The December 26 inspection at The Rehabilitation Center of North Hills found staff had violated the facility's own policy by placing excessive linen between the resident and a low air loss mattress. The mattress alternates pressure and allows airflow to prevent skin breakdown and heal existing wounds.
Resident 1 was admitted November 16 with sepsis, dementia, and a stage III pressure ulcer on the sacrum. The resident depends on a respirator and requires assistance from two or more staff members for basic daily activities like bathing and dressing. By the time of the inspection, the pressure ulcer had worsened to stage IV, meaning full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone.
A physician ordered the low air loss mattress on December 22 for wound management.
During the morning inspection, federal investigators observed the resident lying on the specialty mattress wearing an incontinence brief. The mattress had a fitted sheet plus a cloth incontinence pad made of two different fabric textures.
When inspectors asked how many layers of linen should be used between the mattress and the resident's skin, Licensed Vocational Nurse 1 instructed two nursing assistants to remove the resident's incontinence pad and brief. The nurse then counted four layers of linen between the resident's back and the mattress surface.
"The nursing staff should not use multiple layers of linen on the LALM, as doing so will not promote the wound healing process," the nurse told inspectors.
The facility's Director of Nursing confirmed that staff should not use more than two layers of linen. Using more "would defeat the purpose of the LALM use, and will not promote the wound healing process," the director said.
The facility's own policy, last reviewed September 17, specifically addresses proper bedding for low air loss mattresses. The policy states that standard linens should be placed in a single layer loosely over the mattress surface, and fitted sheets should not be used.
Low air loss mattress covers are specially designed to allow airflow to pass through and prevent moisture buildup, according to the policy. This creates a microclimate between the skin and mattress to keep the user comfortable and prevent skin breakdown.
The policy warns that when selecting linens and incontinence pads for these specialty surfaces, staff should choose non-plastic backed products to reduce the potential to block airflow and trap heat and moisture against the patient's skin. Patients should not wear adult incontinence briefs because these obstruct airflow to the skin.
Yet inspectors found the resident wearing an incontinence brief in addition to the multiple layers of linen that blocked the mattress's therapeutic airflow.
Stage IV pressure ulcers represent the most severe form of pressure injury. They occur when prolonged pressure cuts off blood flow to an area of skin, causing tissue death that extends through the skin and fat into deeper tissues. The sacral region, where this resident's ulcer developed, sits at the base of the spine just above the tailbone and bears significant pressure when a person lies on their back.
For residents with severe cognitive impairment like Resident 1, pressure ulcers pose particular risks because they cannot reposition themselves or communicate discomfort. The resident's dependence on a respirator and need for two-person assistance with basic activities further limits mobility and increases vulnerability to skin breakdown.
Low air loss mattresses represent a critical intervention for healing severe pressure ulcers. The mattresses use a series of air-filled cells that inflate and deflate in cycles, redistributing pressure across the body. Small holes in the mattress surface allow air to flow continuously, keeping skin dry and at optimal temperature for healing.
The technology only works when airflow reaches the resident's skin. Multiple layers of linen, fitted sheets, and plastic-backed incontinence products all interfere with this airflow, essentially converting the specialty mattress into a regular bed surface.
Federal inspectors classified the violation as having minimal harm or potential for actual harm. However, improper use of the low air loss mattress had the potential to increase the resident's risk of further skin breakdown and delay healing of the existing stage IV ulcer.
The inspection occurred as part of a complaint investigation, suggesting someone reported concerns about care at the facility. The violation affected few residents, indicating the problem may have been isolated to specific staff or units rather than a facility-wide practice.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Rehabilitation Center of North Hills from 2025-12-26 including all violations, facility responses, and corrective action plans.
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