Health inspection·March 30, 2026

The following reflects the findings of the California Department of Public Health during the annual recertification survey conducted on 1/26/26 to 1/29/26. F686 (Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22) §483.25(b) Skin Integrity §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; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. 22 CCR § 72027 Decubitus ulcer means an ulceration of skin and underlying tissue caused by pressure. 22 CCR § 72315 (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (1) Changing position of bedfast and chairfast patients with preventive skin care in accordance with the needs of the patient. (2) Encouraging, assisting and training in self-care and activities of daily living. (3) Maintaining proper body alignment and joint movement to prevent contractures and deformities. (4) Using pressure-reducing devices where indicated. (5) Providing care to maintain clean, dry skin free from feces and urine. (6) Changing of linens and other items in contact with the patient, as necessary, to maintain a clean, dry skin free from feces and urine. (7) Carrying out of physician's orders for treatment of decubitus ulcers. The facility shall notify the physician, when a decubitus ulcer first occurs, as well as when treatment is not effective, and shall document such notification as required in Section 72311(b). On 1/26/29, an unannounced recertification survey was conducted at the facility. Resident 3 is a 78-year-old female with diagnoses of muscle weakness, unsteadiness on feet, need for assistance for personal care, Dementia (memory loss), lack of coordination, failure to thrive (a syndrome of unintentional weight loss, malnutrition, dehydration, cognitive decline, and reduced physical activity), and a history of falling. Based on interview and record review, the facility failed to accurately complete the Braden Scale ([BS] a tool that assesses a resident's risk of developing pressure injury/sore/ulcer [localized damage to the skin and underlying soft tissue caused by prolonged pressure often combined with shear or friction]. It evaluates sensory perception, moisture, activity, mobility, nutrition, the lower the score the higher the risk of the resident developing a pressure injury [severe risk less than 9, high risk 10 - 12, moderate risk 13 - 14, mild risk 15 - 18]) to reflect the resident's risk of developing a pressure injury, "Check and Change [facility's process for checking residents every 2 hours for incontinent episode]" the resident, implement and/or revise the care plan, and accurately complete the "Comprehensive CNA [Certified Nursing Assistants] Shower Review" ([SR] at every shower CNAs document the condition of the resident's skin) for one sampled resident (Resident 3) which resulted in the resident developing a facility acquired stage III pressure injury (full-thickness skin loss in which fat is visible in the ulcer, and granulation tissue [appears moist, red granular tissue that fills the wound base during healing] is often present). Findings: During a concurrent interview and record review on 1/29/26 at 6:39 p.m. with Director of Nursing (DON), Resident 3's BS dated 12/23/25, was reviewed. The BS indicated a score of 21 (no risk of developing pressure injuries). DON stated this was an inaccurate assessment. DON stated the scoring on activity, sensory, shear and mobility is inaccurate. DON stated Resident 3 should have scored 13 (moderate risk of developing a pressure injury). DON stated with a score of 13 versus a score of 21, the staff would have included interventions to prevent pressure injuries. DON stated these interventions would include turning and repositioning Resident 3 every two hours. DON stated there was no documentation the staff turned and repositioned Resident 3 every two hours. During a review of Resident 3's "Nurses' Admission Record (NAR)," dated 12/23/25, the NAR indicated no skin issues to sacral coccyx area (area located at the base of the spine and above the buttocks). During a review of Resident 3's "Skin Progress Notes (SPN)," dated 1/9/26 at 11:24 a.m., the SPN indicated, "1. Skin Progress Report Site Sacral coccyx type Pressure length 4 [inches] Width 5 [inches] Depth 0.5 [inches] Stage III." During a concurrent interview and record review on 1/29/26 at 6:49 p.m. with DON, Resident 3's "Nursing Weekly Assessment (WA)", dated 1/6/26, was reviewed. The WA indicated, Resident 3 was incontinent of bowel and bladder. DON stated Resident 3 was always incontinent and facility staff should conduct "Check and Change" every two hours. DON stated there was no documentation in Resident 3's Electronic Health Record (EHR) that staff checked the resident every two hours for bowel and bladder incontinence. During a concurrent interview and record review on 1/29/26 at 6:51 p.m. with DON, Resident 3's "Care Plan (CP)" date initiated 1/2/26 was reviewed. The CP indicated, "The resident has potential for pressure ulcer development, and interventions instruct/assist to shift weight in w/c [wheelchair] q [every] 15 minutes." DON stated there was no documentation that Resident 3 had been instructed or assisted to shift weight every 15 minutes. DON stated if it was not documented, it was not done. DON stated if the Braden score was accurate the expectation of the facility would be to develop and implement interventions on the care plan to prevent pressure injuries, which would include turn Resident 3 every two hours. DON stated there were no interventions on the care plan to turn Resident 3 every two hours. During an interview on 1/29/26 at 6:55 p.m. with DON, DON stated Resident 3 was admitted with no pressure injuries and acquired a Stage III pressure injury at the facility (on 1/9/26). During a concurrent interview and record review on 1/29/26 at 6:56 p.m. with DON, Resident 3's "Comprehensive CNA Shower Review (SR)," dated 12/26/25, 12/30/25, 1/2/26, 1/6/26, 1/9/26, 1/13/26, and 1/20/26 were reviewed. DON stated staff give the resident showers twice a week and during every shower staff should complete and document a skin assessment (condition of the skin - note any broken skin, bruises, rash, cuts, discolorations, reddened areas) on the SR. DON stated the SRs reviewed were inaccurate and incomplete. The SRs on 1/9/26, 1/13/26 and 1/20/26 did not indicate the skin issues to Resident 3's sacral coccyx area which was identified on 1/9/26. DON stated SRs were not conducted per her expectations. During a record review of Resident 3's Nursing WA, dated 1/6/26, the WA did not identify any skin conditions to the sacral coccyx area. During a review of the facility's policy and procedure (P&P) titled, "Pressure Ulcer Prevention" dated November 2017, the P&P indicated, "Purpose To identifying residents at risk for skin breakdown, implement measures to prevent and/or manage pressure ulcers and minimize complications. Policy The facility will identify residents at risk for pressure ulcers and provide care and services to promote the prevention of pressure ulcer development. II. Plan of Care: A. The Licensed Nurse will develop a Care Plan specific to the resident's risk factors such as moisture control, pressure reduction, positioning, mobility, and nutrition. . . B. Nursing staff will monitor interventions for effectiveness and resident tolerance. C. The Care Plan will be revised as indicated. III. Ongoing Monitoring: A. CNAs will inspect the resident's skin during ADL [Activities of Daily Living] care and report unusual findings to the Licensed Nurse. B. CNAs will complete body checks on residents' shower days and report unusual findings to the License Nurse." During a review of the facility's P&P titled, "Showering a Resident," dated November 2017, the P&P indicated, "XVI. Report any broken skin, bruises, rashes, cuts, skin discoloration or reddened area to the Charge Nurse." During a review of the facility's P&P titled, "Care and Services," dated November 2017, the P&P indicated, "Purpose To ensure through an interdisciplinary team (IDT) process, that all residents receive the necessary care and services based on an individualized comprehensive assessment process. Residents are provided with the necessary care and services to maintain the highest level of practicable functioning in an environment that enhances quality of life in the scope of a long-term care facility." In violation of the above cited standards, the facility failed to accurately complete the Braden Scale, "Check and Change" the resident, implement and/or revise the care plan, and accurately complete the SR for Resident 3 which resulted in the resident developing a facility acquired stage III pressure injury. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and represents a Class "A" citation.