Health inspection·November 25, 2025

The following reflects the findings of the California Department of Public Health during investigation of Complaint #: 2590797. Event ID: 1D4703-H1 Representing the Department, 51593 RN, HFEN. State Citation (B) was written. 42 C.F.R 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. 22 CCR 72311(a)(1)(A), (a)(2) Nursing Services-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 the admission of the patient and be completed within seven days after admission. (2) Implementing each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 8/19/2025 at 10:55 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding a delay in Resident 1's rehabilitation and discharge to an assisted living facility due to Resident 1's development of a stage 3 pressure injury. The facility failed to ensure: 1. Resident skin assessments to the heels were completed, preventing observation and early identification of a developed pressure injury (a wound or sore that develops from prolonged pressure on the skin, usually over a bony prominence such as heels, knees, elbows, hips, shoulders, and tailbone) when Resident 1's stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible) pressure injury to his left heel was identified on 6/3/25, 31 days after being admitted to the facility. 2. Licensed nurses had the specific competencies, and skill sets necessary to care for the residents' needs, as identified through resident daily assessments and goals to minimize development of pressure injury described in the plan of care. As a result of the above failures, Resident 1 developed a stage 3 pressure injury that was not observed and identified early in development delaying his rehabilitation and discharge to an assisted living facility. During a review of Resident 1's "Admission Record" (a summary of important information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 8/19/25, the admission record indicated Resident 1 was admitted to the facility on 5/3/2025 for rehabilitation due to a fall that resulted in a left partial hip replacement (a surgical procedure where only the damaged part of the hip joint is replaced with an artificial implant). Resident 1 had a history that included type 2 diabetes mellitus (DM - high levels of sugar in the blood). During a review of Resident 1's "Minimum Data Set" (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 8/15/2025, Resident 1's MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 15 out of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating no cognitive impairment. During a concurrent observation and interview on 8/19/25 at 11:08 a.m. with Resident 1 in Resident 1's room, Resident 1 was observed lying in bed with his left leg elevated on a pillow. Resident 1 stated his left foot was elevated on a pillow due to an injury on his left heel. Resident 1 stated he got an injury to his left heel while at the facility and did not have the injury prior to admission. Resident 1 stated he was not as mobile as he was prior to coming to the facility due to his fall and subsequent hip surgery. Resident 1 stated he needed assistance from facility staff with repositioning himself in bed and showering. During a review of Resident 1's MDS assessment, dated 8/15/25, Resident 1's MDS assessment indicated, "A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed ... Supervision or touching assistance ... helper provides verbal (using words) cues and/or touching/ steadying ... as resident completes activity ... Assistance may be provided throughout the activity or intermittently." During an interview on 8/19/25 at 1:15 p.m. with the Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1's skin was assessed for redness, bruises, or skin tears during showers, while changing his clothes, and during positioning. The CNA stated they used a shower assessment (a process of closely observing a resident's skin and overall condition during bathing to identify any abnormalities or changes that require further attention) to help identify skin issues during Resident 1's shower times. CNA 1 stated Resident 1's bony prominences (a part of the skeleton where a bone is close to the surface of the skin) were assessed for redness or signs of pressure injury during shower times. CNA 1 stated any changes found on Resident 1's skin during shower times would have been recorded on the shower assessment form, reported to the nurse for further assessment, and turned into the Director of Nursing (DON). During an interview on 8/19/25 at 2:34 p.m. with the DON, the DON stated Resident 1's left heel pressure injury was acquired at the facility. The DON stated on 6/3/25, when staff noticed Resident 1's pressure injury, it was "a dark black color". The DON stated it was not typical for a resident to develop a pressure injury 31 days after admission. During a concurrent interview and record review on 8/20/25 at 10:42 a.m. with the Licensed Vocational Nurse (LVN) 1, Resident 1's "Nurse's Note (NN)", dated 5/3/25, was reviewed. The NN indicated Resident 1 was admitted to the facility on 5/3/25 from an acute care hospital for a left femur (the bone of the thigh) fracture. LVN 1 stated Resident 1 was "pretty immobile (not able to move)" at the time of his admission. LVN 1 stated Resident 1, "stayed in bed, afraid to get up due to his fall at home". During a concurrent interview and record review on 8/20/25 at 10:45 a.m. with LVN 1, Resident 1's "Advanced Skilled Evaluation (ASE)", dated 5/4/25, was reviewed. The "Advanced Skilled Evaluation" indicated Resident 1's skin was "...warm and dry, skin color WNL (within normal limits) ..." LVN 1 stated Resident 1 had no issues noted with his skin on admission other than his surgical site. LVN 1 stated the "ASE's" were done daily and were a head-to-toe assessment. During a concurrent interview and record review on 8/20/25 at 10:50 a.m. with LVN 1, Resident 1's "ASE", dated 6/1/25, was reviewed. The "(ASE)" indicated Resident 1's skin was "... warm and dry, skin color WNL ..." LVN 1 stated Resident 1 had no issues noted with his skin on 6/1/25. During a concurrent interview and record review on 8/20/25 at 10:55 a.m. with LVN 1, Resident 1's Nurse's Noted, dated 6/3/25, was reviewed. The Nurse's Note indicated, "Note Text: writer was notified that resident had a sore on his left heel ... writer assessed ... noted a large dark red sore to left heel measuring 5cm x 5cm (centimeters - a metric unit of length) ... open area around the edges of the sore and clear drainage." LVN 1 stated she was the writer of the Nurse's note. LVN 1 stated she was notified of Resident 1's pressure injury by a CNA. LVN 1 stated she thought that a CNA noticed Resident 1's pressure injury while they were changing his socks. During a concurrent interview and record review on 8/20/25 at 11 a.m. with LVN 1, Resident 1's "Initial Wound Evaluation & Management Summary", dated 6/5/25, was reviewed. The "Initial Wound Evaluation & Management Summary" indicated, "Stage: Unstageable DTI (deep tissue injury - damage to the muscles, fat, or other underlying tissues that occurs while the outer skin still looks intact, often appearing as a bruise-like discoloration) with intact skin ... Skin: intact with purple/ maroon discoloration ... Electronically signed by: [Wound Doctor]". LVN 1 stated a DTI is a pressure injury that "starts underneath the skin". LVN 1 stated a DTI develops over time, because of pressure. LVN 1 stated Resident 1 would not have developed a DTI between his last "Advanced Skilled Evaluation" on 6/1/25 and 6/3/25 when the pressure injury was noticed by a CNA. LVN 1 stated Resident 1's pressure injury should have been evident prior to 6/3/25. LVN 1 stated she should look at residents' bony prominences when doing the "Advanced Skilled Evaluations". LVN 1 stated the heel is considered a bony prominence and should be checked for redness or other signs of a pressure injury. LVN 1 stated it was difficult for her to observe and complete an assessment of Resident 1's heels due to his hip surgery. LVN 1 stated she should have checked Resident 1's heels during repositioning and showers. LVN 1 stated it is important to check bony prominences to prevent pressure injury. LVN 1 stated Resident 1 could have experienced a prolonged rehabilitation due to his pressure injury. LVN 1 stated that she expected CNAs to look thoroughly at residents' skin during repositioning and shower times and notify the nurse of any skin changes. During an interview on 8/20/25 at 11:21 a.m. with CNA 1, CNA 1 stated the shower assessment form was called a "Skin Monitoring: Comprehensive CNA Shower Review". CNA 1 stated the "Skin Monitoring: Comprehensive CNA Shower Review" form prompted the CNAs to look at residents' heels and other bony prominences. CNA 1 stated these areas are looked at to identify any pressure injuries. During an interview on 8/20/25 at 11:45 a.m. with the DON, the DON stated the nurse should have looked for redness and changes in skin color, or texture, when doing Resident 1's skin assessments. The DON stated the nurse should have looked at areas more prone to pressure during their assessments, which included Resident 1's heels. The DON stated a DTI occurs over time and is the result of prolonged pressure. The DON stated a DTI would not develop overnight. The DON stated the CNAs and nurses should have noticed Resident 1's pressure injury prior to 6/3/25. The DON stated CNAs should have noticed any skin changes for Resident 1 during shower times or repositioning. The DON stated nurses should have identified skin changes for Resident 1 during assessments. The DON stated she expected the CNAs and nurses to look at bony prominences for signs of pressure injury. The DON stated Resident 1's pressure injury could take a long time to heal due to his medical history of type 2 DM which causes wounds to heal slowly. The DON stated the facility should have identified the pressure injury sooner, before it progressed. The DON stated Resident 1 was not admitted to the assisted living facility due to his stage 3 pressure injury. During an interview on 8/20/25 at 12:33 p.m. with the Administrator (ADM), the ADM stated pressure injuries should be prevented in the facility. The ADM stated staff should have assessed residents' skin before a pressure injury developed. The ADM stated that staff should have been more "careful" in identifying pressure injuries for Resident 1 since he was immobile due to hip surgery and because of his type 2 DM. During a review of Resident 1's "Care Plan Report", dated 5/4/25, the Care Plan Report indicated, "Focus: At risk for skin integrity (the health and condition of an individual's skin, referring to its state of being whole, unbroken, and healthy) impairment related to decreased mobility (the ability to move or be moved freely and easily) ... Goal: will minimize development of pressure injury ... Interventions (action, treatment, or procedure performed to achieve a patient's health goals and improve their well-being): Monitor skin daily with ADL (activities of daily living - basic self-care tasks like bathing, dressing, eating, and mobility) and notify charge nurse for any changes." During a review of Resident 1's "Skin Monitoring: Comprehensive CNA Shower Review (CSR)", dated 6/2/25, the CSR indicated, "...Resident: Resident 1 ... Perform a visual assessment of a resident's skin when giving the resident a shower ... Use this form to show the exact location and description of the abnormality ..." The CSR indicated Resident 1's heels had no redness or discoloration. During a review of the facility's policy and procedure (P&P) titled, "Pressure Injuries Overview", dated January 2018, the P&P indicated, "This injury results from intense and/or prolonged (continuing for a long time) pressure ... at the bone-muscle interface (junction where muscle tissue connects to bone)." During a review of the facility's P&P titled, "Repositioning", dated January 2018, the P&P indicated, "General Guidelines: Evaluation of a resident's skin integrity after pressure has been reduced (lower pressure on specific body areas) or redistributed (more evenly spread pressure across a larger surface area) should give the development and implementation of repositioning plans ... Evaluation: Evaluate the resident for an existing pressure ulcer." During a review of the facility's P&P titled, "Shower", dated January 2018, the P&P indicated, "Observe the resident's skin for any redness ... reddish or blue-gray area of skin over a pressure point ..." During a review of a professional reference titled, "Pressure Ulcer", dated January 2024, retrieved from https://www.ncbi.nlm.nih.gov/books/NBK553107/ the professional reference indicated "... Examine the following in a patient with a PI (a localized area of skin and/or underlying tissue damage that develops when prolonged pressure or shear forces exceed the tissue's tolerance): Ulcer history, including etiology (the study of the cause or origin of a disease or abnormal condition) , duration, and previous treatment, Staging by thoroughly examining the depth of the wound, which this activity will cover in detail under "staging", Size of the affected area, Sinus tracts (an abnormal, tube-like passage that connects an infected area to the surface of the skin), undermining (the lifting and separation of skin and underlying tissues), and tunneling (creating or traversing a passage), The presence of drainage, The presence of necrotic tissue... When evaluating the wound characteristics, it is also important to keep risk assessment instruments in mind to reduce the risk of a PI incidence... The primary goal is to prevent pressure injury. This goal requires an interprofessional team, including primary care providers, wound care specialists, surgeons, specialty-trained wound nurses, physical therapists, and nurse aides. Nurses provide care, monitor patients, and notify the team of issues. Nurse aides are often responsible for turning and repositioning patients...The patient should be kept pain-free by giving analgesics (medications that relieve pain). They should try to increase physical activity, which a nurse's aide, medical assistant, or rehab nurse can facilitate. Frequent follow-ups are an absolute necessity, and a team approach to patient education and pressure injury management involving the wound care nurse and wound care clinician lead to the best results..." In violation of the above cited standards, the facility failed to ensure Resident 1's skin assessments were completed, preventing observation and early identification of pressure injuries when facility staff did not observe and assess Resident 1's heels during repositioning and shower times. The failure to assess Resident 1's heels resulted in Resident 1 developing a stage 3 pressure injury, that was not observed and identified early in development delaying his rehabilitation and discharge to an assisted living facility. These violations, jointly, separately or in any combination, presented actual harm and was a direct proximate cause o