Health inspection·August 20, 2025

F 0686 Level of Harm - Actual harm Residents Affected - Few Nursing (DON). During an interview on 8/19/25 at 2:34 p.m. with the DON, the DON stated Resident 1's left heel pressure injury was acquired at the facility. The DON stated on 6/3/25, when staff noticed Resident 1's pressure injury, it was a dark black color. The DON stated it was not typical for a resident to develop a pressure injury 31 days after admission. During a concurrent interview and record review on 8/20/25 at 10:42 a.m. with the Licensed Vocational Nurse (LVN) 1, Resident 1's Nurse's Note (NN), dated 5/3/25, was reviewed. The NN indicated Resident 1 was admitted to the facility on [DATE] from an acute care hospital for a left femur (the bone of the?thigh) fracture. LVN 1 stated Resident 1 was pretty immobile (not able to move) at the time of his admission. LVN 1 stated Resident 1, stayed in bed, afraid to get up due to his fall at home.During a concurrent interview and record review on 8/20/25 at 10:45 a.m. with LVN 1, Resident 1's Advanced Skilled Evaluation (ASE), dated 5/4/25, was reviewed. The Advanced Skilled Evaluation indicated Resident 1's skin was .warm and dry, skin color WNL (within normal limits) . LVN 1 stated Resident 1 had no issues noted with his skin on admission other than his surgical site. LVN 1 stated the ASE's were done daily and were a head-to-toe assessment. During a concurrent interview and record review on 8/20/25 at 10:50 a.m. with LVN 1, Resident 1's ASE, dated 6/1/25, was reviewed. The (ASE) indicated Resident 1's skin was . warm and dry, skin color WNL . LVN 1 stated Resident 1 had no issues noted with his skin on 6/1/25.During a concurrent interview and record review on 8/20/25 at 10:55 a.m. with LVN 1, Resident 1's Nurse's Note, dated 6/3/25, was reviewed. The Nurse's Note indicated, Note Text: writer was notified that resident had a sore on his left heel . writer assessed . noted a large dark red sore to left heel measuring 5cm x 5cm (centimeters - a metric unit of length) . open area around the edges of the sore and clear drainage. LVN 1 stated she was the writer of the Nurse's note. LVN 1 stated she was notified of Resident 1's pressure injury by a CNA. LVN 1 stated she thought that a CNA noticed Resident 1's pressure injury while they were changing his socks.During a concurrent interview and record review on 8/20/25 at 11 a.m. with LVN 1, Resident 1's Initial Wound Evaluation & Management Summary, dated 6/5/25, was reviewed. The Initial Wound Evaluation & Management Summary indicated, Stage: Unstageable DTI (deep tissue injury damage to the muscles, fat, or other underlying tissues that occurs while the outer skin still looks intact, often appearing as a bruise-like discoloration) with intact skin . Skin: intact with purple/ maroon discoloration . Electronically signed by: [Wound Doctor]. LVN 1 stated a DTI is a pressure injury that starts underneath the skin. LVN 1 stated a DTI develops over time, because of pressure. LVN 1 stated Resident 1 would not have developed a DTI between his last Advanced Skilled Evaluation on 6/1/25 and 6/3/25 when the pressure injury was noticed by a CNA. LVN 1 stated Resident 1's pressure injury should have been evident prior to 6/3/25. LVN 1 stated she looks at residents' bony prominences when doing the Advanced Skilled Evaluations. LVN 1 stated the heel is considered a bony prominence and should be checked for redness or other signs of a pressure injury LVN 1 stated it was difficult to observe and complete an assessment of Resident 1's heels due to his hip surgery. LVN 1 stated Resident 1's heels should have been checked during repositioning and showers. LVN 1 stated it is important to check bony prominences to prevent pressure injury. LVN 1 stated Resident 1 could have experienced a prolonged rehabilitation due to his pressure injury. LVN 1 stated that she expected CNAs to look thoroughly at residents' skin during repositioning and shower times and notify the nurse of any skin changes. During an interview on 8/20/25 at 11:21 a.m. with CNA 1, CNA 1 stated the shower assessment form was called a Skin Monitoring: Comprehensive CNA Shower Review. CNA 1 stated the Skin Monitoring: Comprehensive CNA Shower Review form prompted the CNAs to look at residents' heels and other bony prominences. CNA 1 stated these areas are looked at to identify any pressure injuries. During an interview on 8/20/25 at 11:45 a.m. with the DON, the DON stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555347 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555347 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete nurse should have looked for redness and changes in skin color, or texture, when doing Resident 1's skin assessments. The DON stated the nurse should have looked at areas more prone to pressure during their assessments, which included Resident 1's heels. The DON stated a DTI occurs over time and is the result of prolonged pressure. The DON stated a DTI would not develop overnight. The DON stated the CNAs and nurses should have noticed Resident 1's pressure injury prior to 6/3/25. The DON stated CNAs should have noticed any skin changes for Resident 1 during shower times or repositioning. The DON stated nurses should have identified skin changes for Resident 1 during assessments. The DON stated she expected the CNAs and nurses to look at bony prominences for signs of pressure injury. The DON stated Resident 1's pressure injury could take a long time to heal due to his medical history of type 2 DM which causes wounds to heal slowly. The DON stated the facility should have identified the pressure injury sooner, before it progressed. The DON stated Resident 1 was not admitted to the assistive living facility due to his stage 3 pressure injury. During an interview on 8/20/25 at 12:33 p.m. with the Administrator (ADM), the ADM stated pressure injuries should be prevented in the facility. The ADM stated staff should have assessed residents' skin before a pressure injury developed. The ADM stated that staff should have been more careful in identifying pressure injuries for Resident 1 since he was immobile due to hip surgery and because of his type 2 DM. During a review of Resident 1's Skin Monitoring: Comprehensive CNA Shower Review (CSR), dated 6/2/25, the CSR indicated, .Resident: Resident 1 . Perform a visual assessment of a resident's skin when giving the resident a shower . Use this form to show the exact location and description of the abnormality . The CSR indicated Resident 1's heels had no redness or discoloration. During a review of the facility's policy and procedure (P&P) titled, Pressure Injuries Overview, dated January 2018, the P&P indicated, This injury results from intense and/or prolonged (continuing for a long time) pressure . at the bone-muscle interface (junction where muscle tissue connects to bone). During a review of the facility's P&P titled, Repositioning, dated January 2018, the P&P indicated, General Guidelines: Evaluation of a resident's skin integrity after pressure has been reduced (lower pressure on specific body areas) or redistributed (more evenly spread pressure across a larger surface area) should give the development and implementation of repositioning plans . Evaluation: Evaluate the resident for an existing pressure ulcer. During a review of the facility's P&P titled, Shower, dated January 2018, the P&P indicated, Observe the resident's skin for any redness . reddish or blue-gray area of skin over a pressure point . Event ID: Facility ID: 555347 If continuation sheet Page 3 of 3