Health inspection·January 9, 2026

REGULATION VIOLATIONS: Code of Federal Regulations, Title 42, Section §483.25(b)(1)(i)(ii) Quality of Care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: (b) Skin integrity— (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. California Code of Regulations, Title 22, Section §72315(f) Nursing Service – Patient Care (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. California Code of Regulations, Title 22, Section § 72557(a) Equipment and Supplies (a) Equipment and supplies in each facility shall be of the quality and in the quantity necessary for care of patients as ordered or indicated. California Code of Regulations, Title 22, Section §72523(a) Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. FINDINGS: On 12/1/2025, the California Department of Public Health (CDPH) conducted an unannounced recertification survey at the facility and investigated the facility’s lack of pressure injury (damage to skin from pressure) prevention, monitoring and treatment for Patient 30. The facility failed to: 1. Implement their policy and procedure entitled, “Assessment, Prevention and Treatment of Pressure Injuries and Wounds,” to ensure the provision of pressure-injury care, including weekly assessment by the physician or nurse practitioner or more often if clinically indicated. 2. Prevent the formation and progression of decubiti, monitor, and treat Patient 30’s buttocks, which were previously identified as areas of impaired skin integrity and were not monitored for two months. 3. Failed to utilize equipment as indicated in the manufacturer’s instructions when Patient 30’s Low Air Loss mattress (LAL-pressure relieving air mattress) was not set to the accurate weight. As a result, Patient 30 developed three unidentified and untreated wounds: Stage II pressure injury (open sore with a red or pink wound bed) on the left buttock), a Stage II pressure injury and a Deep Tissue Injury (DTI-dark purple spot showing underlying skin damage) on the right buttock. During a review of Patient 30’s Face Sheet (demographics), the Face sheet indicated Patient 30 was admitted to the facility on 8/28/2025 with a diagnosis of type 2 diabetes mellitus (condition when the body cannot use insulin correctly and sugar builds up in the blood). During a review of Patient 30’s "Minimum Data Set (MDS- federally required assessment tool used to guide patient care)," dated 9/3/2025, the MDS indicated Patient 30 required maximum assistance (needing extensive two-person physical help) for all mobility, was dependent on a wheelchair and at risk for developing pressure injuries. The MDS further indicated Patient 30’s BIMS (Brief Interview for Mental Status), score was 9 (score of 9 indicated moderate difficulty with thinking). During a review of Patient 30’s “Impaired Skin Integrity Risk Care Plan,” dated 10/9/2025, the “Impaired Skin Integrity Risk Care Plan” indicated, “Two boils on gluteal area are open… mild redness to surrounding area noted… Monitor the patient’s skin both buttocks and abdomen area noting, color, moisture, texture and temperature, qshift [every shift]…”  During a review of Patient 30’s “Photographic Wound Documentation,” dated 10/10/2025, the “Photographic Wound Documentation” indicated the nurse photographed three open sores to the right buttocks that had deep red wound bed and two areas on the right buttocks that were intact and deep red, that were not included in the assessment, treatments, and interventions. During a review of Patient 30’s “Medication and Treatment Records,” dated October 2025 to December 2025 (two months), the “Medication and Treatment Records” indicated no wound treatment entries or weekly wound assessments after 10/10/2025.  During a review of Patient 30’s full medical record, dated from October 2025 to December 2025 there were no weekly wound assessments by the Physician/Nurse Practitioner. During a review of Patient 30’s “Height/Weight/BMI [body mass index] Record,” [undated], the Height/Weight/BMI Record indicated Patient 30’s weight in November 2025 was 167.8 lbs. (pounds). During a review of the low air loss mattress instructions manual titled, “Proactive Medical Products Operational Manual for Protekt Aire 4000DX…,” [undated], the instructions manual indicated, "System is designed for prevention, treatment and management of pressure ulcers… Press up or down buttons to select the correct patient weight.” During an observation on 12/1/2025 at 2:14 p.m., in Patient 30’s room, Patient 30 was lying flat on his back with an inflated LAL mattress programmed for 400 lbs., despite Patient 30 not weighing 400 lbs. During a concurrent observation and interview on 12/2/2025 at 3:15 p.m. in Patient 30’s room with Patient 30, Patient 30 was lying flat on his back in bed on an LAL mattress. Patient 30 reported having a painful wound on his “bottom” and stated he was not receiving wound care.  During an interview on 12/2/2025 at 3:50 p.m. with Registered Nurse Shift Lead (RNSL) 2, RNSL 2 confirmed Patient 30 required an LAL mattress and that the device must be programmed based on the patient’s actual weight to function correctly. During a concurrent interview and record review on 12/4/2025 at 11:52 a.m. with RNSL 1 who was responsible for overseeing provision of care for all patients on the unit, stated he was unaware that Patient 30 had any pressure injuries to the buttock’s area and confirmed that there were multiple wounds shown in the photograph on 10/10/25 without assessments, treatments and interventions. RNSL 1 further stated each wound should have an individual assessment, treatment and intervention. During a concurrent interview and record review on 12/4/2025 at 3:49 p.m. with Registered Nurse Unit Supervisor (RNUS 1), Patient 30’s full health-record was reviewed. RNUS 1 who was responsible for overseeing provision of care for all patients on the unit, confirmed there were multiple wounds identified on 10/10/25 that did not have wound care assessments and treatments. RNUS 1 stated she was unaware if Patient 30 had pressure injuries. RNUS 1 confirmed that daily RN assessments, weekly wound photographs, and treatment documentation should have been completed for each individual wound.  During a concurrent observation and interview on 12/4/2025 at 3:53 p.m. in Patient 30’s room with Patient 30 and RNSL 2, during a toileting observation with RNSL 2, Patient 30 was noted to have:  * Approximately 1 centimeter (cm- unit of measurement) open sore with a red wound bed with approximately 5 cm of redness to the area around the wound on the left buttock; * Approximately 1.5 cm open sore with a red wound bed with approximately 10 cm of redness to the area around the wound on the right buttock;  * Approximately 1.5 cm deep purple discoloration that was non-blanchable on the right buttock;  Patient 30 stated he developed the wounds from being “stuck in the wheelchair” for long periods. During the observation RNSL 2 stated the open sore with a red wound bed on the left buttock was a stage II pressure injury, the open sore with a red wound bed on the right buttock was a stage II pressure injury and the non-blanchable (skin discoloration that does not fade to white when pressed on) deep purple discoloration was a DTI. RNSL 2 also confirmed there was no previous wound documentation for the three newly identified, untreated pressure injuries. During an interview on 12/5/2025 at 9:24 a.m. with Medical Doctor (MD 1), MD 1 stated he was unaware of the status of Patient 30’s wounds and he did not physically examine Patient 30’s wounds/pressure injuries until the untreated wounds/pressure injuries were discovered on 12/4/25.  During an interview on 12/5/2025 at 4:56 p.m. with Program Director (PD), PD stated she was responsible for record keeping of wound care and photographs. PD further stated program management did not have a tracking system for monitoring wounds.   During a review of facility’s policy and procedure (P&P) titled, “Assessment, Prevention and Treatment of Pressure Injuries and Wounds,” dated February 2024, the P&P indicated, “All patients shall have an assessment of the condition and integrity of their skin… the assessment shall be conducted… as clinically indicated… the RN shall assess wound or pressure injury daily… The Physician/Nurse Practitioner shall assess the wound on a weekly basis and more often if clinically indicated… Measure wound weekly to track and measure the progression of healing… inspection and monitoring at least daily when patients are deemed at risk for pressure injury or have an existing impaired skin integrity…PRESSURE INJURY PREVENTION… Conduct a comprehensive skin inspection for those at risk as soon as possible... subsequent inspections and monitoring at least daily when patients are deemed at risk for pressure injury or have an existing impaired skin integrity.” The facility’s lack of pressure injury (damage to skin from pressure) prevention, monitoring and treatment for Patient 30: 1.Implement their policy and procedure entitled, “Assessment, Prevention and Treatment of Pressure Injuries and Wounds,” to ensure the provision of pressure-injury care, including weekly assessment by the physician or nurse practitioner or more often if clinically indicated. 2.Prevent the formation and progression of decubiti, monitor, and treat Patient 30’s buttocks, which were previously identified as areas of impaired skin integrity and were not monitored for two months. 3.Failed to utilize equipment as indicated in the manufacturer’s instructions when Patient 30’s Low Air Loss mattress (LAL-pressure relieving air mattress) was not set to the accurate weight. As a result, Patient 30 developed three unidentified and untreated wounds: Stage II pressure injury (open sore with a red or pink wound bed) on the left buttock), a Stage II pressure injury and a Deep Tissue Injury (DTI-dark purple spot showing underlying skin damage) on the right buttock. 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.