LOS ANGELES, CA - Federal inspectors found The Rehabilitation Center On Pico failed to properly implement pressure injury prevention measures for a vulnerable resident, resulting in a preventable heel injury despite having specific protocols in place.
Improper Heel Protection Led to Injury
During the January 28, 2025 inspection, surveyors discovered a resident with multiple serious health conditions, including chronic obstructive pulmonary disease (COPD), muscle weakness, and adult failure to thrive, had developed a pressure injury on their left heel. The resident required substantial assistance with daily activities and spent most of their time in bed, placing them at high risk for pressure injuries.
The facility's own care plan, revised in July 2024, specifically identified this resident as having "higher risk/potential for pressure ulcer development" and required staff to "encourage resident to turn/reposition frequently" and "float heels in bed" to prevent injuries.
However, when inspectors observed the resident at 2:17 PM, they found the resident positioned with their right leg properly elevated on a pillow while their left leg and heel remained directly on the bed surface. This positioning violated the facility's own care protocols designed to prevent pressure injuries.
Clinical Assessment Revealed Tissue Damage
During the inspection, a Certified Nursing Assistant identified a red area on the resident's left heel and stated she would report it to the charge nurse. When the Treatment Nurse assessed the area at 2:27 PM, applying pressure to determine if the redness would blanch (turn white temporarily when pressed), she found the area was blanchable and recommended offloading the heels.
However, when the Director of Nursing conducted a more thorough assessment at 3:30 PM, she discovered that while the outer edges of the reddened area were blanchable, the center portion remained red even when pressure was applied. This non-blanchable redness indicates tissue damage has already occurred beneath the skin surface.
Understanding Pressure Injury Development
Pressure injuries develop when sustained pressure restricts blood flow to tissue, causing cell death. The heel is particularly vulnerable because it bears significant weight when patients are positioned on their backs, and the bone is close to the skin surface with minimal protective tissue.
Non-blanchable redness represents Stage 1 pressure injury, where the superficial skin remains intact but underlying tissue damage has begun. Without proper intervention, these injuries can progress to deeper stages involving skin breakdown, muscle damage, and potentially life-threatening infections.
Prevention Standards Were Clear
The facility's policy, revised in March 2023, clearly outlined prevention strategies including "redistribute pressure (such as repositioning, protecting and/or offloading heels)." The policy specifically identified Deep Tissue Pressure Injury characteristics as "persistent non-blanchable deep red, maroon or purple discoloration" due to underlying tissue damage.
Medical standards require nursing homes to assess residents for pressure injury risk upon admission and implement prevention measures immediately. For high-risk residents like this individual, heel offloading should be continuous, not intermittent.
Care Plan Implementation Failures
The resident's care plan documented multiple risk factors: disease process, history of ulcers, immobility, incontinence, advanced age, and recent significant weight loss due to poor oral intake. Despite this comprehensive risk assessment, staff failed to consistently implement the prescribed heel protection measures.
The resident was also receiving nutritional supplements three times daily between meals, indicating ongoing efforts to address the weight loss and poor nutrition that contributed to pressure injury risk. However, nutritional support cannot compensate for mechanical pressure prevention failures.
Regulatory Violations and Implications
Federal regulations require nursing homes to provide care and services to prevent pressure ulcers for residents who are at risk. The facility received a citation with "minimal harm or potential for actual harm" affecting "few" residents, indicating this was an isolated incident rather than a systemic problem.
However, pressure injuries can significantly impact quality of life, extend healing time, and increase infection risk, particularly for residents with compromised health conditions like COPD and muscle weakness.
The facility must now develop a plan of correction addressing how staff will consistently implement heel offloading procedures for all high-risk residents and ensure proper positioning techniques are maintained throughout all shifts.
This violation highlights the critical importance of translating written care plans into consistent bedside practices, particularly for vulnerable residents who depend entirely on staff for proper positioning and pressure relief.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Rehabilitation Center On Pico from 2025-01-28 including all violations, facility responses, and corrective action plans.
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