Health inspection·October 10, 2025

F686 §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that— (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Title 22, Section 72523. Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. Title 22, Section 72315 Nursing Service – Patient Care (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures, and deformities. Such care shall include: (1) Changing position of bedfast and chairfast positions with preventive skincare in accordance with the needs of these patients (4) Using pressure reducing-devices where indicated (7) Carrying out of physician’s orders for treatment of decubitus ulcers. The facility shall notify the physician when a decubitus ulcer first occurs, as well as when treatment is not effective, and shall document such notification as required in Section 72311(b). On 8/25/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct its annual health recertification survey. The facility failed to ensure that Resident 69 received care and treatment in accordance with professional standards of practice to prevent the worsening of a Stage Two Pressure Ulcer (a shallow, open wound where the epidermis [outermost layer of skin] and the underlying dermis [middle layer of the skin] are damaged, potentially with a fluid-filled blister [a painful skin condition where fluid fills a space between layers of skin] that may be intact or ruptured) with a fluid-filled blister on Resident 69’s left heel, initially identified on 8/22/2025. The facility failed to: 1. Offload (to reduce or remove pressure on the affected area to promote healing and prevent further damage) Resident 69’s left heel to relieve pressure and prevent the worsening of an existing Stage Two Pressure Ulcer with fluid-filled blister on the left heel, resulting in prolonged pressure impairing local blood flow and compromised perfusion. 2. Provide Resident 69 an alternating pressure pad (APP – alternating pressure mattress system used to prevent and treat pressure ulcer [PU – damage to an area of the skin caused by prolonged pressure or friction, often over bony areas like the tailbone, heels or elbows], works by constantly changing the pressure points on a person’s body to improve blood circulation and reduce the risk of tissue damage from prolonged, unrelieved pressure) to reduce pressure and friction that contribute to the development and progression of PU when TN 1 failed to recommend and obtain physician’s order for pressure relieving devices (reduces pressure on the affected area to promote healing and prevent further damage such as pressure ulcers) for Resident 69, identified as high risk for developing pressure ulcers. As a result, Resident 69’s Stage Two Pressure Ulcer with fluid-filled blister on the left heel opened, became macerated (the skin surrounding the wound becomes soft, soggy, wrinkled due to excessive exposure to moisture – typically the fluid draining from the blister), and enlarged, causing pain and discomfort to Resident 69. A review of Resident 69’s Admission Record indicated the facility initially admitted Resident 69 on 1/15/2025 and re-admitted Resident 69 on 6/26/2025 with diagnoses including type two (2) diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (paralysis [inability to move] on one side of the body), and hemiparesis (a condition where there is weakness on one side of the body) following cerebral infarction (commonly known a stroke, caused by a blockage in a blood vessel in the brain, leading to brain tissue damage) affecting the right side and dysphagia (difficulty swallowing). A review of Resident 69’s History and Physical (H&P- a comprehensive assessment of a resident’s medical condition), dated 6/27/2025 indicated Resident 69 had the capacity to understand and make decisions. A review of Resident 69’s Minimum Data Set (MDS - a resident assessment tool) dated 6/30/2025 indicated that Resident 69 was usually understood by others and was also able to usually understand others. The MDS indicated Resident 69 was dependent on facility staff for Activities of Daily Living (ADLs- essential, basic self-care tasks required to live independently) including toileting, bathing, and lower body dressing and required maximal assistance from staff with mobility (movement) such as rolling from side to side, transitioning from lying to sitting on the side of the bed, sit-to-stand transfers, and toilet transfers. The MDS indicated Resident 69 did not have any PU at the time of assessment but was identified as being at risk for developing PU. A review of Resident 69’s Braden Scale (a scoring tool used to predict resident’s risk of developing a pressure ulcer, total score ranges from six [6] to 23. A lower score indicating a higher risk of developing a pressure ulcer) Assessment form dated 6/26/2025, timed at 10:21 p.m. indicated a score of 15, placing Resident 69 at moderate risk for developing pressure ulcer. A review of Resident 69’s Care Plan, untitled, initiated on 6/27/2025 indicated that Resident 69 is at risk for pressure ulcer development and further skin breakdown related to type two DM, requires staff assistance with bed mobility and repositioning, incontinence (inability to control the flow of urine from the bladder [organ that stores the urine] or the escape of stool from the rectum [serves as temporary storage site for stool before it is eliminated from the body]), and decreased overall mobility. The interventions included were to administer treatments as ordered and monitor for effectiveness, encourage to turn and reposition and provide assistance as necessary. A review of Resident 69’s Care Plan, titled “Alteration in Musculoskeletal (refers to muscles and skeleton) Status” initiated on 7/18/2025 indicated that Resident 69 required position changes to prevent pressure-related skin breakdown due to osteoarthritis (breakdown of cartilage [the protective tissue that cushions the ends of bones]) and osteoporosis (a condition in which bones become weak and brittle, making them more prone to fractures) of the right knee. A review of Resident 69’s Change of Condition (COC- when there is a sudden change in a resident’s condition) Evaluation form completed by Treatment Nurse 1 (TN 1), dated 8/22/2025, timed at 2:54 p.m. indicated that Resident 69 had a Stage Two Pressure Ulcer characterized with fluid-filled blister on the left heel measuring 3.2 centimeters (cm – unit of measure) in length x (by) 3.4 cm in width x unable to determine (UTD) depth. A review of Resident 69’s Physician’s Order, dated 8/22/2025 indicated to cleanse Resident 69’s Stage Two fluid-filled blister on the left heel with normal saline (a mixture of water and salt), pat dry, apply betadine external solution (brand name for povidone-iodine, a topical [applied directly to skin] antiseptic solution [substance that keeps the broken skin from getting infected] used to clean and disinfect the skin to prevent an infection from developing, thus promoting healing) topically and cover with dry dressing (wound covering that keeps the wound surface dry) every day shift for 30 days. During a review of Resident 69’s Care Plan titled “Has Actual Impairment to Skin Integrity,” initiated on 8/22/2025 indicated an intervention to float Resident 69’s heels. During an interview on 8/25/2025 at 9:03 a.m. with TN 1, outside of Resident 69’s room, TN 1 stated that he had just completed treatment for Resident 69’s fluid-filled blister on the left heel and that Resident 69 was currently attending an activity. TN 1 stated that the fluid-filled blister had been initially identified by Certified Nursing Assistant 5 (CNA 5) on 8/22/2025 during morning care and skin check on 8/22/2025, during the 7 a.m. to 3 p.m. shift. TN 1 stated that the blister was dry, intact, and stable (not worse, not better, not showing signs of infection) at the time of assessment (on 8/22/2025). TN 1 stated that current interventions included floating the heels and applying Betadine daily to promote drying and help prevent infection. TN 1 further stated that the blister most likely developed due to pressure from the bed, as Resident 69’s heels had not been floated. During an observation on 8/27/2025 at 8:30 a.m., in Resident 69’s room, Resident 69 was observed lying flat on a regular mattress, with both heels in direct contact with the mattress surface. There was no pillow or offloading device (specialized footwear and mechanical supports designed to reduce pressure on a specific area of the foot) observed in place to offload Resident 69’s heels. During a concurrent observation and interview on 8/27/2025 at 8:40 a.m., with CNA 5, in Resident 69’s room, observed Resident 69’s both heels touching the mattress surface. CNA 5 stated that she (CNA 5) forgot to float Resident 69’s heels. CNA 5 stated that it is extremely important to offload Resident 69’s heels because of the existing blister on the left heel, which could open and worsen if not properly offloaded. CNA 5 then called CNA 6 to assist with transferring Resident 69. Resident 69 was assisted into a sitting position on the left side of the bed (feet not touching the floor) and was transferred to a wheelchair with assistance from both CNAs (CNA 5 and CNA 6). During a concurrent observation and interview on 8/28/2025 at 8:33 a.m. in the hallway near Resident 69’s room, observed Resident 69 sitting upright in her (Resident 69) wheelchair while being pushed by CNA 5. Observed a pillow was positioned behind Resident 69’s lower legs and heels, resting against the wheelchair’s footrests. CNA 5 stated she (CNA 5) was transporting Resident 69 to the activity and had placed the pillow for comfort. CNA 5 stated that she (CNA 5) did not realize that the pillow and foot rests were in contact with Resident 69’s heels, which could potentially worsen the fluid-filled blister on Resident 69’s left heel. CNA 5 further stated that the pillow must have slipped down and then readjusted the pillow to ensure Resident 69’s heels were floating. During a concurrent observation and interview on 8/28/2025 at 1:07 p.m., with CNA 5, in Resident 69’s room, observed Resident 69 sitting upright in her (Resident 69) wheelchair next to her (Resident 69) bed with a pillow positioned behind Resident 69’s lower legs and heels and up against the wheelchair’s footrests. CNA 5 stated that the pillow must have slipped down again for an unknown period of time. CNA 5 then proceeded to readjust the pillow to ensure that Resident 69’s left heel was properly floated. During an interview on 8/28/2025 at 1:12 p.m. with TN 1, TN 1 stated Resident 69 has a care plan intervention in place to float her (Resident 69) heels and that the heels must remain floating at all times to prevent further skin breakdown. TN 1 stated that Resident 69 is at high risk for developing a pressure ulcer. TN 1 stated that upon Resident 69’s readmission to the facility on 6/26/2025, Resident 69 had a now healed non-blanchable redness (an area of skin that does not turn white when pressure is applied) on her (Resident 69) sacrum (triangular-shaped bone at the base of the spine) which has since healed. TN 1 further stated that it is his (TN 1) responsibility to recommend and obtain physician’s order for pressure relieving devices (reduces pressure on the affected area to promote healing and prevent further damage such as pressure ulcers) for residents identified as high risk for developing pressure ulcers. TN 1 stated he (TN 1) should have obtained an order for APP mattress when Resident 69 had the non-blanchable redness (defining characteristic of a Stage One Pressure Ulcer) on the sacrum area identified on 6/26/2025 as it may have helped prevent further skin breakdown in other areas such as the development of fluid-filled blister on Resident 69’s left heel. During a concurrent observation and interview on 8/28/2025 at 1:37 p.m., with TN 1 and Treatment Nurse 2 (TN 2), in Resident 69’s room, observed TN 1 and TN 2 providing wound care to Resident 69’s left heel. TN 1 removed the dressing on Resident 69’s heel and stated that there was a light-yellow tinge on the dressing. TN 1 stated that the light-yellow tinge may have been caused by the betadine solution. While TN 1 repositioned Resident 69 to assess the left heel, a teardrop was observed rolling down Resident 69’s right cheek. TN 2 asked Resident 69 if she (Resident 69) was experiencing pain in her (Resident 69) left heel, to which Resident 69 responded “Yes, it hurts a lot.” TN 1 stated that the heel now appeared worse and described the left heel as a Stage Two Pressure Ulcer with partial-thickness skin lesion (any abnormal lump, discoloration [any change in the normal color of the skin], sore [refers to pressure ulcer] or other change on or in the skin that differs from the surrounding skin’s normal appearance) with a shallow open area and a pink wound bed (surface at the base of a wound), measuring three (3) cm x 3.8 cm x UTD, with the open lesion measuring 0.6 cm x 0.7 cm x UTD. TN 2 stated that when she (TN 2) last changed the dressing on 8/27/2025, the blister had been intact. TN 1 further stated that the use of an APP mattress, and consistent heel-floating could have prevented Resident 69’s pain and the worsening of the blister on Resident 69’s left heel. During an interview on 8/28/2025 at 4:37 p.m., with the Director of Nursing (DON), the DON stated that Resident 69’s pressure ulcer on her (Resident 69) left heel was avoidable. The DON stated that the licensed nurses should have obtained a physician’s order for an APP mattress, especially given that Resident 69 had a history of a pressure ulcer, mobility limitations and pain related to osteoarthritis. The DON stated that Resident 69’s heels should never have been resting flat on the bed. A review of the facility provided APP Owner’s Manual, undated indicated that the APP is a flotation therapy device that provides pressure management to assist in the prevention and treatment of pressure injuries. A review of the facility's Policy and Procedure (P&P) titled “Skin and Wound Monitoring and Management” last reviewed on 4/2025 indicated a resident who enters the facility without a pressure injury does not develop a pressure injury unless the individual’s clinical condition demonstrates it was unavoidable. The P&P defines stage 2 pressure injury as partial thickness skin loss with exposed dermis. The P&P further indicates to prevent pressure ulcers by repositioning and using pressure relieving device, mattresses, wedges and pillows. The facility failed to ensure that Resident 69 received care and treatment in accordance with professional standards of practice to prevent the worsening of a Stage Two Pressure Ulcer with a fluid-filled blister on Resident 69’s left heel, initially identified on 8/22/2025. The facility failed to: 1. Offload Resident 69’s left heel to relieve pressure and prevent the worsening of an existing Stage Two Pressure Ulcer with fluid-filled blister on the left heel. 2. Provide Resident 69 an APP to reduce pressure and friction that contribute to the development and progression of PU when TN 1 failed to recommend and obtain a physician’s order for pressure relieving devices for Resident 69, identified as high risk for developing pressure ulcers. As a result, Resident 69’s Stage Two Pressure Ulcer with fluid-filled blister on the left heel opened, became macerated, and enlarged, causing pain and discomfort to Resident 69. The above violation