Health inspection·December 30, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a specialized mattress to two of four sampled residents (Resident 1, Resident 4) who required them, due to both residents having significant pressure injuries (a severe wound, involving full-thickness tissue loss where skin, fat, muscle, tendon, or bone is exposed, also known as a pressure ulcer) to their sacrum (tailbone area), and failed to include the intervention of using a specialized mattress in the care plan for Resident 1. These failures had the potential for delayed healing to the pressure injuries, and an increase in the risk of the pressure injuries worsening, including further tissue loss, pain, and infection, to the two residents.During a concurrent interview and record review on 12/30/25, at 11:30 a.m., with the Assistant Director of Nursing (ADON), Resident 1's clinical record was reviewed. Resident 1's admission Record (AR), dated 12/30/25, indicated Resident 1 was admitted to the facility on [DATE], and was discharged on 12/30/25. Resident 1's Order Summary Report (OSR) indicated Resident 1 had a physician's order to care for a stage 4 pressure ulcer to Sacrum. Resident 1's Progress Notes (PG), dated 12/13/25, at 1:16 a.m., indicated she was admitted to the facility with the wound.Resident 1's PG dated 12/12/25, at 7:50 p.m., indicated Interventions for Skin/Wound Condition(s) were Pressure Redistributing Devices (e.g., .Mattress.) This PG entry was repeated eight (8) more times during Resident 1's stay at the facility: on12/23/25, at 12:16 p.m.12/22/25, at 10:55 a.m.12/20/25, at 9:39 a.m.12/19/25, at 10:41 a.m.12/18/25, at 3:54 p.m.12/17/25, at 3:54 p.m.12/16/25, at 1:24 p.m., and,12/15/25, at 9:11 a.m.The ADON stated, I remember [Resident 1]. She actually left the faciity on [DATE] to go to the hospital for low blood pressure but was not discharged from our census until today, on 12/30/25. She was on a regular mattress when she was here, I remember. She should have been on a specialized air mattress, like a low air loss mattress [LALM]. I don't know why she was not. [The need for] a LALM or other specialized mattress is not in her care plan. It should be there.During a concurrent observation and interview, on 12/30/25, at 12:15 p.m., with the ADON, Resident 4 was observed in his room, while he was in bed. The ADON stated Resident 4 had a pressure injury to his tailbone. While observing Resident 4's bed, the ADON stated he should have a pressure redistribution mattress. He does not have one, he has a regular mattress.During an interview with Resident 4, on 12/30/25, at 12:16 p.m., in his room while he was in bed, Resident 4 stated his mattress sucks, it's lumpy and unpleasant.During a concurrent interview and record review, on 12/30/25, at 12:35 p.m., with the ADON, Resident 4's clinical record was reviewed. The ADON stated, Resident 4's LALM was ordered on 12/24/25, I am not able to find where his physician was notified that the mattress he ordered for his patient is not in use. The ADON stated, We are out of them right now.During a review of Resident 4's AR, it indicated he was admitted to the facility on [DATE]. Resident 4's OSR, dated 12/24/25, indicated he had a physician's order for Pressure Redistribution Mattress - Low Air Loss. for wound to [tailbone]. Resident 4's PG dated 12/24/25, at 9:05 a.m., indicated a physician specializing in wound care into see resident [4] on Residents Affected - Few Page 1 of 2 056100 056100 12/30/2025 Cornerstone Care Center 2550 9th Street Sanger, CA 93657

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 12/23/25 and wrote detailed orders for the care of Resident 4's pressure injury, including air mattress for wound to [tailbone] .During a review of the facility's Policy and Procedure (P&P) titled, Pressure Injury Prevention and Management, dated 9/12/23, the P&P indicated, This facility is committed to . provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. Evidence-based interventions for prevention will be implemented for all residents who assessed at risk for who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: Provide appropriate, pressure-redistributing, support surfaces. Interventions will be documented in the care plan.During a review of the facility's Policy and Procedure (P&P) titled, Wound Treatment Management, dated 9/2/22, the P&P indicated, In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. 056100 Page 2 of 2