Health inspection·September 24, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care in accordance with professional standards of practice to prevent pressure ulcers (PU- a localized injury to the skin and underlying tissues) for one of four residents (Resident 1) when licensed nurses assessed Resident 1 upon admission on [DATE] and were aware of the Resident 1's high risk for pressure ulcers and did not implement effective interventions to prevent pressure ulcers such as changes for size, dimension, weekly description. Resident 1 was assessed to have a stage 2 (a partial-thickness skin injury that involves damage to the epidermis (outer layer of skin) and extends into the dermis (middle layer of skin) pressure ulcer on 5/5/25 and nurses did not implement interventions to prevent wound progression.Resident 1 was diagnosed by a wound specialist physician with an unstageable (a type of pressure injury where the depth of the wound cannot be determined because it is covered by slough or eschar. Slough is yellow, gray, or green dead tissue, while eschar is a hard, black or brown crust that covers the wound.) pressure ulcer on 6/9/25 and required wound vacuum (wound vac-medical device that uses suction to promote wound healing) for healing. These failures resulted in an avoidable Stage 2 pressure ulcer to left buttocks and shearing (a type of skin damage that occurs when tissue layers are pulled in opposite directions, causing them to separate) to the right buttocks that progressed to two avoidable Stage 4 (a severe form of pressure injury that involves full-thickness tissue loss, exposing bone, tendon, or muscle) pressure ulcers (left and right buttocks), suffering, pain and loss of mobility. Resident 1 stated because of the pressure ulcers he acquired, he did not feel the facility acted promptly in providing the care he needed to improve, which caused him to limit his rehabilitation because he was concerned about his wounds. Resident 1 made the decision to be discharged home on 8/8/25 with wound care and wound a vac because he was not accepted at another facility due to his wounds. Resident 1 experienced psychosocial harm when he felt hopeless in his recovery and did not feel the facility addressed his psychosocial needs and quality of care. During a review of Resident 1's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission record indicated, Resident 1 was admitted from the general acute care hospital to the facility on 5/2/25. Resident 1 has a history that includes but not limited to cervical vertebral fracture with surgical intervention(a break in one or more of the seven vertebrae (bones) that make up the neck that required a surgical procedure to repair and stabilize structure), impaired/decrease mobility (a limitation in the independent and purposeful movement of the body or one or more extremities), idiopathic peripheral autonomic neuropathy (damage to the nerves that control automatic bodily functions, such as heart rate, blood pressure, digestion, and bladder function), ankylosing spondylitis (a chronic inflammatory disease that primarily affects the spine), cirrhosis of the liver (disease characterized by the formation of scar tissue (fibrosis) that replaces healthy liver cells), Residents Affected - Few Page 1 of 5 555652 555652 09/24/2025 Willow Creek Healthcare Center 650 W. Alluvial Clovis, CA 93611

F 0686 Level of Harm - Actual harm Residents Affected - Few muscle weakness (a decreased ability of muscles to generate force or contract effectively), and neuromuscular dysfunction of the bladder (nerve damage to the brain, spinal cord, or peripheral nerves disrupts the coordination between the nerves and muscles needed to store and empty urine).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive (the process of acquiring knowledge and understanding through thought, experience, and the senses) and physical function) assessment dated [DATE], Resident 1's MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 15 out of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating no cognitive impairment.During an interview and observation on 8/4/25 at 3:45 p.m., with Resident 1, Resident 1 was observed up in his wheelchair with a wound vac attached along the side of the wheelchair, Staff wheeled Resident 1 to a private area at his request for the interview. Resident 1 stated he was not comfortable discussing his care with the facility staff around because he stated he had concerns with the care he received. Resident 1 stated, he came into the facility with hopes of rehabilitating. Resident 1 stated he wanted to go home after he improved with physical therapy but stated that it did not occur in the facility because he was concerned about his wounds which he felt interfered with his physical therapy. Resident 1 stated, the facility delayed treating his wounds to his buttocks which caused him to lose hope for his recovery and interfered with his physical therapy and rehabilitation. Resident 1 stated, he mentally, physically and emotionally has declined since his arrival into the facility. Resident 1 stated the care he received did not meet his expectations for care and rehabilitation. Resident 1 stated, he came into the facility without any wounds and now has plans to discharge home with two wounds to his buttocks and a wound vac (medical device that uses suction to promote wound healing) in place. Resident 1 felt the facility should have taken actions once his wounds were initially identified to prevent them from getting worse and to work on healing them. Resident 1 stated he was told he could not go to another facility for rehabilitation because other facilities denied him due to his wounds. Resident 1 stated his wounds had limited his ability to receive further physical therapy. Resident 1 stated I came here for therapy the wounds have affect me enough where I can't do therapy to get better. I will refuse therapy because of my wounds, yes, they will give me pain medications, but I don't feel like going. I came to do therapy, I didn't come here to get wounds. Resident 1 stated he had a meeting with the facility leadership regarding his concerns, and he was told things would get better but remained the same.During a review of Resident 1's electronic medical record admission Summary Note, dated 5/2/25, the admission Summary Note indicated Resident 1 did not have any open skin areas to his buttocks.During a concurrent interview and record review on 9/24/25 at 10:30 a.m., with the Director of Nurses (DON), Resident 1's electronic medical record, Skin/Wound Note, dated 5/5/25, and IDT (IDT-a collaborative group of healthcare professionals and other relevant individuals who work together to plan, coordinate, and deliver care for a patient or resident) Note dated 5/16/25 were reviewed. The Skin/Wound Note on 5/5/25 indicated, . Primary medical provider reassessed skin and noted stage 2 PU to left buttocks. The DON stated, the IDT Note dated 5/16/25 indicated the wound was present on admission but that was not accurate. The DON stated the wound was observed three days post admission. The DON stated there were no facility records indicating it was identified on admission. The DON stated that the pressure ulcer found on 5/5/25 on Resident 1's left buttocks was a facility acquired. The DON stated Resident 1 had the standard interventions implemented on admission for all residents which included baseline labs and turning and repositioning. The DON stated wound treatment for Resident 1's left buttock started on 5/5/25 and was measured on 5/5/25 as 2 cm x 2 cm 555652 Page 2 of 5 555652 09/24/2025 Willow Creek Healthcare Center 650 W. Alluvial Clovis, CA 93611

F 0686 Level of Harm - Actual harm Residents Affected - Few (centimeters (cm)a unit of measurement) the wound was measured on 5/16/25 and 5/22/25 with the same measurements. The DON stated the next measurement was not until 6/9/25 when the wound specialist completed an assessment and Resident 1's left buttock wound measured 4.5 cm x 3 cm and a second wound on the right buttock measuring 5 cm x 3 cm was identified. The DON stated the treatment nurse should follow professional standards for wound care and should have been documenting any changes for size, dimension, and description every week and as needed during daily treatments for Resident 1. The DON stated, because Resident 1 had a specific insurance group she did not initiate a wound consultation with a facility wound specialist until 6/9/25.During a concurrent interview and record review on 9/24/25 at 11:30 a.m., with the licensed vocation nurse (LVN 1), Resident 1's electronic medical record, Skin & Wound Evaluation, dated 5/5/25,5/16/25,5/22/25 and 6/9/25 were reviewed. The Skin & Wound Evaluation on 5/5/25 indicated, .stage 2 PU to left buttocks 2cm x 2cm. on 5/16/25 .stage 2 PU to left buttocks 2cmx2cm. on 5/22/25 .stage 2 PU to left buttocks 2cmx2cm. on 6/9/25 .left buttocks PU unstageable 4.5x3cm and right buttocks shearing 5cmx3cmx0.1cm. LVN 1 stated she is the facility treatment nurse and her roles and responsibilities include measuring residents' wounds weekly in order to identify if wounds are healing and treatment is appropriate. LVN 1 stated Resident 1's wound measurements were not conducted from 5/23/25 to 6/9/25 per professional standards that the facility follows. LVN 1 stated it would have been difficult to determine if Resident 1's wound was healing without an accurate assessment and measurement. LVN 1 stated she did not measure Resident 1's wounds weekly and missed it. LVN 1 stated from the measurement taken on 5/22/25 to wound specialist assessment on 6/9/25 new shearing was found on Resident 1. LVN 1 stated on 6/6/25 during assessment with Resident 1's primary care provider identified a second wound, and it was not measured. LVN 1 stated no staff documented any measurement changes from 5/23/25 to 6/9/25. LVN 1 stated it was not until the facility wound specialist assessed Resident 1 that additional wound measurements were conducted. LVN 1 stated the wound specialist assessed Resident 1 as having an unstageable PU to left buttock and a shearing to the right buttock. LVN 1 stated she is not wound certified but was trained by a previous wound nurse. LVN 1 stated in her new role as a treatment nurse she did not realize she missed the measurements for Resident 1. LVN 1 stated it is important to relay detailed information concerning wounds to a resident's primary care physician or wound specialists to identify further needs for each resident, this did not occur for this Resident 1 and his wounds worsened.During a concurrent interview and record review on 9/24/25 at 1:50 p.m., with the licensed vocation nurse (LVN) 2, Resident 1's electronic medical record, admission Summary Note, dated 5/2/25, was reviewed. LVN 2 was the admitting nurse for Resident 1. The admission Summary Note indicated, LVN 2 completed a full body assessment of Resident 1 on 5/2/25. LVN 2 stated he documented two surgical sites (chest and neck) on Resident 1. LVN 2 stated there was no visible skin breakdown to Resident 1's buttocks. LVN 2 stated that he is knowledgeable in wound care and is certified from an wound care certification program and would be able to identify the presence of pressure ulcers or injuries. LVN 2 stated, Resident 1's Braden scale (used to predict a patient's risk for developing pressure injuries: 19-23 No Risk, 15-18 Mild Risk, 13-14 Moderate Risk, 10-12 High Risk, and 9 or less Severe Risk) score was 17 which indicated resident was at mild risk for skin breakdown. LVN 2 stated, standard interventions used for Resident 1 included turning and repositioning every two hours, and baseline labs.During a concurrent interview and record review on 9/24/25 at 2:03 p.m., with the licensed vocation nurse (LVN) 3, Resident 1's electronic medical record, Skin & Wound Evaluation, dated 5/5/25,5/16/25,5/22/25 and 6/9/25 was reviewed. LVN 3 stated she was not aware that Resident 1 was admitted with any pressure ulcers. LVN 3 stated during the weeks of 5/26/25 to 6/7/25 she worked two times on the floor as the fill in treatment 555652 Page 3 of 5 555652 09/24/2025 Willow Creek Healthcare Center 650 W. Alluvial Clovis, CA 93611

F 0686 Level of Harm - Actual harm Residents Affected - Few nurse and, there was no instruction indicating she was required to or that it was necessary to measure Resident 1 wounds. LVN 3 stated, she was not aware that the usual wound specialist was not overseeing the wound care for Resident 1 per the facilities (professional) standards. LVN 3 stated she assumed that all wounds were measured and accounted for every Monday by the full-time treatment nurse. LVN 3 stated she did not measure Resident 1 wounds on the days she covered for the full-time treatment nurse. LVN 3 stated because she used her naked eye to assess Resident 1's wounds she believed there was not a change of condition. LVN 3 stated wounds require measurement and detail explanation of appearance, to communicate to physicians. LVN 3 stated, since Resident 1 developed two different pressure ulcers at the facility, she would consider the standard interventions that were put into place inadequate and insufficient based on the needs of Resident 1. LVN 3 stated it is the responsibility of staff to assess skin.During an interview on 9/24/25 at 2:25 p.m., with the DON. The DON stated Resident 1's skin was assessed for the first time on 6/9/25 by the wound specialist. The DON stated Resident 1 wound assessments included two separate PUs to left and right buttocks The DON stated Resident 1's wound to the left buttock was 4.5cmx3cm and newly identified wound to the right buttock measured 5cmx3cmx0.1cm. The DON stated both wounds identified on 6/9/25 were facility acquired pressure ulcers. The DON stated, the treatment nurse failed to follow professional standards for wound care. The DON stated the required weekly assessments included gathering information to identify wound stages, drainage, and measurement of wounds which are used to communicate to the physician. The DON stated it is the expectation of the facility that professional standards of care for wounds are followed by staff. The DON stated that when wounds develop at the facility it means the interventions put into place were not sufficient. The DON stated that the facility failed to maintain the skin integrity of Resident 1 during his length of stay and limited his ability to receive physical therapy. The DON stated Resident 1 had expressed his concerns to her about his wounds interfering with his rehabilitation.During a review of Resident 1's electronic medical record Physical Therapy Missed Visit Details, dated 8/5/25, was reviewed. The Physical Therapy Missed Visit Details indicated, Resident 1 refused treatment because he was more concerned about his wounds at this time and doesn't wish to partake in physical therapy. During a review of the facilities job description manual titled, Treatment Nurse dated Feb. 2024, the job description indicated, . provide primary care to the resident under the medical direction and supervision of the residents attending physician, the DON or the Medical Director of the facility, with an emphasis on treatment and therapy of skin disorders .make written and oral reports/recommendations to the attending physician, Medical Director, or the DON concerning the status and care of the residents .work with the interdisciplinary care plan team in developing comprehensive assessment and care plan for assigned residents . provide written and/or oral status reports of residents that you are treating .evaluate and implement recommendations .identify, manage and treat specific skin disorders . provide assessment and diagnosis services to the resident .ensure that residents with decubitus ulcers (localized areas of skin damage that occur due to prolonged pressure on the body) receive appropriate prophylaxis (any measure taken to prevent disease, rather than treat it once it has occurred) and treatment daily, inspection, turning and activity .During a review of the facility policy and procedure (P&P) titled, Wound Care dated [DATE], the policy and procedure indicated, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. review the residents care plan to assess for any special needs of the resident.obtain equipment and supplies necessary.documentation in residents medical record.type of wound.date and time wound care provided.any change.all assessment data obtained when inspecting wound. problems or complaints by the resident.report other information in accordance with facility policy and 555652 Page 4 of 5 555652 09/24/2025 Willow Creek Healthcare Center 650 W. Alluvial Clovis, CA 93611

F 0686 Level of Harm - Actual harm Residents Affected - Few professional standards of practice.During a review of the facility policy and procedure (P&P) titled, Pressure Ulcers/Skin Breakdown- Clinical Protocol dated April 2018, the policy and procedure indicated, .The nurse shall describe and document/report the following: Full assessment of pressure sore including location, stage, length and depth, presence of exudates (fluid that leaks from blood vessels into surrounding tissues or cavities, rich in protein, cells, and solid materials) and necrotic tissue (dead or dying tissue).the staff.will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions.the physician will evaluate and document the progress of wound healing- especially for those with complicated, extensive, or poor-healing wounds.the physician will help identify factors contributing or predisposing resident to skin breakdown.the physician will order pertinent wound treatments, including pressure reducing surfaces, wounds cleaning and debridement (the removal of damaged tissue) approaches, dressings and application of topical agents (a medication or substance applied to a specific area of the body's surface, such as the skin) .when wounds are not healing as anticipated or new wounds develop. current approaches should be reviewed for whether they remain pertinent to the resident medical conditions, are affected by factors influencing wound development or healing and the impact of specific treatment choices.During a review of a professional reference titled, Pressure Ulcer, dated January 2024, retrieved from https://www.ncbi.nlm.nih.gov/books/NBK553107/ the professional reference indicated . Examine the following in a patient with a PI (a localized area of skin and/or underlying tissue damage that develops when prolonged pressure or shear forces exceed the tissue's tolerance): Ulcer history, including etiology (the study of the cause or origin of a disease or abnormal condition) , duration, and previous treatment, Staging by thoroughly examining the depth of the wound, which this activity will cover in detail under staging, Size of the affected area, Sinus tracts (an abnormal, tube-like passage that connects an infected area to the surface of the skin), undermining (the lifting and separation of skin and underlying tissues), and tunneling (creating or traversing a passage), The presence of drainage, The presence of necrotic tissue. When evaluating the wound characteristics, it is also important to keep risk assessment instruments in mind to reduce the risk of a PI incidence. The primary goal is to prevent pressure injury. This goal requires an interprofessional team, including primary care providers, wound care specialists, surgeons, specialty-trained wound nurses, physical therapists, and nurse aides. Nurses provide care, monitor patients, and notify the team of issues. Nurse aides are often responsible for turning and repositioning patients.The patient should be kept pain-free by giving analgesics (medications that relieve pain) . They should try to increase physical activity, which a nurse's aide, medical assistant, or rehab nurse can facilitate. Frequent follow-ups are an absolute necessity, and a team approach to patient education and pressure injury management involving the wound care nurse and wound care clinician lead to the best results. 555652 Page 5 of 5