**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pressure ulcers/injuries (PIs, injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) care, and treatments for six of six sampled residents (Residents 4, 5, 6, 7, 8, and 9) by failing to: 1. Implement the facility's policies on Pressure Injury Risk Assessment, Quality of Care-Pressure Injuries, when the licensed nurses (in general) did not update the care plans, assess, measure, and follow the physician's orders to treat the following: a. Resident 4's Stage 3 PIs (full-thickness loss of skin in which adipose/fat is visible in the ulcer/open sore) on the right and left buttock, and Stage 2 PI (the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) on the sacral region (at the bottom of the spine). Licensed Nurses also failed to ensure Resident 4 who was six feet and four inches (6'4) tall, had a long bed to decrease the pressures on the resident's PIs. b. Resident 5's Stage 2 PI on the coccyx (tailbone). c. Resident 6's Stage 4 PI (full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures such as tendon, joint capsules) on the Sacrococcyx (sacrum and coccyx/tailbone). d. Resident 7's Stage 2, facility acquired PI (a new pressure injury that developed after admission to the facility) on the right buttock. e. Resident 8's Stage 1 PIs (redness, painful area on the resident skin that does not turn white/blanch) on the right and left buttocks. f. Resident 9's Stage 1 PI on bilateral (both) heels and a Stage 3 PI to the coccyx. 2. Ensure Registry (a staffing agency which provide nursing personnel per shift or temporarily) Nurses (in general) received in-services (training) regarding PI treatments and assessments upon admission and weekly after. As a result, Residents 4, 5, 6, 7, 8, and 9 did not receive PI care and treatments, and placed the residents at risk for developing/worsening of the PIs, or infection which could lead to hospitalization, health complications which could result in death. On [DATE] at 1:04 PM, during a complaint investigation, The California Department of Public Health (CDPH) called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident), in the present of the facility's Administrator (ADM), Director of Health Operations (DHO), and Director of Nursing (DON), for the facility's failure to provide PIs care and treatments to Residents 4, 5, 6, 7, 8, and 9. On [DATE], at 4:48 pm, the facility submitted an acceptable Plan of Action (POA/ IJ removal plan, a detailed plan to address the IJ finding), while onsite the surveyor verified and confirmed the implantation of the POA by observation, interview, record review, and confirmed the removal of the IJ on [DATE] at 6:17 pm with the ADM. The acceptable IJ Removal Plan included the following: 1. On [DATE], the ADM ordered a long bed for Resident 4. Resident 4 received a long bed on the same day ([DATE]). 2. On [DATE], the DON completed the skin assessments on all 32 residents who resided in the facility including Residents 4, 5, 6, 7, 8, and 9 who had PIs. 3. On [DATE], the Wound Physician (WP 1, health care professional who has specialized in the treatment of wounds [injury to the body such as the skin]) assessed Resident 4's, 5's, 6's, 7's, 8's, and 9's PIs. 4. On [DATE], the DON updated Resident 4's, 5's, 6's, 7's, 8's and 9's care plans to reflect current PIs status and care. 5. On [DATE], an outside Wound Consultant (WC 1) provided in-services on Wound Treatment Guidelines for PI management to all Licensed Nurses including facility's nurses and registry nurses. 6. On [DATE], WC 1 conducted competencies for Licensed Nurses on skin assessments, care for PIs, measuring and staging PIs. (Cross Reference F726) Findings: 1a. A review of Resident 4's admission Record indicated the facility admitted the resident on [DATE] with diagnoses that included, type 2 diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels), and muscle weakness. A review of Resident 4's Physician's Order, dated [DATE], indicated to cleanse Resident 4's Stage 2 PI on the coccyx with wound cleanser (solution to clean the wound), pat dry, apply Medihoney (mixture of two honeys, used for wound care and contribute to wound healing), and cover the PI with foam dressing (dressing that can hold fluid/drainage) every day shift. A review of Resident 4's Generations Post-Acute admission Data Collection (New admission Assessment), dated [DATE], at 9:51 PM, indicated Resident 4 had two Stage 3 PIs (one on the right and one on the left buttocks), and a Stage 2 PI with redness on the sacral area. The skin integrity (the health of the skin) review section which required PI wound measurements was left blank. A review of Resident 4's Braden Scale (an assessment tool to assess the risk of PIs) for Predicting Pressure Sore Risk, dated [DATE], indicated Resident 4 was at high risk for developing PIs. A review of Resident 4's Care Plan for actual impairment in skin integrity, dated [DATE], indicated nursing interventions included to provide pressure relieving mattress. A review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated [DATE], indicated the resident had an intact cognition (ability to think and process information). The MDS indicated Resident 4 was admitted to the facility with one Stage 2 PI, and two Stage 3 PIs (locations not indicated). A review of Resident 4's Generations Weekly Skin Evaluation, dated [DATE], at 3:01 PM, indicated Resident 4 had Stage 2 and Stage 3 PIs. There was no documented evidence that the weekly assessments were done for Resident 4's PIs in [DATE]. The description section for these PIs were blank. A review of Resident 4's Care Plan, dated [DATE], indicated Resident 4 was admitted with Stage 3 PIs on the right and left buttocks and a Stage 2 PI on the coccyx related to decreased mobility. The care plan indicated the goal was for Resident 4's PIs to heal and remain free from infection. The nursing interventions included to administer treatments as ordered (specific and follow the facility's policies/protocols for prevention and treatments of PIs). A review of Resident 4's Treatments Administration Record for [DATE], indicated the resident did not receive treatments for Stage 2 PI on the coccyx area, and the Stage 3 PIs on the left and right buttocks on [DATE]. The record indicated Resident 4 did not receive treatments for the Stage 3 PIs on the left and right buttocks from [DATE] to [DATE]. During an observation inside Resident 4's room and concurrent interview on [DATE], at 9:10 AM, Resident 4 was sitting on a wheelchair, awake and alert. Resident 4 stated he could not recall the last time the nurses (in general) changed the PI dressings. Resident 4 stated the nurses would peak, at the dressing. Resident 4 stated the nurses did not change the resident's PIs dressings daily. Resident 4 did not allow surveyor to observe the resident's PIs. During a concurrent interview with Licensed Vocational Nurse 1 (LVN 1) and a review of Resident 4's Physician Orders, Skin Assessments, and Care Plans, on [DATE], at 12:40 PM, LVN 1 stated Resident 4 had a Stage 2 PI on the coccyx area and two Stage 3 PIs with active orders for PIs treatments. LVN 1 stated Resident 4's PI assessments did not include measurements or description of the PIs. LVN 1 stated Resident 4's admission assessment for the PIs, dated [DATE], was incomplete. LVN 1 stated the admission assessment needed to be completed with accurate PIs' description and measurement to identify any new changes in Resident 4's PI. LVN 1 stated Resident 4's PIs needed to be monitored closely to evaluate the effectiveness of PIs treatments. LVN 1 reviewed Resident 4's care plans for PI, dated [DATE] and stated the care plan was not updated to address Resident 4's needs. LVN 1 stated the care plan did not specify the type of mattress Resident 4 (who was 6'4 tall) needed to relieve the pressure on the resident's PIs. During a concurrent observation and interview on [DATE] at 10:21 AM, Resident 4 was lying on a low air loss mattress (LAL mattress that operates using a blower-based pump that was designed to circulate a constant flow of air). Resident 4 had both feet resting on two seat pads positioned over the foot of the bed with resident's knees bent. Resident 4 stated Family Member 1 (FM 1) placed the seat pads at the foot of the bed because the resident was too tall for the bed. Resident 4 stated he was 6'4 tall and the bed was a standard twin size bed. Resident 4 stated he had to sleep with his knees bent. Resident 4 stated it was difficult for him to turn and reposition in the bed. Resident 4 stated the Licensed Nurses (in general) changed his (the resident's) dressings every other [NAME]. b. A review of Resident 5's admission Record indicated the facility admitted the resident on [DATE] with diagnoses that included type 2 diabetes and muscle weakness. A review of Resident 5's Braden Scale for Predicting Pressure Sore Risk, dated [DATE], indicated Resident 5 was at high risk for developing PIs. A review of Resident 5's New admission Assessment, dated [DATE], at 7:30 PM, indicated the resident was admitted with a PI that was not blanchable (discoloration of the skin that does not turn red when pressed), redness on both heels, and a Stage 2 PI on the coccyx area. The skin integrity review section that included sizes, measurements, and description of the PI was blank. A review of Resident 5's Physician's Order, dated [DATE], indicated to cleanse Resident 5's Stage 2 PI on the coccyx with normal saline (salt water), pat dry, apply Santyl (ointment that removes dead tissue from wounds so that they start healing), and cover the PI with foam dressing every day, for wound care, for 21 days. A review of Resident 5's Care Plan for actual skin impairment due to Stage 2 PI on the coccyx, dated [DATE], indicated the interventions included to keep the resident's skin clean and dry. A review of Resident 5's Treatments Administration Record for [DATE], indicated the resident did not receive treatments for the Stage 2 PI on [DATE]. A review of Resident 5's MDS, dated [DATE], indicated the resident had an intact cognition. The MDS indicated Resident 5 had two Stage 1 a Stage 2 PIs (location no indicated). A review of Resident 5's Generations Weekly Skin Evaluation, dated [DATE], at 5:46 PM, indicated the resident's skin was intact (no PI). A review of Resident 5's Medication Administration Audit Report, dated, [DATE], indicated to cleanse Resident 5's Stage 2 PI on the coccyx region with normal saline, pat dry, apply Santyl, and cover with foam dressing. During a concurrent interview with LVN 1 on [DATE] at 12:40 PM, and a review of Resident 5's New admission Assessment, dated [DATE], LVN 1 stated Resident 5's admission skin assessment was incomplete. LVN 1 stated the weekly skin evaluation, dated [DATE], indicated Resident 5's skin was intact when it was not. LVN 1 reviewed Resident 5's care plan for actual skin impairment, dated [DATE], and stated the care plan was not specific to addressed Resident 5's PI treatments. During an interview on [DATE] at 11:09 AM, Resident 5 stated the nurses (in general) changed the PI dressing to her PI every three days. Resident refused to allow surveyor to observe the resident's PI. c. A review of Resident 6's admission Record indicated the facility admitted the resident on [DATE] with diagnosis that included Stage 4 PI on the sacral area. A review of Resident 6's untitled Care Plan, initiated on [DATE], indicated Resident 6 had a Stage 4 PI and the goal was for the PI to show signs of healing. The care plan indicated the nursing interventions including to assess, monitor PIs weekly. The care plan indicated to measure length, width, depth of the PIs. A review of Resident 6's Physician Order, dated [DATE], indicated to cleanse Resident 6's Stage 4 PI on the Sacrococcyx with wound wash solution, apply collagen (protein), lightly pack the PI with Calcium Alginate (dressing used for moderate to heavily draining PIs), and cover the PI with foam dressing or abdominal pad (pad used for large wounds that require high absorbency) every day shift. A review of Resident 6's MDS, dated [DATE], indicated the resident had severe impaired cognition. The MDS indicated Resident 6 had a Stage 4 PI (location not indicated). A review of Resident 6's Generations Weekly Skin Evaluation, dated [DATE], indicated the resident had a Sacrococcyx Stage 4 PI. There was no other information documented, and the skin integrity review section which required PI's description and measurements was blank. A review of Resident 6's Generations Weekly Skin Evaluation, dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] indicated Resident 6's skin was intact (no PIs). During a concurrent interview, on [DATE] at 12:40 PM, and a concurrent review of Resident 6's Generations Weekly Skin Evaluations, dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], LNV 1 stated the nurses (in general) did not assess Resident 6's PI and documented Resident 6'skin as intact. LVN 1 stated Resident 6's care plan for Stage 4 PI indicated the PI needed to be measured weekly. During a wound observation on [DATE] at 3:35 PM, Resident 6's PI on the Sacrococcyx region was observed with RN 1. RN 1 was asked to measure and describe the PI; RN 1 stated the wound was small round 0.25 x 0.25 x 0.25, surrounding skin dry and clear and no exudate. The wound was observed to be small around the size of a q tip head, no drainage, no malodors. The wound bed could not be visualized. Surrounding skin appeared clean and dry. The resident denied pain during the observation. A review of the facility's document titled, Generations: Missing Treatment TAR (Treatment Administration Record), wound treatments documentation, dated [DATE], indicated PI treatments administrations were not documented as done for Resident 6 on [DATE], [DATE], [DATE], and [DATE]. d. A review of Resident 7's admission Record indicated the facility admitted the resident on [DATE] with diagnosis that included diabetes mellitus. A review of Resident 7's New admission Assessment, dated [DATE], at 4:30 PM, indicated Resident 7 did not have a history of skin issues. The skin integrity review section did not indicate the presence of PIs upon admission. A review of Resident 7's MDS, dated [DATE], indicated the resident had moderate impaired cognition. The MDS indicated Resident 7 had a stage 2 PI (location not indicated). A review of Resident 7's physician order's, Generations Weekly Skin Evaluations, and progress notes, dated [DATE] to [DATE], there was no documentation indicating the facility identified or obtained orders to treat a stage 2 PI for Resident 7. A review of Resident 7'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 [DATE] at 10:38 AM, indicated the resident had a new Stage 2 PI in the right buttock area. The evaluation note did not indicate a description or measurement of the PI, the section was blank. A review of Resident 7's Physician Order, dated [DATE], indicated to cleanse Stage 2 PI on the right buttock area with soap and water, pat dry, apply calmoseptine (medication used to treat and prevent minor skin irritations) cream and cover with dry dressing every shift for 21 days. A review of Resident 7's untitled Care Plan, dated [DATE], indicated the resident had a Stage 2 PI on the right buttocks area. The goal included for the PI to heal. The nursing interventions included to provide treatment, assess, monitor for PI healing, measure length, width, and depth of the PI weekly. A review of Resident 7's Generations Weekly Skin Evaluation, dated [DATE], indicated the resident did not have a PI. During a concurrent interview with LVN 1 on [DATE] at 12:40 PM, and a review of Resident 7's skin assessments, COC forms, and care plan, LVN 1 stated upon admission, Resident 7 did not have a PI. LVN 1 stated Resident 7 developed a facility acquired PI on [DATE] and LVN 1 completed the COC form. LVN 1 stated upon her assessment, she identified the PI as a Stage 2. LVN 1 stated she did not measure the PI. During an interview on [DATE] at 2:08 PM, Resident 7 stated the nurses (unidentified) did not check his skin and did not help him get out of bed. During a concurrent observation in Resident 7's room, and interview on [DATE] at 2:33 PM, Resident 7 complained of being itchy, on his buttocks. Resident 7 started scratching his buttocks and stated it felt like there was something there. Certified Nursing Assistant 2 (CNA 2) was present in Resident 7's room and asked the resident for permission to check his buttocks. Resident 7's right buttock had one inch of open skin and approximately two inches of redness around the open skin area. Resident 7 stated it felt like a pimple. A review of the facility's document titled, Generations: Missing TAR wound treatments documentation, dated [DATE], indicated treatments administrations were not documented as done for Resident 7 on [DATE], [DATE], and [DATE]. e. A review of Resident 8's admission Record indicated the facility admitted the resident on [DATE], and was readmitted on [DATE], with diagnosis that included muscle weakness. A review of Resident 8's New admission Assessment, dated [DATE], at 10:22 PM, indicated the resident had non-blanchable redness (skin redness that does not turn white when pressed) on the inner buttocks upon admission. The skin integrity review section indicated no PI measurements were done, and the section was blank. A review of Resident 8's Generations Care Conference note, dated [DATE] at 9:55 AM, did not indicate Resident 8 had a PI. The note indicated there were no interventions or recommendations to treat and care for the resident's PI. A review of Resident 8's readmission Assessment, dated [DATE] at 1:43 PM, indicated the resident had a Stage 1 PI on the coccyx area and redness to both buttocks. The skin integrity review section was blank with no measurements. A review of Resident 8's Physician's Order, dated [DATE], indicated to cleanse bilateral buttocks with water, pat dry, apply Secura Protective Ointment (a petrolatum-based skin barrier that helps treat and prevent incontinence-associated dermatitis), two times a day for skin care preventative. A review of Resident 8's Generations Care Conference note, dated [DATE], at 1:12 PM, did not indicate the resident had PIs. The note did not indicate any interventions or recommendations to treat the PI. A review of Resident 8's MDS, dated [DATE], indicated the resident had an intact cognition. The MDS indicated Resident 8 had a Stage 1 PI (location not indicated). During a concurrent interview with LVN 1, on [DATE], at 1 PM and a review of Resident 8's New admission Assessment, dated [DATE], LVN 1 stated the PI assessment was not completed and there were no measurements for the PI. LVN 1 was unable to provide a care plan for Resident 8's PI. During an observation on [DATE], at 9 AM inside Resident 8's room, the resident was out of the facility and was not available for PI observation. A review of the facility's document titled, Generations: Missing TAR wound treatments documentation, dated [DATE], indicated treatments administrations were not documented as done for Resident 8 on [DATE]. f. A review of Resident 9's admission Record indicated the facility admitted the resident on [DATE] with diagnosis that included sepsis (life-threatening complication of an infection). A review of Resident 9's Braden Scale for Predicting Pressure Sore Risk, dated [DATE], indicated Resident 9 was at high risk for developing PIs. A review of Resident 9's New admission Assessment, dated [DATE], at 11:40 AM, indicated Resident 9 had a Stage 3 PI on the coccyx area. The skin integrity review did not indicate PI description or measurements. The section was blank. A review of Resident 9's Care Plan for Stage 3 PI on the coccyx area, dated [DATE], indicated the goal section was blank. The nursing interventions included to keep Resident 9's skin clean and dry. A review of Resident 9's Physician's Order, dated [DATE], indicated to cleanse Resident 9's Stage 3 PI on the Sacro-coccyx area, pat dry, apply Medihoney, and cover the PI with dry dressing every day shift for 21 days. A review of the facility's document titled, Generations: Missing TAR wound treatments documentation, dated [DATE], indicated treatments administrations for Resident 9's PI were not documented as done for Resident 9 on [DATE]. During an interview on [DATE] at 12:40 PM, LVN 1 stated licensed nurses (in general) needed to complete PI assessments and document the findings in the residents' (in general) medical records. LVN 1 stated the facility utilized registry nurses and they (registry nurses) did not complete the skin assessments upon admission and weekly after admission. During an interview on [DATE] at 1 PM, the DON stated two wound consultants/doctors used to go to the facility to conduct PI assessments on residents (in general). The DON stated he did not know the reason the wound consultants/doctors stopped going to the facility. The DON stated licensed nurses (in general) did not measure the PIs. The DON stated when the facility admitted a new resident, the LVNs (in general) would call the wound consultant/doctor to go to the facility to assess the PIs. The DON stated the facility did not have a full time Registered Nurse (RN) and relied on the wound consultants/doctors for the care and management of all PIs. The DON stated he could not assess the residents' PIs due to his workload. The DON stated, I can't do it. The DON stated the facility use registry nurses daily, and the registry nurses did what they wanted. The DON stated Residents 4, 5, 6, 7, 8, and 9 did not have their PIs measure upon admission and weekly thereafter. The DON stated PI treatments and interventions were based upon admission and weekly assessments. The DON stated facility license nurses (in general) did not update and implement Residents 4's, 5's, 6's, 7's, 8's, and 9's care plans. The DON stated he did not have a system to ensure Residents 4, 5, 6, 7, 8, and 9 received ordered treatments for PIs. During an interview with Resident 9's Family Member 2 (FM 2) [DATE] at 3:05 PM, FM 2 stated she did not want the surveyor to observe the PI. 2. During an interview on [DATE], at 1:25 PM, RN 1 stated he was a registry nurse, and the facility did not provide an orientation regarding PI. RN 1 stated he did not know the facility' protocol for PI assessments and treatments. During an interview on [DATE] at 1:35 PM, LVN 2 stated she was a registry nurses and the facility did not provide orientation regarding PI treatments requirements. During an interview on [DATE] at 3:04 PM, LVN 3 (registry nurse) stated she was assigned to Residents 6 and 7. LVN 3 stated Residents 6 and 7 did not have PIs. LVN 3 stated Resident 6 had a calmoseptine order, but she did not apply it. During the same interview and a concurrent review of Resident 6's physician orders, LVN 3 stated Resident 6 had a treatment order for the resident's Stage 4 PI. LVN 3 stated she documented in the PI treatments record that she completed the treatment, but she did not do it. During a concurrent interview regarding Resident 7, LVN 3 stated Resident 7 did not have a PI, just redness, on the right buttock. LVN 3 stated a CNA (unidentified) washed Resident 7's buttocks during the morning bath. LVN 3 stated she (LVN 3) was present during Resident 7's bath so she documented that Resident 7's PI treatments was done. LVN 3 stated she assumed the facility had a treatments nurse. LVN 3 stated the facility did not provide training or orientation regarding PIs. LVN 3 stated she did not know that she had to provide PI treatments. During an interview on [DATE] at 3:57 PM, LVN 4 stated it was her first time at the facility and stated she informed LVN 1 she had never done treatments on PIs. LVN 4 stated LVN 1 told her Oh well. LVN 4 stated she was not experienced with PI treatments and assessments. LVN 4 stated the facility did not provide her the help or training and left her to figure the PI treatments out on her own. During an interview on [DATE] at 12 PM, the ADM and DON both stated the facility did not have a Director of Staff Development (DSD). The AMD stated the facility's training and in service contract expired on [DATE]. The ADM stated facility's staff and registry staff did not receive regular in-services regarding PI treatment/assessment, and other care areas since the contract expired ([DATE]). During an interview on [DATE] at 1 PM, the ADM stated the facility did not have a policy for PI management. A review of the facility's policy titled, Pressure Injury Risk Assessment, dated [DATE], indicated steps in conducting a PI risk assessment including: Conduct a comprehensive skin assessment with every risk assessment, and Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. A review of the facility's policy and procedure titled Medication Administration, dated [DATE], indicated the facility would administer medications in a safe and timely (unidentified time) manner, and as prescribed. The policy indicated topical medications (medications that are applied to the skin) used in treatments were recorded on the resident's TAR. A review of the facility's policy titled, Quality of Care-Pressure Injuries, dated [DATE], indicated Skin Assessment: 1. Conduct comprehensive skin assessment upon admission (or soon after, within 8 hours), with each risk assessment, as indicated according to the resident's risk factors. The policy indicated skin assessments were to be done upon admission, weekly, and while performing ADLs.