Health inspection·September 5, 2025

42 Code of Federal Regulations § 483.25 - Quality of Care. (b) Skin Integrity - (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. 22 California Code of Regulations § 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: (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 of 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 of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 California Code of Regulations § 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. (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). 22 California Code of Regulations § 72523 - Patient Care Policies and Procedures. Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. On or about 7/23/2025 during a standard annual recertification survey, which was conducted from 7/21 through 7/26, the California Department of Health (CDPH) identified that Resident 6 had developed a pressure ulcer (an injury to the skin and underlying tissue caused by continuous pressure on the skin). Based on observation, record review, and interviews, CDPH determined that the facility failed to ensure: 1. The Certified Nurse Assistants (CNA's) monitored and documented the repositioning of Resident 6, who was at moderate risk for pressure ulcers. 2. The interdisciplinary team (IDT) should include the Registered Dietician (RD) to discuss and implement interventions for promoting the healing of Resident 6's unstageable (when the full extent of the skin damage cannot be determined because there is dead tissue present) at the Sacro coccyx (an area of the body where the lower end of the spine meets the tailbone). 3. Licensed Nursing Staff followed up with RD on the referral as requested on the Weekly Pressure Ulcer Record, dated 6/18/2025. 4. Follow up on lab results for albumin (a protein in the blood that helps keep fluid from leaking out into blood vessels and into surrounding tissues) 2.6 grams per deciliter (g/dl, a unit of measurement) that helps in wound closure and healing process and hemoglobin (a protein in the red blood cells that carries oxygen to the body) 8.6 g/dl, dated 7/18/2025. As a result, Resident 6 developed an unstageable pressure ulcer on the Sacro coccyx extending to the left and right buttock measuring 10.1 centimeters (cm, a unit of measurement) in length and 14.0 cm in width. A review of Resident 6's Face sheet (Admission Record) dated 7/24/2025, the Face sheet indicated Resident 6, a 77 year old male, was admitted to the facility on 8/14/2023 with diagnosis that included hemiplegia and hemiparesis (a condition where there is paralysis or severe weakness on one side of the body) and anemia (a condition where the blood does not have enough red blood cells to carry oxygen throughout the body). A review of Resident 6's admission assessment dated 7/3/2024, the Admission Assessment did not indicate Resident 6 was assessed for skin breakdown. A review of the Care plan, last reviewed on 5/28/2025 titled "skin breakdown related to fragile skin, Incontinence of bowel and bladder" does not indicate Resident 6 repositioning. A review of Resident 6's Minimum Data Set (MDS, a resident assessment tool used for screening of clinical and functional status) dated 7/25/2025, the MDS indicated Resident 6 had impaired function on one upper extremity, impaired function on both lower extremities, and required staff assistance to roll from lying on their back to the left and right side and return to back-lying position in bed. The MDS did not indicate Resident 6 had a pressure ulcer/injury. A review of Resident 6's Braden Scale (a tool used to assess a person's risk of developing pressure ulcers), dated 4/30/2025, The Braden Scale indicated Resident 6 was at a moderate risk (score of 14 out of 18), to develop a pressure ulcer. A review of Resident 6's Braden Scale reassessment, dated 6/18/2025, the Braden Scale indicated Resident 6 was at a high risk (score of 12 out of 18), to develop a pressure ulcer. A review of the Weekly Pressure Ulcer Record dated 6/18/2025 indicates the RD was requested to evaluate Resident 6 but RD did not see the resident. A review of the Registered Dietitian's (RD) recommendation monthly visit, dated 6/19/2025, the RD recommendation monthly visit did not indicate the RD visited Resident 6. A review of the Registered Dietitian's (RD) recommendation monthly visit, dated 6/26/2025, the RD recommendation monthly visit did not indicate the RD visited Resident 6. A review of the Registered Dietitian's (RD) recommendation monthly visit, dated 7/3/2025, the RD recommendation monthly visit did not indicate the RD visited Resident 6. A review of the Registered Dietitian's (RD) recommendation monthly visit, dated 7/10/2025, the RD recommendation monthly visit did not indicate the RD visited Resident 6. A review of the Registered Dietitian's (RD) recommendation monthly visit, dated 7/18/2025, the RD recommendation monthly visit did not indicate the RD visited Resident 6. A review of the Registered Dietitian's (RD) recommendation monthly visit, dated 7/23/2025, the RD recommendation monthly visit did not indicate the RD visited Resident 6. A review of Resident 6's Physician Assistant (PA) Wound Care note, dated 6/27/2025, the PA's Wound Care note indicated Resident 6 had a sacrococcyx wound extending to left and right buttock unstageable pressure induced tissue damage measuring 10.1 cm in length and 14.0 cm in width. The PA's Wound Care note indicated to change the dressing after a shower, bath or soilage, to avoid leaving a wet/moist dressing. The PA's Wound Care note indicated to change positions often to keep pressure off the wound, and spread body weight evenly with cushions, mattresses, pillows, foam wedges, or other pressure-relieving devices. A review of the Resident's 6 Documentation Survey Report for turning and repositioning for the months of 06/2025 and 7/2025. The Documentation Survey Report indicated a N (for resident's body position not turned was documented on the following dates and times: 1. On 6/1/2025, there was an "N" at 8 AM, an "N" at10AM, an "N" at 12 PM, and an "N" at 2PM. 2. On 6/3/2025 there was an "N" at 4PM, an "N" at 6PM, and "N" at 8PM, and an "N" at 10PM. 3. On 6/6/2025 there was an "N" at 4AM. 4. On 6/7/2025 there was an "N" at 12PM. 5. On 6/8/2025 there was an "N" at 8AM, an "N" at 10AM, an "N" at 12PM, and an "N" at 2PM. 6. On 6/14/2025 there was an "N" at 8AM, an "N" at 10AM, an "N" at 12PM, and an "N" at 2PM. 7. On 6/15/2025 there was an "N" at 8AM, an "N" at 10AM, an "N" at 12PM, and an "N" at 2 PM. 8. On 6/18/2024 there was an "N" at 8PM. 9. On 6/20/2025 there was an "N" at 12AM, an "N" at 2AM, an "N" at 4AM, and an "N" at 6AM. 9. On 6/21/2025 there was an "N" at 8AM, an "N" at 10AM, an "N" at 12PM, and an "N" at 2 PM. 10. On 6/23/2025 there was an "N" at 12AM, an "N" at 2AM, an "N" at 4AM, and an "N" at 6AM. 11. On 6/25/2025 there was an "N" at 12AM, an "N" at 2AM, an "N" at 4AM and an "N" at 6AM. 12. On 6/28/2025 there was an "N" at 8AM, an "N" at 10AM, an "N" at 12PM, and an "N" at 2PM. 13. On 6/29/2025 there was an "N" at 12AM, an "N" at 2AM, an "N" at 4AM, an "N" at 6AM, an "N" at 8AM, an "N" at 10AM, an "N" at 12PM, and an "N" at 2PM. 14. On 6/30/2025 there was an "N" at 12AM, an "N" at 2AM, an "N" at 4AM, and an "N" at 6AM. 15. On 7/1/2025 there was an "N" at 12AM, an "N" at 2AM, an "N" at 4AM, and an "N" at 6AM. 16. On 7/2/2025 there was an "N" at 12AM, an "N" at 2AM, an "N" at 4AM, and an "N" at 6AM. 17. On 7/7/2025 there was an "N" at 2AM, an "N" at 4AM, and an "N" at 6AM. 18. On 7/8/2025 there was an "N" at 12AM, an "N" at 2AM, an "N" at 4AM, and an "N" at 6AM. 19. On 7/9/2025 there was an "N" at 12AM, an "N" at 2AM, an "N" at 4 AM, and an "N" at 6AM. A review of Resident's Order Summary report dated 7/15/2025, the order Summary report indicated re-opened Pressure Injury on Sacro coccyx extending bilateral buttocks; Cleanse with Normal Saline Solution (NSS) pat dry apply Barrier cream on peri wound Medi Honey and Calcium Alginate on the wound bed and dry dressing. A review of Resident 6's Lab Results Report, dated 7/18/2025, the Lab Results Report indicated a level for albumin of 2.6g/dl and hemoglobin 8.6 g/dl. A review of Resident 6's Order Summary Report, dated 7/24/2025, the Order Summary Report did not indicate the resident was on supplements (something added to enhance something else) that could help promote wound healing or increase hemoglobin level. During an observation on 7/23/2025 at 12:03 p.m. in Resident 6's room, Resident 6 was positioned onto their back after wound care treatment. During an observation on 7/23/2025 at 2:10 p.m. in Resident 6's room, Resident 6 was observed to be lying on his back. During an interview on 7/23/2025 at 1:23 p.m. with Certified Nursing Assistant 11 (CNA 11), CNA 11 stated that CNAs were unable to chart whether a resident is repositioned to the left or right side because it is only a yes or no task. CNA 11 mentioned that there is no set schedule for offloading (reducing or removing pressure from a specific body part to promote healing and prevent further damage) or repositioning residents, but CNAs clicks on the yes/no at the daily task list if they perform it. During an interview on 7/23/2025 at 12:00 p.m. with Treatment Nurse (TN), TN stated Resident 6 developed a reopened unstageable pressure ulcer on sacrococcyx (a pressure ulcer that was once healed and now has opened again) on 6/18/2025 in the facility. TN stated Resident 6 had no pressure ulcers since 7/3/2024. During an interview on 7/24/2025 at 9:19 a.m. with TN, TN stated there should be documentation indicating repositioning was done and the blank spaces on the report indicate that it was not done. TN stated pressure ulcers are avoidable when interventions are implemented. During an interview on 7/24/2025 at 9:19 a.m. with TN, TN stated it was important for RD to be involved because the RD could make recommendations for nutritional supplements (vitamins, minerals, or protein that can help aid in tissue repair). TN stated that RD did not see or assess Resident 6. During a subsequent interview on 7/24/2025 at 11:10 a.m. with TN, The TN stated the albumin level should be between 3.5 g/dl and 3.7 g/dl and low albumin levels are associated with delayed tissue repair and impaired healing. TN stated the hemoglobin level should be between 13.7 g/dl and 17.5 g/dl and reduced levels can impair oxygen deliver to tissues, contributing to delayed wound healing. TN stated the physician may prescribe supplements to help improve hemoglobin levels and support the healing process. TN stated it was not followed up to MD. During an interview on 7/24/2025 at 11:27 a.m. with IDON, the IDON stated the interdisciplinary team (IDT) meeting was held on 6/18/2025 and the RD should have been involved in the IDT meeting and there were no notes from the RD indicating she was in the IDT meeting. IDON stated the importance of involving the RD to evaluate Resident 6's nutrition and hydration status. If necessary, the RD should consider adding a supplement to support wound healing. IDON stated that nurses must follow up on consultations, and Resident 6 was overlooked. IDON further stated repositioning and turning was not done by the CNA's. During a continued interview on 7/24/2025 at 11:27 a.m. with IDON, IDON stated the resident's albumin was low at 2.6 g/dl and can indicate inflammation and the facility protocol required the RD to be notified so she could make supplement recommendations for healing but there was no documentation indicating the RD was notified and there was no documentation indicating the low albumin level was addressed. A review of the facility's policy and procedure (P&P) titled, Treatment Services to Prevent/Heal Pressure Ulcers, dated 1/2025, the P&P indicated, the purpose is to promote healing...and prevent the development of additional pressure ulcer/injury. The P&P indicated prolonged or excessive pressure can lead to injury, the facility did not do the initiation of appropriate, individualized interventions and ongoing evaluation of their effectiveness, and residents identified as at risk may be more vulnerable to developing pressure ulcers or injuries when in one position for an extended duration. The P&P indicated that "Based on the assessment and resident's clinical condition, the identified needs, basic or routine care could include to redistribute pressure such as repositioning, protecting and/or offloading heels, etc." The P&P indicated clinicians may use laboratory tests to evaluate potential nutritional deficiencies in residents with pressure ulcers. The facility failed to ensure: 1. The Certified Nurse Assistants (CNA's) monitored and documented the repositioning of Resident 6, who was at moderate risk for pressure ulcers. 2. The interdisciplinary team (IDT) should include the Registered Dietician (RD) to discuss and implement interventions for promoting the healing of Resident 6's unstageable (when the full extent of the skin damage cannot be determined because there is dead tissue present) at the sacrococcyx (an area of the body where the lower end of the spine meets the tailbone). 3. Ensure Licensed Nursing Staff followed up with RD on the referral as requested on the Weekly Pressure Ulcer Record, dated 6/18/2025. 4. Follow up on lab results for albumin (a protein in the blood that helps keep fluid from leaking out into blood vessels and into surrounding tissues) 2.6 grams per deciliter (g/dl, a unit of measurement) that helps in wound closure and healing process and hemoglobin (a protein in the red blood cells that carries oxygen to the body) 8.6 g/dl, dated 7/18/2025. As a result, Resident 6 developed an unstageable pressure ulcer on the Sacro coccyx extending to the left and right buttock measuring 10.1 centimeters in length and 14.0 centimeters in width. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm for Resident 6.