Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
interview and record review, the facility failed to ensure residents at risk for developing pressure ulcers
localized damage to the skin and/or underlying tissue usually over a bony prominence) had their skin
assessed and documented on a weekly basis per the facility policy and procedure (P&P) for two of three
sampled residents (Resident 1 and Resident 2).
Residents Affected - Few
This deficient practice had the potential to delay necessary treatments and services and to increase the
residents' risk of skin breakdown.
Findings:
1. During a review of Resident 1's admission Record, the admission Record indicated the facility originally
admitted Resident 1 to the facility on 7/13/2018 and readmitted the resident on 12/05/2018 with diagnoses
including diabetes mellitus (DM- a chronic condition that affects the way the body processes blood glucose
[sugar]) and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/21/2024,
the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and
understanding through thought, experience, and the senses) skills for daily decision making was severely
impaired, and the resident was dependent on staff with oral/personal/toileting hygiene, upper/lower body
dressing, bed mobility (movement) and transfer. The MDS further indicated that Resident 1 had a risk of
developing pressure ulcers/injuries (PU/I).
During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following
physician orders:
- Treatment, renewal, site; sacrococcyx (the area at the base of the spine near the tailbone) skin integrity
maintenance, cleanse with normal saline (NS - a saltwater solution), pat dry, apply skin barrier ointment,
leave open to air every day shift for 30 days; Order Date: 2/19/2025, Start Date: 2/19/2025, and Stop Date:
3/21/2025.
- Treatment, site; open blister on sacrococcyx; cleanse with NS, pat dry, apply thera-honey (used as a
wound dressing), followed by collagen granules (used to promote wound healing process), cover dry
dressing every day shift for 30 days; Order Date: 3/2/2025, Start Date: 3/2/2025, and Stop Date: 4/1/2025.
During a review of Resident 1's Care Plan Report, initiated on 12/16/2018 and last revised on
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
056149
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
1/13/2025, the care plan indicated that Resident 1 was at risk for developing pressure sore and other types
of skin breakdown related to fragile skin due to aging process, reduced mobility, and dementia. The care
plan indicated an intervention for weekly body checks.
During a review of Resident 1's weekly Licensed Nurses Note dated 2/23/2025, the weekly Licensed
Nurses Note indicated Skin Management Protocols was not marked for skin clear/intact or skin alteration
present.
During a review of Resident 1's Change of Condition (COC- a sudden clinically important deviation from a
resident's baseline in physical, cognitive, behavioral, or functional domains) Licensed Nurses Note, dated
3/5/2025, the COC Licensed Nurses Note indicated Skin Management Protocols was not marked for skin
clear/intact or skin alteration present.
During a concurrent interview and record review on 3/12/2025 at 4:45 p.m., with the Director of Nursing
(DON), reviewed Resident 1's weekly Licensed Nurses Notes dated 2/23/2025 and Resident 1's COC
Licensed Nurses Note dated 3/5/2025. The DON stated that the licensed nurses did not document for the
section of skin management protocol and was left blank, so the facility was unable to provide information of
Resident 1's skin condition and/or skin progress. The DON stated the skin condition and/or skin progress
should be assessed and documented at least weekly by the licensed nurses.
2. During a review of Resident 2's admission Record, the admission Record indicated the facility originally
admitted Resident 2 to the facility on 1/15/2023 and readmitted the resident on 2/18/2023 with diagnoses
including right hip broken bone and dementia (a progressive state of decline in mental abilities).
During a review of Resident 2's MDS dated [DATE], the MDS indicated the resident's cognitive skills for
daily decision making was severely impaired, and the resident was dependent on staff with toileting hygiene
and transfer and needed moderate assistance with upper/lower body dressing and bed mobility. The MDS
further indicated that Resident 2 had a risk of developing PU/I.
During a review of Resident 2's Care Plan Report, initiated on 11/19/2023 and last revised on 2/22/2025,
the care plan indicated that Resident 2 was at risk for developing pressure sore and other types of skin
breakdown related to aging process, incontinence of bowel and bladder, reduced mobility, and dementia.
The care plan indicated an intervention for weekly body checks.
During a review of Resident 2's weekly Licensed Nurses Note dated
2/23/2025 and 3/2/2025, the weekly Licensed Nurses Notes indicated Skin Management Protocols were
not marked for skin clear/intact or skin alteration present.
During a concurrent interview and record review on 3/12/2025 at 4:35 p.m., with the DON, reviewed
Resident 2's weekly Licensed Nurses Notes dated 2/23/2025 and 3/2/2025. The DON stated that the
licensed nurses should mark for skin clear/intact if no issues with the resident's skin, but the licensed
nurses did not mark for Resident 2's skin conditions. The DON stated if not marked, the facility was unable
to prove that Resident 2's skin was assessed weekly.
During a review of the facility's P&P titled, Pressure Sore Management, last reviewed on 7/16/2024, the
P&P indicated, All available measures shall be taken to reduce skin breakdown and pressure sores
Individual care plan for management of skin condition will be developed as indicated.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056149
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Healthcare and Rehabilitation Center
6700 Sepulveda Blvd.
Van Nuys, CA 91411
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Level of Harm - Minimal harm
or potential for actual harm
During a review of the facility's P&P titled, Licensed Nurses Notes, last reviewed on 7/16/2024, the P&P
indicated, Weekly progress notes are to be written on each resident regardless of the amount of daily
entries recorded. These progress notes shall include the following Any pertinent information to reflect an
overall profile of the resident. When a licensed nurse is writing a weekly summary, the following records are
to be reviewed to ensure that the information entered coordinates with the other discipline's documentation.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056149
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
FAQ · About this visit
Common questions about this visit
What happened during the March 12, 2025 survey of CALIFORNIA HEALTHCARE AND REHABILITATION CENTER?
This was a inspection survey of CALIFORNIA HEALTHCARE AND REHABILITATION CENTER on March 12, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CALIFORNIA HEALTHCARE AND REHABILITATION CENTER on March 12, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.