North Starr PostAcute: Stage 3 Pressure Sore Missed - CA
The missed injury at North Starr PostAcute Care prevented Resident 1 from transferring to an assisted living facility as planned. Federal inspectors found that certified nursing assistants and registered nurses overlooked warning signs during routine care over multiple days or weeks.
"The facility should have identified the pressure injury sooner, before it progressed," the Director of Nursing told inspectors during an August interview. She acknowledged that deep tissue injuries develop over time from prolonged pressure and would not appear overnight.
Resident 1 faced elevated risks due to his immobility following hip surgery and type 2 diabetes, which slows wound healing. The DON said staff should have been "more careful" identifying pressure injuries given these conditions.
CNAs documented skin assessments during showers using the facility's Comprehensive Shower Review form. On June 2, the day before the stage 3 injury was discovered, a CNA recorded that Resident 1's heels showed "no redness or discoloration."
The contradiction troubled facility leadership. During interviews, both the Director of Nursing and Administrator acknowledged their staff should have spotted skin changes much earlier.
"CNAs should have noticed any skin changes for Resident 1 during shower times or repositioning," the DON explained. "Nurses should have identified skin changes for Resident 1 during assessments."
The facility's own policies required visual skin assessment during showers, specifically directing staff to "observe the resident's skin for any redness" and watch for "reddish or blue-gray area of skin over a pressure point." The shower policy instructed CNAs to document the exact location and description of any abnormality.
Repositioning protocols called for evaluating skin integrity after pressure reduction and developing individualized repositioning plans. The pressure injury policy, dated January 2018, defined such injuries as resulting from "intense and/or prolonged pressure at the bone-muscle interface."
Yet none of these safeguards prevented Resident 1's injury from progressing undetected.
The DON emphasized that nurses conducting skin assessments should examine areas prone to pressure, particularly heels on immobile patients. She expected both CNAs and nurses to check bony prominences for pressure injury signs during routine care.
"A DTI occurs over time and is the result of prolonged pressure," she told inspectors, referring to deep tissue injuries. "The CNAs and nurses should have noticed Resident 1's pressure injury prior to 6/3/25."
The Administrator reinforced that pressure injuries should be prevented entirely. "Staff should have assessed residents' skin before a pressure injury developed," he said during his August 20 interview.
The timing proved costly for Resident 1. His planned transfer to assisted living fell through specifically because of the stage 3 pressure injury discovered on June 3. The wound's severity required continued skilled nursing care that assisted living facilities cannot provide.
Stage 3 pressure injuries extend through the full thickness of skin and into underlying tissue. They represent serious breakdowns in preventive care, particularly for high-risk patients like Resident 1.
The DON warned that healing would be complicated by the patient's diabetes. "Resident 1's pressure injury could take a long time to heal due to his medical history of type 2 DM which causes wounds to heal slowly," she explained.
Federal inspectors determined the facility failed to provide adequate skin monitoring and pressure injury prevention. The violation affected few residents but caused actual harm, earning a citation under federal nursing home regulations governing resident care standards.
The inspection revealed a gap between written policies and actual practice. While the facility maintained detailed procedures for skin assessment, repositioning, and shower monitoring, staff execution fell short when a vulnerable patient needed protection most.
Multiple opportunities existed to identify Resident 1's developing pressure injury. Daily skin assessments, shower monitoring, and repositioning protocols all should have detected changes before the injury reached stage 3 severity.
Instead, documentation shows staff consistently recorded normal findings right up until the serious injury's discovery. The June 2 shower assessment noting "no redness or discoloration" on Resident 1's heels came just one day before the stage 3 injury was finally identified.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Starr Postacute Care from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
NORTH STARR POSTACUTE CARE in TURLOCK, CA was cited for violations during a health inspection on August 20, 2025.
The missed injury at North Starr PostAcute Care prevented Resident 1 from transferring to an assisted living facility as planned.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.