Health inspection·August 8, 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 two of three sampled residents Resident 2 and Resident 3) received care and services to promote wound healing by:1.Failing to ensure Resident 2's low air loss mattress (LAL - a specialty bed that alternates pressure to help heal and prevent pressure injuries [PI - an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure]) was properly set to the correct setting.2.Failing to ensure licensed nurses obtained clarification from the physician regarding Resident 2 and Resident 3's LAL mattress order. 3.Failing to ensure licensed nurses were knowledgeable on how to check for functionality of Resident 2 and Resident 3's LAL mattress.These failures had the potential to place the residents at risk of developing or worsening pressure ulcers. 1.During a review of Resident 2's admission Record, the admission Record indicated the facility readmitted Resident 2 on 3/16/2025 with diagnoses including pressure ulcer of sacral region (the bottom of the spine), stage 4 (a severe, full-thickness tissue loss where the injury extends down to the bone, tendon, or muscle), need for assistance with personal care, and peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 5/2/2025, the MDS indicated Resident 2 had severe cognitive (the mental process involved in knowing, learning, and understanding things) impairment. The MDS indicated Resident 2 was dependent on oral hygiene, toileting hygiene, shower/bathing, and personal hygiene. During a review of Resident 2's Order Summary Report dated 3/16/2025, the Order Summary Report indicated an order for the low air loss (LAL) mattress to be set based on [Specify: setting on comfort OR weight] of resident and to check the setting and functionality of the LAL mattress every shift. During a review of Resident 2's Braden scale (a widely used assessment tool in healthcare to predict the risk of a patient developing pressure injuries) for predicting pressure sore risk dated 8/1/2025 timed at 2:09 p.m., the Braden scale indicated Resident 2 was at high risk for developing a pressure injury.During an observation on 8/7/2025 at 8:30 a.m., in Resident 2's room, observed Resident 2 in bed with the LAL mattress settings set to static mode (function that stops the mattress from alternating pressure).During a concurrent observation and interview on 8/7/2025 at 8:32 a.m. with Treatment Nurse 1 (TN 1), in Resident 2's room, observed Resident 2 in bed with the LAL mattress settings set to static mode. TN 1 stated that Resident 2's LAL setting is not correct and that the LAL mattress setting should be on alternate mode. TN 1 stated that the LAL mattress setting should be in alternating mode because Resident 2 currently has a pressure injury and if the correct setting is not set Resident 2's pressure injury could worsen and delay the healing process.2. a. During a concurrent interview and record review on 8/7/2025 at 9:43 a.m. with TN 1, TN 1 reviewed Resident 2's LAL mattress order dated 3/16/2025. When asked if Resident 2's LAL mattress setting is based on Resident 2's comfort or weight, TN 1 stated that the order does not specifically indicate whether the LAL mattress should be set according to Resident 2's Residents Affected - Some Page 1 of 3 555822 555822 08/08/2025 Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some comfort or weight. TN 1 continued to state that TN 1 should have called Resident 2's physician to clarify the order. The order should state the LAL mattress for Resident 2 is based on her weight because Resident 2 currently has a pressure injury. TN 1 stated that it is important to clarify if an LAL mattress order is for comfort or weight because if a resident has a pressure injury, the pressure injury can worsen if the LAL mattress is not set correctly. b. During a review of Resident 3's admission Record, the admission Record indicated the facility readmitted Resident 3 on 11/12/2024 with diagnoses including pressure ulcer of right buttock, stage 4, pressure ulcer of left buttock, and need for assistance with personal care.During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had moderately cognitive impairment. The MDS indicated Resident 3 was dependent on oral hygiene, toileting hygiene, shower/bathing, and personal hygiene.During a review of Resident 3's Order Summary Report, the Order Summary Report indicated an order dated 11/13/2024 for low air loss mattress set based on [Specify: setting on comfort OR weight] of resident and to check the setting and functionality of the LAL mattress every shift. During a review of Resident 3's Braden scale for predicting pressure sore risk dated 7/11/2025 timed at 8:33 a.m., the Braden scale indicated Resident 3 was at high risk for developing a pressure injury.During a concurrent interview and record review on 8/7/2025 at 9:43 a.m. with TN 2, TN 2 reviewed Resident 3's LAL mattress order dated 11/13/2024. When asked if Resident 3's LAL mattress setting was set for Resident 3's comfort or weight, TN 2 stated that Resident 3's LAL mattress was set for Resident 3's comfort. TN 2 stated that the order does not specifically indicate whether the LAL mattress should be set based on Resident 3's comfort or weight. TN 3 stated that she needs to clarify the order with Resident 3's physician because TN 2 does not know the correct setting for Resident 3's LAL mattress.3.a. During an interview on 8/7/2025 at 9:57 a.m. with TN 1, TN 1 stated that the functionality of Resident 2's LAL mattress is checked daily. When asked how to check for the functionality of Resident 2's LAL mattress, TN 1 stated that Resident 1's LAL mattress will beep and flash a red light if the mattress was not functioning correctly.During a review of the LAL's manual titled, Power Pro Elite Mattress System User Manual, the manual indicated, check to see if the suitable pressure is selected by sliding one hand between a deflated air cell and the patient's buttocks areas and there should be minimum contact. Always leave at least 1 in space between a deflated air cell and patient's buttocks areas to prevent bottoming-out. According to the weight of the patient, adjust the pressure setting to the most suitable level without bottoming-out. User can determine an appropriate pressure by adjusting the Comfort level. Please consult with your physician for proper setting. b. During an interview on 8/7/2025 at 12:32 a.m. with TN 2, TN 2 stated that the functionality of Resident 3's LAL mattress is checked daily. When asked how to check for the functionality of Resident 3's LAL mattress, TN 2 stated that she would check Resident 3's LAL mattress machine to see if all the lights were on. She further stated that if the lights were not on, then the mattress was not functioning correctly. TN 2 further stated that she would then unplug and re-plug the machine and if the problem persisted, she would call the LAL mattress company. During an interview on 8/7/2025 at 1:45 p.m. with the Director of Nursing (DON), the DON stated to check the functionality of a LAL mattress, staff should place their hand on the LAL mattress and apply pressure. If staff are able to feel the bed frame, the setting is incorrect. During a review of the LAL's manual titled, Med-Aire 8 Alternating Pressure Mattress Replacement System with Low Air Loss, the manual indicated, Hand Check Procedure: A suitable way to verify that the patient is not bottoming out is to perform a hand check as described below: 1) Ensure that the patient is lying supine (on his/her back) in the middle of the mattress. 2) Place hand with four (4) fingers stacked vertical beneath the air cell directly underneath the sacral region. 3) Ensure that the 4 fingers 555822 Page 2 of 3 555822 08/08/2025 Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some can slide with minimal resistance between the patients' sacral region and the lower portion of the mattress. 4) Adjust the comfort setting as needs. 5) Wait for the mattress to adjust to the selected range. 6) Revaluate with the hand check and adjust to patients' comfort level. During a review of the facility's policy and procedure (P&P) titled Pressure Ulcers/Skin Breakdown- Clinical Protocol, reviewed 1/15/2025, the P&P indicated the physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressing, and application of topical agents. During a review of the facility's P&P titled Low Air Loss Mattress, reviewed1/15/2025, the P&P indicated, law air loss mattress has been an integral tool for wound care management as a facility protocol to enhance healing and treatment of pressure ulcer. 555822 Page 3 of 3