Health inspection·March 2, 2026

The following reflects the findings of the California Department of Public Health during the recertification survey conducted from January 20, 2026, through January 23, 2026. Event ID: 1E10FB-H1 State Citation Class “B” was written. Regulations: Title 42 of the Federal Code of Regulations: §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. Title 22 California Code of Regulations: §72523. 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. An unannounced recertification survey was conducted on January 20, 2026, through January 23, 2026. Two (2) of two sampled patients (Patients 23 and 4) were reviewed for pressure ulcers (injury to skin and underlying tissues that develop because of prolonged pressure, shear [skin tissues slide in opposite directions when sticks to a surface], or friction). The facility failed to implement their patient care policies when:   1. For Patient 23, there was no documented evidence of wound treatment for Left Iliac Crest (thick, curved bony ridge at the very top of the hip bone), PI (Pressure Injury), change in condition, physician orders for January 7, 2026 through January 16, 2026, IDT meeting (Interdisciplinary Team meeting - a meeting where different professionals come together to discuss a patient’s care) and care plan, to address Patient 23’s unstageable (when the base of the wound is covered by a layer of dead tissue and it is not possible to determine the stage [classifying wounds]) PI prior to January 21, 2026. 2. Patient 4’s moisture associated skin damage (MASD- a condition caused by repeated exposure to bodily secretions such as urine resulting in skin breakdown) had no documented evidence of assessment, monitoring, treatment, and interventions. These failures resulted in Patient 23’s worsening pressure injury left undetected and Patient 4 MASD was left unaddressed, placing both patients at higher risk for infection, development of new pressure ulcers, and delayed wound healing. Findings: 1.During a record review of Patient 23’s “Admission Record” (contains demographic and medical information), it indicated, Patient 23 was admitted to the facility on December 30, 2025, with diagnoses which included, Parkinson’s disease with dyskinesia (a progressive disorder that affects the nervous system, causing involuntary, jerky, or writhing movements) dysphagia (difficulty swallowing), dementia (a condition characterized by the decline mental ability, affecting memory, thinking and language interfering with daily life), heart failure (a condition in which the heart muscle is too weak or stiff to effectively pump enough oxygen). During an observation and interview on January 20, 2026, at 4:00 PM, in Patient 23’s room, with Treatment Nurse 1 and 2 (TX 1 and TX 2), Patient 23 was lying on bed with the eyes open. TX 1 and TX 2 positioned Patient 23 to his right side. There was a brown dressing covering his left iliac crest area (top, outer edge of the left hip bone), undated. TX 1 stated, “we don’t date the dressing when we do treatments,” and proceeded to remove the dressing from Patient 23’s left iliac crest area.  An open wound with black colored edges appeared dry with yellow color slough (a yellowish, soft, stringy, or creamy dead tissue found in wounds) in the center of the wound, was noted. TX 1 stated, Patient 23’s wound was “unstageable with yellow slough in the center and eschar (a thick, dry, black or brown layer of dead tissue that forms over deep wounds or pressure ulcers).”  TX 1 and TX 2 stated they were not sure when the last wound treatment was rendered. TX 1 further stated Patient 23’s wound treatment “was not done today (January 20, 2026).” During a record review of Patient 23’s physician orders, a verbal order dated December 31, 2025, indicated “(Treatment) Left Iliac Crest, PI (Pressure Injury). Cleanse with NS (normal saline - a solution of water with dissolved salts) pat dry apply [name of brand] oint (ointment) and cover w/DD (dry dressing). As needed, may change dressing if soiled/dislodged, every day shift for wound care 14 days.” During a record review of Patient 23’s physician’s orders, dated January 16, 2026, it indicated “(Treatment) Left Iliac Crest, PI. Cleanse with NSS (normal saline solution) pat dry apply small amount of skin barrier (cream to protect the skin) cover with DD X (times) 21 days every day shift for wound management, for 21 days.” During a record review of Patient 23’s “Skin Observation Tool-V2,” the following skin assessments were reviewed: a. December 31, 2025, indicated, “2. Notes… L (left) ILIAC CREST PRESUURE INJURY: DTI (Deep Tissue Injury - soft tissues under intact or broken skin are damaged often appearing as a maroon or purple discoloration) DARK DEEP DISCOLORATION, SKIN INTACT.”  Signed by TX 2 on December 31, 2025. b. January 7, 2026, indicated, “2. Notes: ...L ILIAC CREST PRESSURE INJURY: DTI Deep Tissue Injury - the area often appears as purple or maroon localized, intact skin, or a blood-filled blister) DARK DEEP DISCLORATION, SKIN INTACT.” Signed by TX 2 on January 20, 2026. c. January 13, 2026, indicated, “2. Notes: ...L ILIAC CREST PRESSURE INJURY: DTI DARK DEEP DISCLORATION, SKIN INTACT.” The document was not signed by staff. d. January 20, 2026, indicated, “2. Notes: ...L ILIAC CREST PRESSURE INJURY: UNSTAGEABLE. 90% S (slough), 10% G (granulation – healthy tissue), MILD SEROUS EXUDATE (a thin, clear to pale yellow, watery fluid that leaks from wounds), PERIWOUND (the skin and tissue immediately surrounding a wound) W/DRY EXUDATE. PERIWOUND W/MILD ERYTHEMA (skin redness). ADMITTED WOUND DTI NOW UNSTAGEABLE DUE TO SLOUGH PRESENT TO WOUND BED (base of the wound). TX (treatment): [name of brand] + DD (dry dressing) DAILY. SIGNED 01/20/2026 (January 20, 2026). During a record review of Patient 23’s Braden scale assessment (tool used to predict the risk for developing pressure ulcers, categorized as: score of 19–23 (No risk), 15–18 (Mild risk), 13–14 (Moderate risk), 10–12 (High risk), and less than 9 (Severe risk)), dated December 31, 2025, it indicated, Patient 23 had a Braden score of 9, placing him at severe risk for pressure sore development. During a concurrent interview and record review on January 20, 2026, at 4:28 PM, with interim Director of Nursing (DON) and TX 2. DON and TX 2 reviewed Patient 23’s Treatment Administration Record (TAR - a legal document used to document the specific treatments and medications administered to a Patient), for the month of January 2026.  The TAR indicated, a treatment order for January, “(Treatment) Left Iliac Crest, PI (Pressure Injury). Cleanse with NS (normal saline) pat dry apply [name of brand] oint (ointment) and cover w/DD (dry dressing) every day shift for wound care for 14 days. “Start date 01/01/2026 (January 1, 2026) D/C (discontinue) date 01/06/2026 (January 6, 2026).”   The treatment order was initiated again on January 17, 2026. The DON stated there was no treatment order for January 7 through January 16, 2026, he was not sure why. DON further stated, he was not sure why Patient 23’s TAR had missing initials that indicated wound treatment was done, on January 7, 2026, through January 16, 2026. TX 2 stated, treatment for Left Iliac Crest, PI was done on January 17, 18, and 19. TX2 stated, she (TX2) did the treatment on January 17, 2026, but did not write the description of the wound. TX 2 further stated she does not document description of the wound every time she renders patients’ treatments and only checks the box indicating she did the treatment, with her initials. The DON further stated, “we only do skin assessment and wound description and document it weekly,” and after each wound treatment, the treatment nurse only write the initials to show treatment was done for that date. During a concurrent interview and record review on January 21, 2026, at 11:40 AM, with Assistant Director of Nursing (ADON) and TX 1. ADON and TX1 reviewed Patient 23’s TAR for the month of January 2026. The TAR indicated, “(Treatment) Left Iliac Crest, PI (Pressure Injury). Cleanse with NS (normal saline) pat dry apply [name of brand] oint (ointment) and cover w/DD (dry dressing) every day shift for wound care for 14 days. “Start date 01/01/2026 (January 1, 2026) D/C (discontinued) date 01/06/2026 (January 6, 2026).” The ADON stated the order started on January 17, 2026.  TX1 stated she did not know why there was no treatment rendered from January 7, 2026, to January16, 2026. In addition, ADON and TX 1 could not provide documented evidence that Patient 23’s care plan, change of condition and IDT notes that address unstageable left Iliac Crest wound, was initiated before January 20, 2026. TX 1 acknowledged there was no care plan, change of condition documented, and IDT to address Patient 23’s Left iliac Crest unstageable wound. During a concurrent interview and record review on January 21, 2026, at 11:45 AM, with ADON and TX 1, the ADON and TX 1 reviewed the facility’s policy and procedures (P&P) titled, “Wound Care/Skin Management,” revised October 2010, the P&P indicated “… Steps in the procedure…13. Dress wound. Pick up sponge with paper and apply directly to area. Mark tape with initials, time, and date and apply to dressing… Documentation… The following information should be recorded in the Patient’s medical record… 6. All assessment data (i.e., wound bed color, size, drainage, description of skin impairment, etc.) obtained when inspecting the wound/skin.” TX 1 stated, she (TX 1) does not write the description of wounds during daily treatment, only weekly, and documented on the “Skin Observation Tool-V2.”  TX 1 further stated, “We don’t date the dressing on the wound”. The ADON stated, if the policy stated, the wound dressing should be dated. ADON further stated, “I thought we only have to do skin assessment once a week.”  ADON acknowledged the policy. During a concurrent interview and record review on January 23, 2026, at 9:38 AM, with the Administrator (ADMIN) and DON, the ADMIN and DON reviewed the facility policy and procedures (P&P) titled, “Wound Care/Skin Management,” revised October 2010. The P&P indicated, “… Steps in the procedure…13. Dress wound. Pick up sponge with paper and apply directly to area. Mark tape with initials, time, and date and apply to dressing… Documentation… The following information should be recorded in the Patient’s medical record… 6. All assessment data (i.e., wound bed color, size, drainage, description of skin impairment, etc.) obtained when inspecting the wound/skin.” The DON acknowledged the policy and stated it had not been followed. ADMIN stated staff should be following the facility policy.  The DON acknowledged there were no documented treatments for January 7, 2026, through January 16, 2026, and there was no change in Patient 23’s condition, IDT meeting notes and care plan documentation before January 20, 2026.  The DON further stated that treatment nurses are responsible for renewing treatment orders and informed the physician about Patients’ wounds change in condition. 2. During a review of Patient’s 4 “Admission Records” indicated, Patient 4 was admitted to the facility on September 23, 2025, with diagnoses which included pressure ulcer of sacral region (at the bottom of the spine), stage 4 (a wound involving full-thickness tissue loss where skin, fat, and deeper tissues are gone, exposing underlying muscle, tendon, or bone), sepsis (a life threatening medical emergency caused by the body’s extreme response to an infection), and neuromuscular dysfunction of bladder (a dysfunction of the bladder muscle resulting in an inability to properly store or empty urine). During a review of Patient’s 4’s clinical records, the “Physician Note” (contains history and physical information), dated September 24, 2025, it indicated Patient 4 “does not have capacity to make and understand medical decisions.” During a review of Patient’s 4 “Braden scale for predicting pressure sore risk,” dated August 28, 2025, it indicated Patient 4 was at a high risk for developing pressure sore with a score of 11 out of 18 (range for high risk is 10-12). During a concurrent observation and interview on January 22, 2026, at 9:54 AM, with the wound treatment nurse (TX 1) and a Certified Nursing Assistant (CNA 1), Patient 4 was lying in bed. The TX 1 and CNA 1 turned Patient 4 to his left side. Patient 4 had a wound vacuum (tool used to suction drainage from a wound) attached to his sacral region (tailbone). On the left buttock was a foam dressing, the TX 1 removed the dressing and revealed a pink tinged skin wound with dark bruising around the edges. The TX 1 stated it was an MASD and there were wound care orders in place. During a review of Patient 4’s clinical records, the document titled “Section M-Skin Conditions” (Patient assessment instrument that gathers information regarding a Patient’s skin integrity),” dated November 28, 2025, the section M-skin conditions indicated “… M1040: Other ulcers, Wounds, and Skin Problems… H. Moisture Associated Skin Damage (MASD) (e.g., incontinence-associated dermatitis - (IAD - skin damage, caused by prolonged exposure to urine, feces, or both), perspiration, drainage)” was checked. During a review of Patient 4’s clinical records, the document “Section GG-Functional Abilities- OBRA (Omnibus Budget Reconciliation Act of 1987 - It requires to conduct comprehensive assessments for all Patients to ensure quality of care, focusing on Patient safety, rights, and proper placement)/Interim,” dated November 28, 2025, section GG-functional abilities indicated Patient 4 is dependent on toileting hygiene and transfers. During a review of Patient 4’s “Skin Observation Tool-V2” dated December 31, 2025, there was no documentation of Patient 4’s MASD on the left buttock. During a review of Patient 4’s “Skin Observation Tool-V2” dated January 07, 2026, there was no documentation of Patient 4’s MASD on the left buttock. During a review of Patient 4’s “Skin Observation Tool-V2” dated January 12, 2026, there was no documentation of Patient 4’s MASD on the left buttock. During a review of Patient 4’s “Skin Observation Tool-V2” dated January 13, 2026, there was no documentation of Patient 4’s MASD on the left buttock. During a concurrent interview and record review on January 23, 2026, at 9:20 AM, with the Assistant Director of Nursing (ADON), Patient 4’s “Change in Condition- SBAR Communication Form - Situation, Background, Assessment, Recommendation, a structured communication tool used in healthcare to quickly and clearly convey critical patient information),” dated January 22, 2026, was reviewed. The SBAR communication form addressing the MASD was started on January 22, 2026. ADON acknowledged the SBAR communication form addressing MASD on Patient 4’s left buttock was not initiated prior to January 22, 2026. During a concurrent interview and record review on January 23, 2026, at 9:22 AM, with the ADON, Patient 4’s “Treatment Administration Record” (TAR- document used to record treatments administered to the Patients) for the month of December 2025, and January 2026, was reviewed. The TAR indicated a treatment order for “left lower buttock MASD: Cleanse w/NS (normal saline-solution used to clean wound), pat dry, apply ointment and cover w/dd (dry dressing), every day shift for wound management for 14 days. The order started on January 22, 2026. The ADON stated there was no treatment order prior to January 22, 2026. During a review of Patient 4’s “Care Plan” dated January 22, 2026, there was no focus, goals, and interventions fo