Health inspection·July 11, 2025

Code of Federal Regulations, Title 42, Section 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. California Code of Regulations, Title 22, Section 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. California Code of Regulations, Title 22, Section 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. 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 5/28/2025 the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to the facility to investigate a complaint regarding a resident who developed additional pressure injuries while in the facility. The facility failed to ensure: 1. Resident 1's level of risk for development of pressure ulcers/pressure injuries (PUs/PIs) was accurately assessed upon admission to the facility on 4/2/2025 at 4 pm. 2. Resident 1's care plan to address Resident 1's PIs on both heels included offloading pressure on the resident's bilateral heels. As a result of the investigation, the Department determined the facility failed to prevent the development of new pressure injuries for Resident 1 by failing to assess Resident 1’s level of risk for development of PIs and by failing to develop and implement Resident 1’s care plan in accordance with the facility’s policies and procedures (P&Ps) titled, "Pressure Injury Prevention" and "Skin and Wound Management”. As a result, on 4/3/2025 at 2:27 pm, Resident 1 developed additional PIs on the left buttocks and on both heels 22 ½ hours after Resident 1 was admitted to the facility. A review of Resident 1's Face Sheet (FS), indicated Resident 1, a 77-year-old male, was admitted to the facility from the General Acute Care Hospital (GACH) 1 on 4/2/2025, with diagnoses which included congestive heart failure (CHF) and paraplegia. A review of Resident 1's medical records from GACH 1, dated 3/15/2025 to 4/2/2025, indicated Resident 1 had a sacral PI. The hospital records did not indicate Resident 1 had any other pressure injuries upon discharge from GACH 1 to the facility. A review of Resident 1's Progress Note (PN) by Licensed Vocational Nurse (LVN) 4, dated 4/2/2025 and timed at 4:22 pm, indicated Resident 1 arrived at the facility on 4/2/2025 at 4 pm and was admitted with a wound on the right buttock. A review of Resident 1's Braden Scale (BS - used to assess the resident's level of risk for development of pressure ulcers or pressure injuries), dated 4/2/2025 and timed 6:48 pm, indicated Resident 1 had no impairment in sensory perception, no limitation in mobility, and only had a potential problem with friction and shear when being moved and/or lifted in bed/chair. The BS indicated Resident 1 scored a 17 and was at risk for pressure ulcer/injury development (total score of 12 or less represents high risk). A review of Resident 1's Skin Check, dated 4/2/2025 and timed at 7:05 pm, the Skin Check indicated LVN 1 completed a head-to-toe assessment and a foot evaluation of Resident 1. The Skin Check indicated Resident 1 had a Stage 4 PI on the sacrum present on admission. A review of Resident 1's History and Physical, dated 4/3/2025, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Skin Issues assessment, dated 4/3/2025 and timed at 2:27 pm, indicated Treatment Nurse (TN) 1 completed a head-to-toe assessment of Resident 1 on 4/3/2025. The assessment indicated Resident 1's Stage 4 PI on the sacrum was healed. The assessment indicated Resident 1 had a Stage 4 PI on the left ischium, a Stage 3 on the right buttock, and a deep tissue injury (DTI) on both heels. A review of Resident 1's BS, dated 4/3/2025 and timed at 2:28 pm, indicated Resident 1 had no impairment in sensory perception, had very limited mobility, and had a problem with friction and shear when being moved and/or lifted in bed/chair. The BS indicated Resident 1 scored a 15 and was at risk for pressure ulcer development. A review of Resident 1's untitled Care Plan (CP), initiated on 4/3/2025, indicated Resident 1 was admitted with a Stage 4 pressure ulcer on the sacrum. The CP interventions included the following: administer medications and treatments as ordered and monitor/document for side effects and effectiveness; assess/record/monitor wound size, wound perimeter, wound bed, healing, progress, signs of infection, and report to the physician; avoid positioning the resident in the same position for prolonged periods of time; educate the resident/family/caregivers on causes of skin breakdown, importance of frequent repositioning, and good nutrition for prevention of pressure ulcers; and to provide staff assistance to turn and reposition Resident 1 at least every 2 hours. During a review of Resident 1's another untitled Care Plan (CP), initiated on 4/3/2025, the CP indicated Resident 1 had a DTI on both heels. The CP interventions did not include offloading pressure on Resident 1's heels. A review of Resident 1's Admission Minimum Data Set (MDS - a resident assessment tool), dated 4/8/2025, indicated Resident 1 had decreased movement on both lower extremities and was dependent on staff for toileting hygiene, showering/bathing, dressing, putting on/taking off footwear, rolling left and right, and transfers. The MDS indicated Resident 1 was 68 inches tall and weighed 235 pounds. The MDS indicated Resident 1 was at risk of developing PIs. A concurrent interview and record review on 5/28/2025 at 4:35 pm with LVN 1, Resident 1's Skin Check dated 4/2/2025 and timed at 7:05 pm and Resident 1's Skin Issues assessment dated 4/3/2025 and timed at 2:27 pm were reviewed. LVN 1 compared Resident 1's Skin Check by LVN 1 with Resident 1's Skin Issues assessment by TN 1. LVN 1 stated, "Maybe (Resident 1) had socks on (during admission skin check) and I (did not) remove them." LVN 1 stated LVN 1 relied on the treatment nurse's assessment "too much." During a concurrent interview and record review on 5/29/2025 at 9:53 am with TN 1, Resident 1's Skin Check dated 4/2/2025 and timed at 7:05 pm and Resident 1's Skin Issues assessment dated 4/3/2025 and timed at 2:27 pm were reviewed. TN 1 stated the nurse who admitted the resident (in general) needed to do the head-to-toe body check of the resident, write down what the nurse saw, and inform the resident's doctor. TN 1 stated, the following day after admission, the treatment nurses would assess the resident's (in general) skin again and would restage (wound staging is a system used to categorize wounds based on their depth and extent of tissue damage) any wounds. TN 1 compared Resident 1's Skin Check by LVN 1, dated 4/2/2025 and timed at 7:05 pm, to Resident 1's Skin Issues assessment by TN 1, dated 4/3/2025 and timed at 2:27 pm. TN 1 stated there was a big difference between the Skin Check by LVN 1 and the Skin Issues assessment by TN 1. TN 1 stated TN 1 remembered Resident 1 only had a scar on the sacrum and Resident 1's skin on the sacrum was not open. TN 1 stated TN 1 identified a PI on Resident 1's left ischium, a PI on Resident 1's right ischium, and a DTI on Resident 1's bilateral heels when TN 1 assessed Resident 1's skin that day (4/3/2025). TN 1 stated because of the big difference between Resident 1's Skin Check and Resident 1's Skin Issues assessment, it would be difficult to determine which PIs were acquired from admission and which PIs were acquired in the facility. TN 1 stated it would only take one shift to not turn and reposition Resident 1 for Resident 1 to develop a PI. TN 1 verified the Skin Check done by LVN 1, dated 4/2/2025 and timed at 7:05 pm, only identified a PI on Resident 1's sacrum upon Resident 1's admission. TN 1 reviewed Resident 1's GACH 1 records, dated 3/15/2025 to 4/2/2025, and stated Resident 1's GACH 1 records indicated Resident 1 had a Stage 4 PI on the sacrum, but did not mention a DTI on both heels. During an interview on 5/29/2025 at 4:15 pm with the Director of Nursing (DON), the DON stated the nurse who admitted the resident (in general) would do a head-to-toe body check of the resident upon admission and write down whatever the admitting nurse found on the resident. The DON stated the treatment nurse would then do a thorough assessment the following day because the facility needed to have an accurate description and staging of the wound by the treatment nurse. A review of the facility's P&P titled, "Skin and Wound Management," revised on 1/1/2013 indicated, "a licensed nurse will perform a skin assessment upon admission for each resident as part of the Comprehensive Resident Admission Assessment ...the licensed nurse will also complete the Braden Scale upon admission/re-admission ...and the licensed nurse will develop a care plan to identify interventions to prevent the development of pressure ulcers ..." A review of the facility's P&P titled, "Pressure Injury Prevention," revised on 8/12/2016 indicated, "A risk assessment (Braden Scale) for developing pressure injuries will be completed upon admission ...and regardless of the risk score the licensed nurse will develop a care plan specific to the resident's risk factors ...The Nursing Staff will implement interventions identified in the care plan based on the individual risk factors, which may include ...pressure redistributing devices when in bed and chair, repositioning and turning, heel and elbow protectors, increasing mobility when appropriate through a RNA program or therapy programs, offloading pressure from heels, use of pillows and wedges for positioning and pressure relief, moisturizers and barrier creams to protect the skin, bowel and bladder training, scheduled toileting, incontinence management programs, devices to reduce friction and shear when repositioning such as bed trapeze, draw sheets, mechanical lifts and positioning aides ..." The facility failed to ensure: 1. Resident 1's level of risk for development of pressure ulcers/pressure injuries (PUs/PIs) was accurately assessed upon admission to the facility on 4/2/2025 at 4 pm. 2. Resident 1's care plan to address Resident 1's PIs on both heels included offloading pressure on the resident's bilateral heels. As a result of the investigation, the Department determined the facility failed to prevent the development of new pressure injuries for Resident 1 by failing to assess Resident 1’s level of risk for development of PIs and by failing to develop and implement Resident 1’s care plan in accordance with the facility’s policies and procedures (P&Ps) titled, "Pressure Injury Prevention" and "Skin and Wound Management”. As a result, on 4/3/2025 at 2:27 pm, Resident 1 developed additional PIs on the left buttocks and on both heels 22 ½ hours after Resident 1 was admitted to the facility. The above violations had a direct relationship to the health, safety, or security of Resident 1.