Health inspection·June 26, 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 a low air loss mattress (help prevent skin breakdown) was in placed or implemented for one of one resident (Resident 1) with a pressure ulcer (localized injury to the skin). Residents Affected - Few This failure had the potential to worsen Resident 1's skin injury. Findings. Per the facility's admission Record , Resident 1 was admitted to the facility on [DATE] with diagnoses which included Pressure Ulcer of sacral (area of the lower back) region, unstageable and Functional Quadriplegia (paralysis affecting all limbs and torso). On 6/26/25 at 11:20 A.M., an interview with Resident 1 was conducted. Resident 1 stated she had complained to a certified nursing assistant (CNA) to checked if the settings were right on the air-loss mattress on her bed. The CNA stated there was a regular mattress on Resident 1's bed and no air-loss mattress. A record review of Resident 1's minimum data set (MDS- a federally mandated assessment tool) dated 5/31/25 indicated Resident 1's brief interview for mental status (BIMS) was 15 which meant Resident 1's cognition (thought process) was intact. On 6/26/25 at 10:45 A.M., an interview with the Treatment Nurse (TXN) was conducted . The TXN stated she did Resident 1's treatment to her wounds daily and that Resident 1 had a low air-loss mattress on her bed for offloading and to aid in healing. The TXN stated the nurses had to check and sign that the low air-loss mattress was on Resident 1's bed. The TXN stated she was not aware that the air-loss mattress was missing for weeks until Resident 1 reported it to the Director of Nursing (DON). On 6/26/25 at 11:00 A.M., an interview and record review with Licensed Nurse (LN) 1 was conducted . LN 1 stated, per the Physician's order report dated 5/5/25 indicated orders for a low air-loss mattress for skin management and prevention and to Monitor for functioning and settings every shift. LN 1 stated she was not aware that Resident 1's air-loss mattress had been missing for weeks. LN 1 stated the treatment nurses should have checked the air-loss mattress before signing it when they did Resident 1's treatment on her wounds. LN 1 stated license nurses were signing off the Treatment Administration Record (TAR) for the low air-loss placement and settings for the months of May and June 25 without checking. A record review of Resident 1's care plan dated 2/11/25, category- pressure ulcer , indicated one Page 1 of 2 555754 555754 06/26/2025 Village Square Healthcare Center 1586 W. San Marcos Blvd San Marcos, CA 92078

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of the approaches was a LAL (low air-loss) mattress for skin management and prevention and to monitor for functioning and settings every shift. On 6/26/25 at 12 P.M., an interview with the DON was conducted. The DON stated the low air-loss mattress might have been switched to another bed instead of Resident 1's room which was 207 B. The DON stated 207 B does not need an air-loss mattress since 207B did not have any skin issues. The DON stated it was important to have the air-loss mattress on Resident 1's bed due to Resident 1's multiple skin issues that would aid in wound healing. A review of the facility's undated policy titled, Pressure Ulcer Injury & Skin Care Management indicated .Procedure .#8 The interdisciplinary team .c. considers and includes interventions for pressure ulcer/injury prevention and treatment .d. implements treatment procedures in accordance with professional standards of practice. 555754 Page 2 of 2