Health inspection·December 12, 2024

F686 Code of Federal Regulations, Title 42, Section 483.25 (b)(1(i)(ii) §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. California Code of Regulations, Title 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: (4) Using pressure-reducing devices where indicated. (5) Providing care to maintain clean, dry skin free from feces and urine. § 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 10/28/2024 at 8:45 am, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to the facility for the annual recertification survey. The facility failed to ensure care and services were provided to prevent pressure ulcers for Resident 47 and Resident 79. As a result of these failures, Resident 47 developed a recurrent Associated Skin Damage (MASD, an erosion or inflammation of the skin caused by long-term exposure to moisture and irritants such as urine or stool) and Resident 79 developed a skin rash on the scrotum (the bag of skin that holds and helps protect the testicles) and buttocks. a. A review of Resident 47's Admission Record indicated Resident 47 was a 57-year-old male. The facility admitted Resident 47 on 5/25/2021, with diagnoses that included hemiplegia and hemiparesis following cerebral infarction (paralysis/weakness of one side of the body following a stroke,) type 2 diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose/sugar in the blood and urine.) A review of Resident 47's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/24/2024, indicated Resident 47 had intact cognition. The MDS indicated Resident 47 was totally dependent with toileting hygiene and transfers and required maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with bed mobility such as rolling left and right, lying to sitting on the side of the bed, and sit to lying. The MDS indicated Resident 47 was always incontinent. A review of Resident 47's Braden Scale for Predicting Pressure Ulcer Risk, dated 8/23/2024, indicated Resident 47 had a score of 14 (a score of 13-14 indicated moderate risk for the development of pressure ulcer). A review of Resident 47's care plan for being at risk for unavoidable pressure ulcer or potential for pressure ulcer development related to impaired mobility and incontinence with both bowel and bladder, dated 7/21/2024, indicated the goal was for the resident to have intact skin, free from redness, blisters, or discoloration. The care plan had interventions that included to monitor/document/report to the physician changes in skin status and to monitor nutritional status. The care plan interventions did not indicate ways to prevent the development of pressure ulcer related to the following risk factors, immobility, and incontinence. During an observation on 10/30/2024 at 9:07 AM, Resident 47 was asleep, lying in bed on his back. During an observation on 10/30/2024 at 11:07 AM, Resident 47 was asleep, lying in bed on his back. During an observation on 10/30/2024 at 12:50 PM. Resident 47 was asleep after lunch, lying on his back. During multiple observations of Certified Nursing Assistant 1 (CNA 1) who was assigned to care for Resident 47. CNA 1 did not enter Resident 47's room from 9:07 am to 1:04 pm. 10/30/2024 09:20 AM, CNA 1 was standing in the hallway. 10/30/2024 10:00 AM, CNA 1 was off the floor for lunch break. 10/30/2024 10:15 AM, two other CNAs were on the floor, CNA 1 was still on break. 10/30/2024 10:30 AM, CNA 1 was back on the floor, standing in the hallway. 10/30/2024 10:47 AM, CNA 1 was standing in the hallway. 10/30/2024 10:48 AM, CNA 1 was answered call light in Room 2 10/30/2024 10:51 AM, CNA 1 was standing in the hallway. 10/30/2024 11:03 AM, CNA 1 checked another resident, a roommate of Resident 47. 10/30/2024 11:07 AM, Resident 47 was asleep, lying in bed on his back. 10/30/2024 11:08 AM, CNA 1 repositioned another resident. 10/30/2024 11:09 AM, CNA 1 answered Room 10's call light 10/30/2024 11:11 AM, CNA 1 went to a room across Resident 47. 10/30/2024 11:16 AM, CNA 1 was standing in the hallway, talking to someone. 10/30/2024 11:22 AM, CNA 1 left the floor, to the nurse's station. 10/30/2024 11:25 AM, CNA 1 was back on the floor. 10/30/2024 11:33 AM, CNA 1 was inside Resident 47's room, talking to Resident 47's roommate. 10/30/2024 11:43 AM, CNA 1 was standing in the hallway. 10/30/2024 11:56 AM, CNA 1 answered a call light adjacent to Resident 47's room. 10/30/2024 12:05 PM, CNA 1 was at the Nurse's station. 10/30/2024 12:16 PM, CNA 1 was distributing lunch trays, then assisted another resident with lunch. 10/30/2024 12:50 PM, Resident 47 was asleep, lying in bed on his back. 10/30/2024 12:52 PM, CNA 1 was assisting a resident adjacent to Resident 47's room. 10/30/2024 1:08 PM, CNA 1 and the Treatment Nurse (TN) was preparing to help Resident 47 with incontinence care. Resident 47's incontinent pad was wet with urine. During a concurrent observation and interview on 10/30/2024 at 1:08 PM, the TN and Certified Nursing Assistant 1 (CNA 1) went inside Resident 47's room for incontinence care. The incontinence pad was wet with urine and there was pink, peeling area around the sacrococcyx and the buttocks. There were two open areas on the right buttocks and 1 open area on the left buttocks. The TN stated Resident 47 had MASD in the past, the TN stated, "it looked like" Resident 47 had a recurrence of the MASD. During an observation of Resident 47 on 10/30/2024 at 1:14 PM, there were no positioning pillows inside Resident 47's room, CNA 1 left the room and came back with 2 pillows. TN and CNA 1 positioned Resident 47 on his left side. During an interview on 10/30/2024 at 1:21 PM, Resident 47 stated the staff were not repositioning the resident. Resident 47 stated the staff would change the incontinence pad and would apply cream to the buttocks. Resident 47 stated he did not refuse care such as repositioning. A review of Resident 47's Change of Condition (COC) dated 10/30/2024 at 1:17 PM, the COC indicated a change in skin color or condition, a pale, pinkish patchy redness with moist erosion of the skin on the right and left buttocks measuring 5.5 X 6.4 (unit of measurement was not listed). During an observation on 10/31/2024 at 9:57 AM, the opened areas of Resident 47’s right and left buttocks were measured as follows: Length of the open area on the right buttocks measured: 1 inch. Width of the open area on the right buttocks measured: 0.5 inch. Length of the open area on the left buttocks measured 2.2 inches. Width of the open area on the left buttocks measure 2.2 inches. During the same observation, the right and left buttocks had peeling skin with the above open areas on the right and left buttocks. The TN cleaned the whole area of the right and left buttocks then applied nystatin cream (anti-fungal medication.) During an interview on 10/30/2024 at 2:57 PM, CNA 1 stated the facility ‘s practice was to reposition residents (including Resident 47) every 2 hours and CNA 1 showed the repositioning schedule that she had attached to her identification badge. CNA 1 stated CNA 1 asked Resident 47 after breakfast to reposition and CNA 1 did not ask again because Resident 47 was sleeping. CNA 1 did not report Resident 47's refusal to the Charge Nurse or the TN. During an interview on 10/31/2024 at 10:20 AM, The TN stated the measurement on the COC for Resident 47 was the measurement of the entire area of the right and left buttocks that the skin was peeling. The TN did not measure the open area on the right and left buttocks. During an interview on 10/31/2024 at 10:36 AM, the TN stated a pressure ulcer is a change in skin integrity related to pressure, a resident could get a pressure ulcer from steady/constant pressure to an area. The TN stated the moisture from urine could irritate the skin exposed to the urine and could break down the skin. The TN stated the exposure to the moisture could cause a fungal infection of the skin. The TN stated the assigned CNA was responsible for changing and repositioning Resident 47, and the assigned charge nurse and the Registered Nurse Supervisor need to monitor to ensure Resident 47 was changed and repositioned. During an interview on 10/31/2024 at 10:48 AM, the Registered Nurse Supervisor (RNS) stated a pressure ulcer is a skin decline due to being in one position for more than two hours. The RNS stated moisture could open the skin and could cause a fungal rash. The RNS stated the open area on the buttocks could cause by moisture, or a fungal infection or it could be pressure because of the location of the open areas on the buttocks. The RNS stated the weight of the body would be on the pressure areas such as the occipitus (back of the head), the back of the shoulders, the coccyx, the buttocks, and the heels. b. A review of Resident 79's Admission Record, indicated Resident 79 was a 86-year-old male. The facility admitted the resident on 6/4/24, with diagnoses that included lack of coordination, history of transient ischemic attacks (mild stroke, a temporary blockage of blood flow to the brain) and cerebral infarction (stroke - a lack of blood flow to the brain that will eventually cause permanent brain damage) without residual effects. A review of Resident 79's MDS dated 6/11/2024, indicated Resident 79 had severe cognitive impairment. The MDS indicated Resident 79 required moderate assistance (helper does less than half the effort. Helper lifts or holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene, chair/bed-to-chair transfers, bed mobility such as rolling left and right, sit to lying, lying to sitting on the side of the bed and sit to stand. The MDS indicated Resident 79 was always incontinent of bowel and bladder. During a review of Resident 79's Braden Risk for Predicting Pressure Sore Risk dated 9/10/2024, the Braden Risk indicated a score of 15 (a score of 15-18 indicated at risk for the development of pressure ulcer). During an observation on 10/30/2024 at 9:20 AM, Resident 79 was not in Resident 79's room. Certified Nursing Assistant 1 (CNA 1) who was assigned to care for Resident 79 stated Resident 79 was in the dining room for Activities. During an observation on 10/30/2024 at 11:06 AM, Resident 79 was not in Resident 79's room. During an observation on 10/30/2024 at 12:26 PM, Resident 79 was eating lunch in the dining room. During multiple observations from 9:20 am to 1:57 PM, CNA 1 did not assist Resident 79 back to Resident 79's room to change Resident 79's incontinence pad. 10/30/2024 09:20 AM, CNA 1 was standing in the hallway. 10/30/2024 10:00 AM, CNA 1 was off the floor for lunch break. 10/30/2024 10:15 AM, two other CNAs were on the floor, CNA 1 was still on break. 10/30/2024 10:30 AM, CNA 1 was back on the floor, standing in the hallway. 10/30/2024 10:47 AM, CNA 1 was standing in the hallway. 10/30/2024 10:48 AM, CNA 1 answered call light in Room 2 10/30/2024 10:51 AM, CNA 1 was standing in the hallway. 10/30/2024 11:03 AM, CNA 1 checked another resident, a roommate of Resident 47. 10/30/2024 11:08 AM, CNA 1 repositioned another resident. 10/30/2024 11:09 AM, CNA 1 answered Room 10's call light 10/30/2024 11:11 AM, CNA 1 went to a room across Resident 47. 10/30/2024 11:16 AM, CNA 1 was standing in the hallway, talking to someone. 10/30/2024 11:22 AM, CNA 1 left the floor, to the nurse's station. 10/30/2024 11:25 AM, CNA 1 was back on the floor. 10/30/2024 11:33 AM, CNA 1 was inside Resident 47's room, talking to Resident 47's roommate. 10/30/2024 11:43 AM, CNA 1 was standing in the hallway. 10/30/2024 11:56 AM, CNA 1 answered a call light adjacent to Resident 47's room. 10/30/2024 12:05 PM, CNA 1 was at the Nurse's station. 10/30/2024 12:16 PM, CNA 1 was distributing lunch trays, then assisted another resident with lunch. 10/30/2024 12:52 PM, CNA 1 was assisting a resident adjacent to Resident 47's room. 10/30/2024 1:08 PM, CNA 1 and the TN were preparing for Resident 47's incontinence care. During an observation of Resident 79 on 10/30/2024 1:57 PM, Resident 79 was sitting on the wheelchair in a hallway away from Resident 79's room. Licensed Vocational Nurse 5 (LVN 5) stated LVN 5 would wheel Resident 79 back to the activity room. LVN 5 stated she did not know if Resident 79 had not received incontinence care. During a concurrent observation and interview on 10/30/2024 at 2:20 PM, there were open areas on Resident 79's right and left buttocks and on the scrotum. Registered Nurse Supervisor (RNS) stated the open areas looked like excoriated skin. During a review of Resident 79's COC dated 10/30/2024, the COC indicated a fungal skin rash of the scrotum, right and left buttocks. During an interview on 10/30/2024 at 2:56 PM, CNA 1 stated facility practice was for staff to check incontinence residents every 2 hours. CAN 1 stated if the incontinence pad was wet and has urine or bowel movement staff need to change the pad. CNA 1 did not give a reason why CNA 1 failed to check on Resident 79's incontinence pad. CNA 1 stated Resident 79 needed to be back to the Resident 79's bed after lunch at around 1-1:30 PM for incontinence care, CNA 1 stated CNA 1 failed to bring Resident 79 back to his room in the morning for incontinence care and to relieve the pressure from sitting down for long hours. During a review of the facility's Policy & Procedure (P&P) titled, "Prevention of Pressure Injuries," dated February 2024. The P&P indicated to reposition all resident with or at risk for pressure injuries. The P&P indicated to provide skin care that included to keep the skin clean and hydrated and to clean promptly after episodes of incontinence. The facility failed to ensure care and services were provided to prevent pressure ulcers for Resident 47 and Resident 79. As a result of these failures, Resident 47 developed a recurrent MASD and Resident 79 developed a skin rash on the scrotum and buttocks. The above violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 47 and Resident 79.