SAN DIEGO, CA - Federal inspectors cited Brookdale Carmel Valley for failing to promptly assess and treat serious pressure ulcers in residents, with care plans delayed by up to three days after admission.
Delayed Assessment of Stage III Pressure Ulcers
The February 21, 2025 inspection revealed that nursing staff failed to properly evaluate pressure ulcers during admission assessments. Two residents with cognitive impairments experienced delays in receiving appropriate wound care protocols.
A resident with a history of stroke was readmitted with a stage III pressure ulcer measuring 1.5x1.5 centimeters on the tailbone. Despite the visible open wound, nursing staff did not initiate a formal pressure ulcer care plan until three days after admission on February 4, 2025.
The Licensed Nurse explained to inspectors that "admission nurses do not stage pressure ulcers and wait until the wound Medical Doctor stages for them but are not always available during admissions to stage pressure ulcers."
Medical Significance of Pressure Ulcer Staging
Stage III pressure ulcers represent full-thickness skin loss extending into subcutaneous tissue. These wounds require immediate assessment and specialized treatment protocols to prevent infection and further tissue damage.
Federal regulations mandate that nursing facilities assess residents for pressure ulcer risk factors within eight hours of admission and implement protective measures for at-risk individuals.
Facility's Own Standards Violated
The facility's written policy requires assessment of residents "on admission (within eight hours) for existing pressure injury risk factors" and use of "facility-approved protective dressings for at-risk individuals."
The Director of Nursing acknowledged the importance of timely assessment, stating to inspectors: "It was important to include an actual pressure ulcer on the admission assessment and the baseline care plan to prevent the pressure ulcer from worsening and delaying treatment."
Pattern of Assessment Failures
A second resident with malnutrition history also experienced delayed care planning. Admitted with a pressure ulcer to the tailbone described as having a "small skin opening and quarter sized redness," this resident waited three days for initiation of appropriate treatment protocols.
The wound was later classified as a stage III pressure injury measuring 1.2x1.9 centimeters. The Medical Doctor did not order specialized wound care until January 29, 2025 - six days after admission.
Clinical Consequences of Delayed Care
Pressure ulcers can deteriorate rapidly without proper assessment and treatment. Stage III wounds involve significant tissue loss and carry risks of infection, prolonged healing times, and progression to deeper tissue damage affecting muscle and bone.
The Licensed Nurse told inspectors that "delayed care can contribute to the worsening of pressure ulcers and infections if not cared for timely."
Regulatory Requirements and Industry Standards
The Centers for Medicare & Medicaid Services requires nursing facilities to provide appropriate pressure ulcer care and prevent new ulcers from developing. Facilities must conduct comprehensive assessments within 48 hours of admission.
The MDS nurse explained to inspectors that pressure ulcer care plans should be "in place within the 48-hour time frame and should be in place to indicate an actual pressure ulcer to help determine if the pressure ulcer got worse and to provide the proper treatment to promote healing."
Administrative Response
The Director of Nursing stated her expectations were "for the initial admission assessments to be clear and note an actual pressure ulcer that indicated at the minimum if the skin was red or reddened as blanching or non-blanching if they were unsure or stage the pressure ulcer according to what they assessed."
She further emphasized that "admission RNs should not wait for the wound RN to stage the pressure ulcer or wait until the wound RN initiated the actual pressure ulcer care plan within 48 hours to prevent worsening complications and delaying treatments."
Federal Citation Details
The facility received citations under F655 (comprehensive assessments) and F686 (pressure ulcer care) with minimal harm classification affecting few residents. The violations occurred at the 13101 Hartfield Avenue location in San Diego.
Both cited residents had moderate cognitive deficits with Brief Interview for Mental Status scores of 10 out of 15 possible points, making prompt medical assessment particularly crucial for their care outcomes.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brookdale Carmel Valley from 2025-02-21 including all violations, facility responses, and corrective action plans.
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