Health inspection·November 20, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide adequate care and services to promote healing and prevent pressure ulcers (a localized injury to the skin and/or underlying tissue because of prolonged pressure) for two of three sampled residents (Resident 1 and Resident 2), when both residents were observed lying on low-air loss mattresses (LAL mattress, a mattress designed to prevent and treat pressure wounds that uses a continuous, gentle flow of air through a surface of tiny holes to reduce pressure helping to prevent and treat skin breakdown and pressure wounds) that were not correctly calibrated according to their individual weights.This deficient practice had the potential to delay wound healing and place Resident 1 and Resident 2 at increased risk for developing pressure ulcers and/or skin breakdown.Findings:a. Review of an admission Record indicated Resident 1 was admitted to the facility with multiple diagnoses including traumatic subdural hemorrhage (a collection of blood between the brain's surface and its outer covering), Alzheimer's disease (a progressive brain disorder that affects thinking, memory, and language, interfering with daily life), unspecified psychosis (a breakdown in reality where thoughts become jumbled, and external voices or messages might seem real), extrapyramidal and movement disorder (a group of conditions that cause abnormal, involuntary movements, can also include a lack of movement), major depression disorder, anxiety disorder.During an observation on 11/19/25 at 2:28 PM Resident 1 was noted lying on her back in bed on a LAL mattress, which was set for a person who weighed 355 pounds (LBS-a unit of measure).During a concurrent observation and interview, on 11/19/25 at 2:35 PM, CNA 1 stated that Resident 1 had skin breakdown on her right buttock with a wound dressing in place. CNA 1 confirmed that Resident 1 was lying on an LAL mattress on her back and further verified that the mattress was set for someone who weighed 355 LBS.During a concurrent observation, interview, and record review, on 11/19/25 at 3:22 PM, LN 1 stated that Resident 1 had one healed shear wound (when skin sticks to a surface, but underlying tissues (like muscle and bone) slide in the opposite direction due to gravity or movement, damaging deep tissue and blood vessels) on the right buttock and one new wound to the right buttock that was identified during AM shift on 11/19/25. A review of Resident 1's medical record with LN 1 revealed Resident 1's most recent weight, dated 11/2/25, was 137.2 LBS. LN 1 verified the weight and confirmed, in Resident 1's room, that the LAL mattress was set for someone who weighed 355 LBS, which did not reflect Resident 1's actual weight. LN 1 stated that it was the nurses' responsibility to ensure the LAL mattress setting was adjusted according to Resident 1's current weight. LN 1 further explained that incorrect settings posed a potential risk for Resident 1's wound to worsen. LN 1 further stated that the purpose of the LAL mattress was to promote healing of existing wounds and provide preventative care, and that failure to set it correctly could lead to deterioration of the wound. Review of the facility provided user manual for [brand name of LAL] , dated 2019 indicated, . [Model #] LOW AIR LOSS MATTRESS with ALTERNATING PRESSURE. Product Function: (1) Pressure Adjust Valve: Adjust the valve to increase or decrease the pressure for a softer or firmer setting between 1-8 range Residents Affected - Few Page 1 of 2 056324 056324 11/20/2025 Hampton Post Acute 442 Hampton Street Stockton, CA 95204

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few or by patients weight as noted on the panel. b. Review of an admission Record indicated Resident 2 was admitted to the facility with multiple diagnoses including malignant neoplasm (a cancerous tumor that can invade surrounding healthy tissue and spread to other parts of the body), cellulitis (a common infection affecting the skin's deeper layers and tissues)of right lower limb, cellulitis of left lower limb, pressure ulcer of sacral region (an area of damaged skin and tissue near the tailbone, also known as a bedsore, caused by prolonged pressure).During an interview on 11/20/25 at 11:32 AM, Resident 2 stated she was admitted to the facility with multiple skin wounds, including pressure ulcers, and was provided with a LAL mattress for wound management.During a concurrent observation and interview on 11/20/25 at 11:39 AM, the Treatment Nurse (Tx Nurse) stated Resident 2 was admitted with multiple wounds and weighed less than 100 LBS. The Tx Nurse confirmed Resident 2's LAL mattress was set for someone who weighed 160 LBS and verified it was not set correctly for Resident 2's actual weight.During a concurrent interview and record review conducted on 11/20/25 at 12:19 PM, Resident 2's medical record titled Weights and Vitals Summary, dated 11/15/25 was reviewed with the Tx Nurse. The review of Resident 2's weight records indicated the most recent weight on 11/15/25 was 93.4 LBS. The Tx Nurse stated that Resident 2 had pressure wounds, and a LAL mattress was provided to support wound healing and relieve pressure. The Tx Nurse stated the LAL mattress should be set according to Resident 2's current weight. The Tx Nurse reported the mattress was set incorrectly. The Tx Nurse explained that nurses were responsible for adjusting the LAL mattress to match Resident 2's current weight. The Tx Nurse further stated that there was a potential risk of the pressure wounds worsening when the mattress was not set correctly according to Resident 2's weight.Review of Resident 2's Order Summary Report indicated an active order, dated 11/17/25, for pressure ulcer precautions, including providing a pressure relieving mattress.Review of Resident 2's Body Check .x - V2, dated 11/17/25, indicated . SAROCOCCYX UNSTAGEAGBLE PRESSURE INJURY Wound. 2. Pressure Ulcer Prevention Measures. a. Pressure reducing mattress.Review of the facility provided document LAL mattress operator's manual for Brand Name, dated 2016 indicated, . GENERAL. Specifically designed to redistribute pressure, these systems offer a solution for the prevention and treatment of pressure ulcers and offers an optimal solution for pressure redistribution and microclimate control. PRODUCT FUNCTIONS. The WEIGHT SETTING Buttons (+) and (-) can be used to adjust the pressure of the inflated cells based on the patient's weight.During a concurrent interview and record review on 11/20/25 at 4: 20 PM of the facility provided LAL mattress user manual for Brand Name and LAL mattress operator's manual for Brand Name were reviewed with the Director of Nursing (DON). The DON stated nurses were responsible for adjusting the settings on LAL mattresses in the facility. The DON explained the importance of relieving pressure from wound sites and stated that correct weight distribution was essential, noting that improper mattress settings could contribute to the worsening of wounds for residents using LAL mattresses. The DON stated that LAL mattresses were intended to improve pressure wound conditions, and improper pressure distribution might lead to wound deterioration and longer healing periods, potentially affecting the health status of the residents. The DON further stated she expected nurses to adjust the LAL mattress settings for Resident 1 and Resident 2 according to their current weights to ensure the settings matched each resident's actual weight. The DON acknowledged that her expectations were not met. The DON also acknowledged that nursing staff did not follow the manufacturer's guidelines for the LAL mattresses for Resident 1 and Resident 2 when the air pressures were not adjusted to the residents' weights. The DON stated that failure to follow the manufacturer's instructions could significantly contribute to the worsening of Resident 1 and Resident 2's wound conditions and potentially affect their overall health status. 056324 Page 2 of 2