anything unusual, the LVN needed to report the unusual finding to the RN for further assessment of the resident. The DON stated RN 1 who was assigned to Resident 1 should have assessed Resident 1 further to find where the odor was coming from. The DON stated the facility’s GACH 1 transfer form filled out by RN 1 indicated "swelling to left hand/arm" but did not document anything else. During a concurrent interview and record review on 4/10/2025 at 3 p.m. with LVN 1, LVN 1 stated LVN 1 needed to assess Resident 1 further on 3/20/2025 when LVN 1 first noticed the smell coming from Resident 1's body. LVN 1 stated when EMS arrived at the facility on 3/21/2025, one of the members from the EMS (EMT 1) asked where the smell was coming from. LVN 1 stated EMT 1 was preparing to take Resident 1's blood pressure when EMT 1 noticed Resident 1's bracelets (on Resident 1's left wrist). LVN 1 stated when Resident 1’s beaded bracelets and hospital arm band were cut off (from Resident 1's left wrist), LVN 1 witnessed the items (the beaded bracelets and the hospital arm band) falling to the floor. LVN 1 stated LVN 1 did not see Resident 1's (left) wrist due to all the EMS staff huddling around Resident 1. LVN 1 stated LVN 1 heard them (EMS staff) said, "Oh this is where the smell is coming from," and LVN 1 saw EMT 1 wrap Resident 1's left arm with gauze. LVN 1 stated once EMT 1 cut off the bracelets from Resident 1's left wrist, the smell got stronger, and the smell smelled like an infected wound. During a review of the facility's P&P titled, "Comprehensive Care Plans," undated, the P&P indicated, "It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.” The facility failed to ensure LVN 1 and RN 1 assessed/checked Resident 1's body on 3/20/2025 and 3/21/2025 to prevent injury/wound from embedded bracelets as indicated in Resident 1’s care plan and the facility’s P&P titled, “Comprehensive Care Plans,” and “Skin Assessment.” This failure resulted in Resident 1 developing an infected wound to Resident 1's left wrist. This violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.