Health inspection·October 15, 2025

The following reflects the findings of the California Department of Public Health during an investigation of one complaint.  Complaint number: 2589093 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. State B citation 230022493 was written for complaint number 2589093 at §483.25(b)(1) §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. This REQUIREMENT is NOT MET as evidenced by: On 8/20/25 at 10:20 am, an unannounced visit was conducted at the facility to investigate a complaint regarding pressure ulcers. Resident 1 was admitted to the facility on 7/2/25 with a diagnosis of a fractured sacrum (a boney prominence at the base of the spine). Resident 1 had no pressure injuries (PI, Injury to skin and underlying tissue resulting from prolonged pressure on the skin) at the time of admission. On 7/24/25, the facility identified that Resident 1 had developed a PI over the sacrum, which progressively worsened over a period of six days. Despite this change, the facility did not follow its policies regarding wound care and changes in condition and failed to notify Resident 1’s attending physician when the PI worsened. This failure to provide timely and appropriate wound care interventions and physician oversight contributed to the progression of Resident 1’s pressure injury to a Stage 4 PI (a full-thickness loss of skin and tissue with exposed muscle, tendon, or bone in the injury). Within two days of Resident 1 discharging from the facility, she was admitted to an acute care hospital for an infected PI and sepsis (an infection in the bloodstream) and osteomyelitis (an infection in the bone) of the sacrum. This failure had the potential to delay wound healing for any resident who had wounds and/or PI's and subject them to substandard quality of care. Findings: Review of the National Pressure Injury Advisory Panel’s (a nationally recognized resource for professionals), website document titled, “NPIAP Pressure Injury and Stages,” at https://npiap.com, dated September 2016 indicated, Stage 1 pressure injury: non-blanchable (skin redness or discoloration that does not fade or turn white when pressure is applied) erythema (reddening of the skin), which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature or firmness may precede visual changes. Stage 2 pressure injury: partial-thickness skin loss with exposed dermis (the middle layer of the skin). The wound bed is visible, pink, or red, moist and may also present as an intact or ruptured serum-filled blister (a raised pocket of skin filled with fluid, caused by skin injury from friction (rubbing), heat, or certain diseases). Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue may be visible (a type of new, temporary tissue that forms during the wound healing process). These injuries commonly result from adverse microclimate (temperature and moisture on the skin), and shear in the skin (injury that occurs when skin layers are pulled in opposite directions, damaging tissues, and blood vessels beneath the skin). Stage 3 pressure injury: full-thickness loss of skin, in which adipose is visible in the injury and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. Undermining (the destruction of tissue or injury extending under the skin edges so that the pressure injury is larger at its base than at the skin surface) and tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) may occur. Stage 4 pressure injury: full-thickness loss of skin and tissue with exposed fascia, muscle, tendon, ligament, cartilage, or bone in the injury. Slough or eschar may be visible. Epibole, undermining (tissue separation that creates a pocket of dead space), and/or tunneling often occur. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured (hidden or difficult to see) full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (thick stringy yellow or gray dead tissue or eschar (black, brown or tan scab-like dead tissue attached firmly to the wound). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. According to the NIH National Library of Medicine (a nationally recognized professional resource for healthcare providers), website at www.ncbi.nlm.nih.gov, dated 1/3/2024, the most common problem with Stage 3 and Stage 4 pressure injuries is infection. Bacteria in the pressure ulcer wound spreads to deeper tissues and bone causing sepsis (infection in the bloodstream) and osteomyelitis (infection in the bone). Older patients with pressure injuries have a 3.6-fold increased mortality (death) rate. Managing pressure injuries should always be done with an interprofessional approach such as consulting with a general surgeon, a wound care physician (a physician who specializes in wound care), or a dermatologist (a physician who is an expert on skin care). Review of a facility policy titled, “Change in a Resident’s Condition or Status” revised February 2021, indicated, “1. The nurse will notify the resident’s attending physician or physician on call when there has been a: d. significant change in the resident’s physical/emotional/mental condition.” Review of the admission record for Resident 1 indicated that Resident 1 was admitted to the facility on 7/2/25 with diagnoses that included a fractured (broken) sacrum bone (the large triangular bone at the base of the spine). Resident 1 discharged from the facility, on 8/11/25. Review of Resident 1’s Admission Minimum Data Set (MDS, a standardized assessment that measures the health status in nursing home residents), dated 7/11/25, and completed by MDS/Registered Nurse (MDS/RN), indicated under Section C Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment of a resident's memory and decision-making skills and uses a scoring system of 0-very impaired to 15-no impairment). Resident 1 scored 12 of 15, which indicated Resident 1 had no memory or decision-making problems. Section M indicated Resident 1 was admitted without a PI. Review of Resident 1’s progress note, dated 7/24/25, written by Wound Care Nurse/Registered Nurse (WCN/RN) indicated, “Wound Rounds for week of 7/20/25 – 7/24/25: Late last week noted skin discoloration over sacrum that resembled wounding under wrinkled skin. This week, however, noted discolored areas beginning to break down. Upon closer inspection, characteristics of breakdown resemble Stage 1 pressure injury. Exposed tissue coated with yellow fibrotic residue.” There was no documentation that the WCN/RN notified Resident 1's Attending Physician (AP) of this change in the condition of Resident 1's PI. A review of Resident 1’s progress note, dated 7/25/25, written by Registered Nurse (RN) A indicated, “Wound rounds…Wound looks worse than 3 days ago.” There was no documentation that RN A had notified Resident 1's AP, that Resident 1's PI had worsened. A review of Resident 1’s progress note, dated 7/28/25, written by RN A indicated, “Wound is getting worse.” There was no documentation that RN A had notified Resident 1's AP that the PI had worsened. During a phone interview on 9/9/25 at 2:07 p.m., RN A confirmed that she had not notified Resident 1's AP when there was a change of condition and Resident 1's PI began to worsen. RN A stated that she notified the WCN/RN, instead of Resident 1's AP, because the WCN/RN would decide what changes needed to be reported to the AP. A review of Resident 1’s record titled, “Wound Management Detail Report” dated 7/24/25 to 8/11/25, documented by the WCN/RN indicated the following, On 7/24/25, Resident 1 had a PI on her sacrum that measured (length by width), 6.5 centimeters (cm, 2.5 cm equal approximately 1 inch) by 4 cm and was a Stage 2 with no tract/tunneling present, and a light amount of seropurulent exudate (watery pus that is cloudy, yellow or tan and is a sign of infection), that was yellow, or tan, cloudy and thick. The report had not indicated that Resident 1's AP was notified. On 7/30/25, Resident 1’s sacrum PI worsened to 7 cm by 3.5 cm, and was Unstageable with slough and eschar, no tract/tunneling present and a light amount of seropurulent exudate that was yellow, or tan, cloudy and thick. The report had not indicated that Resident 1's AP was notified of this change from a Stage 2 PI to an Unstageable PI. On 8/3/25, Resident 1’s sacrum PI continued to worsen and measured 7.3 cm by 3.5 cm, and was Unstageable with slough and eschar, no tract/tunneling or undermining present, and a moderate amount of seropurulent exudate (increased seropurulent drainage-a sign that the wound was becoming infected), that was yellow, or tan, cloudy and thick. The report had not indicated that Resident 1's AP was notified. On 8/11/25, the WCN/RN documented that she performed Conservative Sharp Wound Debridement (CSWD, a procedure where dead tissue is removed from a PI by using sharp instruments such as a scalpel, scissors and forceps), on Resident 1's sacrum PI. WCN/RN documented, "CSWD completed…with scissors/forceps, then using forceps with #15 [number 15, the size of a scalpel blade], scalpel blade, sm-mod [small to moderate], amount slough removed.” Documentation reflected that Resident 1's PI then measured, 6 cm by 2.5 cm, and was a Stage 4 with undermining that measured 2.6 cm and a heavy amount of seropurulent exudate (increased sign of infection), that was yellow, or tan, cloudy and thick. There was no documented evidence that Resident 1's AP was notified of the change in the condition of Resident 1's PI, or that CSWD procedure had been done. A review of a facility document titled, “Physician Notification & Orders” dated 7/30/25, indicated that six days after Resident 1's PI was determined to be a Stage 2 (identified on 7/24/25), AP was notified but at that point, on 7/30/25, Resident 1's PI had already worsened to an Unstageable PI. There were no other Physician Notification & Orders notification documents for Resident 1. During a concurrent interview and record review of Resident 1’s record titled, “Physician Order Report: 7/2/25 -8/20/25” on 8/20/25 at 2:38 p.m., with the Director of Nursing (DON), the DON confirmed that there was a six-day delay, from 7/24 to 7/30/25, in notifying Resident 1's AP and getting orders for treatment and during that time, Resident 1's PI had worsened from a Stage 2 to an Unstageable PI. DON confirmed that RN A should have notified Resident 1's AP on 7/24/25, when she identified that Resident 1's PI was worsening. DON confirmed that the WCN/RN had not notified Resident 1's AP when she identified that Resident 1's PI had progressed from a Stage 2 to an Unstageable PI and finally to a Stage 4. During an interview on 8/22/25 at 10:33 a.m., with WCN/RN, the WCN/RN confirmed that Resident 1 was admitted without a PI. WCN/RN confirmed that Resident 1 acquired a Stage 2 PI while in the facility on 7/24/25, and the PI was not healing and worsened to a Stage 4 within 18 days. WCN/RN confirmed that she had not reached out to Resident 1's AP at any time during the deterioration of Resident 1's PI, to consider referring Resident 1 to their wound care physician for an evaluation and stated she did not think it was necessary. WCN/RN confirmed that RN A should have notified Resident 1's AP when she determined that Resident 1's PI was worsening on 7/24/25, instead of waiting for WCN/RN to make her weekly visit, because this delayed treatment. WCN/RN confirmed Resident 1's PI had already deteriorated from a Stage 2 to an Unstageable PI by the time her AP was notified, and orders were obtained for treatment. During a second interview on 9/9/25 at 9:42 a.m., with WCN/RN, the WCN/RN confirmed that she had not obtained a physician's order to perform the CWSD on Resident 1's PI on 8/11/25. WCN/RN stated she did not need a physician’s order to perform CSWD. The WCN/RN stated she could not recall whether or not she had notified Resident 1's AP each time Resident 1's PI worsened and was not showing signs of healing or that the PI was possibly infected. WCN/RN stated that she did not have direct communication with Resident 1's AP. During a phone interview on 8/22/25 at 10:47 a.m., with Resident 1's AP, AP confirmed the facility had a wound care physician available that they could consult with. AP stated, "I believed that [Resident 1’s] wound care was very routine, and she did not need to see wound care physician." The AP indicated she thought Resident 1 still had a Stage 2 PI. During a second phone interview on 9/9/25 at 1:01 p.m., with AP, she indicated that she did not know about the progressive worsening and lack of healing to Resident 1’s PI. AP stated that WCN/RN and DON do not usually notify her unless they need her to do something. AP confirmed she had not given specific orders to WCN/RN to perform a CSWD procedure. AP stated she, “had no clue” that nursing staff had identified Resident 1's PI was worsening and not healing. AP stated if she had known there were problems with worsening or lack of healing to Resident 1’s sacrum PI, she would have referred her to their wound care physician for an evaluation. A review of Resident 1’s acute care hospital records, dated 8/13/25, indicated that Resident 1's family had taken her to a local hospital on 8/13/25, two days after Resident 1 had left the facility, because Resident 1's PI was not healing and had a bad smell. The hospital's Admission Note, dated 8/13/25, reflected that Resident 1 had sepsis and osteomyelitis of the sacrum, from her PI being infected. Resident 1 passed away at that hospital 10 days later. In violation of the above cited standards, the facility failed to ensure that Resident 1 received care consistent with professional standards of practice to prevent pressure injuries. The facility failed to notify the physician of changes in the resident’s condition and failed to obtain appropriate treatment orders. This violation had a direct and immediate relationship to the health and safety of the residents.