Health inspection·March 13, 2024

Code of Federal Regulations, Title 42, Section §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, Section §72315 (f)(4)(g) (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. (g) Each patient requiring help in eating shall be provided with assistance when served and shall be provided with training or adaptive equipment in accordance with identified needs, based upon patient assessment, to encourage independence in eating. On 1/26/2024 at 3:17 pm. the California Department of Public Health (CDPH, the Department) conducted an unannounced recertification survey. As a result of the investigation, the Department determined the facility failed to provide care and services, for Resident 14, to prevent the development of new pressure ulcers [PU/PI, localized injury to the skin and or underlying tissue usually over a bony prominence as result of pressure or pressure in combination with shear (mechanical force that cause the skin to break off) and/or friction (movement of one surface of the skin against the others)] by failing to: Provide a Bariatric bed (specialized, heavy duty, wider and longer than a standard bed for tall resident) for Resident 14 who was six feet and five inches (6'5") tall. As a result of this failure, Resident 14 developed four facility acquired PIs (new PIs developed after the resident's admission to the facility) on the bilateral (both sides, left and right) great toes and heels. A review of Resident 14's Admission Record (AR), the AR indicated Resident 14 was an 87-year-old male and was admitted to the facility on 12/12/23 with diagnoses that included muscle wasting atrophy (decrease in size or wasting away of a body part or tissue) on the left and right arms, abnormality of gait (walking pattern) and mobility (ability to move). A review of Resident 14's Generations Post-Acute Admission Data Collection (GPAADC, New Admission Assessment), dated 12/12/2023, at 8:31 pm, indicated Resident 14 had no history of skin issues (conditions that affect the skin), and did not require skin interventions. A review of Resident 14's Progress Notes (PN), dated 12/15/23, indicated Resident 14 had decreased range of motion (ROM, full movement potential of a joint) on both legs. A review of Resident14's Admission Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/18/23, indicated Resident 14 had intact cognition (ability to think and process information). The MDS indicated Resident 14 did not have any unstageable PI [full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed]. A review of Resident 14's Generations Weekly Skin Evaluation (GWSK), dated 12/19/23 and 12/26/24 indicted Resident 14's skin was intact (not damaged or impaired in any way; complete). A review of Resident 14's Situation, Background, Assessment, Recommendation (SBAR) Communication Form (a verbal, or written communication tool that helps provide essential, concise information, usually during crucial situations), dated 12/29/23, indicated Resident 14 had a significant change in condition due to a change in skin color on bilateral heels. The form indicated staff (in general) would float heels to relieve pressure on both heels. A review of Resident 14's Care Plan titled, "Pressure Injury/Skin Care," initiated on 12/31/23, indicated Resident 14 had facility acquired PIs on bilateral heels and great toes. The care plan's goal was for Resident 14's PIs to heal. The nursing interventions included to administer treatments as ordered. A review of Resident 14's Wound Physicians Progress Note (WPPN), dated 1/2/24, indicated Resident 14 had a total of 4 wounds that included: 1. PI on the left heel measuring 4.3 centimeters (cm, unit of measurement) in length by (x) 4.6 cm in width. 2. PI on the right heel measuring 3.8 cm x 3.2 cm. 3. PI on the left great toe measuring 1.6 cm x 1.7 cm. 4. PI on the right great toe measuring 1.7 cm x 1.5 cm. A review of Resident 14's WPP, dated 1/23/24, indicated Resident 14 had a total of 4 wounds: 1) unstageable PI om the left heel measuring 4.0 cm x 3.6 cm. 2) unstageable PI on the right heel measuring 3.5 cm x 2.4 cm. 3) PI on the left great toe measuring 1.6 cm x 1.6 cm. 4) PI on the right great toe measuring 1.3 cm x 1.2 cm. A review of Resident 14's Change in Condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) Evaluation note, dated 1/28/2023, at 8:52 am, indicated Resident 14's PI on bilateral great toes and bilateral heels were developed on 12/31/2023. The COC indicated Resident 14's PIs on bilateral great toes and bilateral heels were facility acquired. During an observation inside of Resident 14's room and concurrent interview with Resident 14 on 1/26/24, at 5:19 pm, Resident 14 was sitting on a wheelchair, awake and alert. Resident 14 stated Resident 14 was 6 feet 5 inches tall. Resident 14 stated this morning (1/26/24), a staff member (unidentified) changed Resident 14's bed to a longer bed frame and mattress (unknow name or length). Resident 14 stated Resident 14's old bed (previous bed, standard size bed was 80 inches long) was too short for Resident 14. Resident 14 stated Resident 14 would often bump Resident 14's feet (heals and toes) and Resident 14's feet rubbed against the footboard of Resident 14's old bed. Resident 14 stated Resident 14 did not have a wound prior to being admitted to the facility, but now Resident 14 had a "few" wounds at the bottom of both feet. Resident 14 stated "my feet hurt when I bumped them (feet) against the footboard." During an interview with Certified Nurse Assistant 5 (CNA 5), on 1/26/24 at 5:52 pm, CNA 5 stated Resident 14 was too tall for Resident 14's old bed. Resident 14 stated Resident 14 often elevated Resident 14's feet on pillows for Resident 14's feet not to touch the footboard of Resident 14's bed. CNA 5 stated Resident 14 had wounds on the heels and great toes of Resident 14's left and right feet. During an interview with the Director of Clinical Services (DCS), on 1/27/24 at 6:59 pm, the DCS stated Resident 14's PIs located on Resident 14's bilateral heels and great toes were avoidable if the proper (extra-long) bed length was provided to Resident 14. During an interview and concurrent record review of Resident 17's GPAADC, dated 12/12/23, and SBAR dated 12/29/23 with Licensed Vocational Nurse 1 (LVN 1), on 1/27/24 at 7:39 pm, LVN 1 stated Resident 14 was admitted to the facility without skin issues. LVN 1 stated upon admission, Resident 14's toes, heels were clear and Resident 14's skin was intact. LVN 1 stated Resident 14's bed was too short and Resident 14's feet would rub against the footboard while Resident 14 was lying in bed. LVN 1 stated the PIs on Resident 14's left, and right heels and great toes were avoidable if Resident 14's bed was long enough to accommodate Resident 14's height. During an interview with the Director of Nursing (DON) on 1/28/24 at 2:08 pm, the DON stated special accommodations should have been done for Resident 14 due to Resident 14's height (6 feet 5 inches tall). The DON stated Resident 14's bed was too short, and the DON observed Residents 14's feet touching the footboard of the bed while Resident 14 was lying in bed. The DON stated Resident 14's PIs located on Resident 14's bilateral heels and great toes were preventable. A review of the facility's policy and procedure (P&P) titled, "Pressure Injury Prevention and Management," implemented on 5/23/23, the P&P indicated, the facility was committed to the prevention of avoidable PI, unless clinically unavoidable, and to provide treatment and services to heal the PU/PI, prevent infection and the development of additional PU/PI. The P&P indicated, the facility should establish and utilized a systematic approach for PU/PI prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce or remove underlying risk factors, monitoring the impact of the interventions, and modifying the interventions as appropriate. As a result of the investigation, the Department determined the facility failed to provide care and services, for Resident 14, to prevent the development of new pressure ulcers by failing to: Provide a Bariatric bed for Resident 14 who was six feet and five inches tall. As a result of this failure, Resident 14 developed four facility acquired PIs on the bilateral great toes and heels. The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 14