Health inspection·July 14, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one resident's (Resident 2) Low Air Loss mattress (LAL, a mattress that uses a continuous flow of air through tiny laser made air holes in the top of the mattress surface so that the user floats on a soft cushion of air that helps to prevent pressure ulcers) was functioning properly when a plastic inflatable overlay mattress was placed on top of the LAL mattress.As a result, this had the potential for Resident 2 to experience skin breakdown and develop pressure ulcers.Findings:A review of Resident 2's admission Record indicated the resident was re-admitted to the facility on [DATE] with a diagnosis of functional quadriplegia (paralysis of all four limbs), hereditary motor and sensory neuropathy (a condition that affects the nerves), pressure ulcer of sacral region stage 3 (a pressure injury that goes down into the fat and muscle tissue), pressure-induced deep tissue damage of left heel, and pressure-induced deep tissue damage of right heel.A review of Resident 2's care plan, dated 10/10/24, indicated Skin: Resident has skin impairment (left foot blister) and is at risk for delayed healing.Interventions/Tasks.Low air loss mattress.A review of Resident 2's orders, dated 1/31/25, indicated On low air loss mattress for skin management, Monitor LAL mattress for proper setting (according to residents weight /comfortability every shift).A review of Resident 2's vital summary, dated 6/21/25, indicated the resident weighed 214.5 pounds.On 7/14/25 at 8:58 A.M., an interview and observation was conducted with Resident 2 in his room. Resident 2 was lying on top of a tan colored plastic inflatable overlay mattress that extended the length and width of the LAL mattress and was approximatively three inches thick. The LAL mattress was underneath the plastic inflatable overlay mattress and had been set to firm for a weight of 350 pounds (lbs). Resident 2 stated that he bought the inflatable overlay mattress because his LAL mattress was uncomfortable.On 7/14/25 at 10:54 A.M., an interview was conducted with Licensed Nurse (LN) 11. LN 11 stated he was the nurse for Resident 2 and was familiar with his care needs. LN 11 stated Resident 2 required maximum assistance from staff for Activities of Daily Living (ADL, activities such as transferring, dressing, and bathing) and was at risk for skin breakdown. LN 11 stated he knew Resident 2 had a plastic inflatable overlay mattress over his LAL mattress but he did not know the purpose of a LAL mattress.On 7/14/25 at 11 A.M., an interview and observation was conducted with the Charge Nurse (CN). The CN stated Resident 2 had a LAL mattress to prevent pressure ulcers from developing. The CN went into Resident 2's room to observe the resident's bed and stated she was unaware that the plastic inflatable overlay mattress was on top of the LAL mattress. The CN stated she should have been made aware of Resident 2's plastic inflatable overlay mattress. The CN stated Resident 2's LAL mattress was set to firm for a resident weighing 350 lbs and should not have been set that high.On 7/14/25 at 11:29 A.M., an interview and observation was conducted with the Director of Nursing (DON) in Resident 2's room. The DON observed Resident 2's plastic inflatable overlay mattress on top of the LAL mattress. The DON stated there should not have been an overlay on top of Resident 2's LAL mattress because it could interfere with the functionality of the mattress. The DON stated Resident 2's LAL mattress setting should have been set to his weight and not to 350 lbs.On 7/14/25 at 1:07 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated Resident 2's LAL mattress should not have anything on top of it because it could affect the function of the mattress. The DSD stated an in-service had not been done related to LAL mattresses. The DSD stated nursing staff should know how to operate LAL mattresses and that they should not be covered with any other mattresses.On 7/14/25 at 1:44 P.M., an interview was conducted with the DON. The DON stated that nursing staff should have known the purpose of a LAL mattress and how to check for proper functioning. The Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555659 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 555659 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Diego Post-Acute Center 1201 South Orange Ave. El Cajon, CA 92020 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 - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete DON stated it was her expectation for the nursing staff to round on the residents every two hours and they should have identified the plastic inflatable overlay mattress and removed it.A review of the facility document titled Med-Aire 8 Alternating Pressure Mattress Replacement System with Low Air Loss User Manual, undated, indicated, Warning.adhere to the following instructions. Failure to do so could result in personal injury or equipment damage.Only use attachments and/or accessories that are recommended by the manufacturer.A review of the facility's policy titled Pressure Injury Risk Assessment, dated 2001, indicated, .2. Risk factors that increase a resident's susceptibility to develop or to not heal PIs [pressure injuries] include.b. Impaired/decreased mobility and decreased functional ability; c. the presence of previously healed PI;.A review of the facility's policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated 2001, indicated, 1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility.and a history of pressure ulcer(s).1. The physician will order.pressure reduction surfaces,. Event ID: Facility ID: 555659 If continuation sheet Page 3 of 3