North Valley Nursing Center: Pressure Ulcer Care Failures - CA
The resident, identified in inspection records only as Resident 1, was admitted to the facility on January 30, 2026, with type 2 diabetes, a pressure ulcer on his sacral region, and a gastrostomy tube for feeding. Diabetes complicates wound healing significantly. A sacral pressure ulcer sits at the base of the spine, between the hips, one of the most vulnerable points on the body for a person who spends long hours in bed.
His care plan, started the day after admission, called for a pressure-reducing mattress. His physician had written an order for a low air loss mattress, a device that circulates air to relieve pressure on damaged tissue. The order was specific: charge nurses were to check the mattress's placement and function every shift and adjust the settings to his weight.
On the morning of May 18, 2026, at 9:33 a.m., an inspector walked into Resident 1's room alongside a licensed vocational nurse. The resident was lying in bed. The mattress was off.
The nurse didn't dispute what the inspector was seeing. She said the mattress should always be on when the resident is in bed. She said Resident 1 had a pressure ulcer on his sacrum. She said it was important for the mattress to be functioning.
Four days later, the facility's Director of Nursing said the same thing. The mattress must be on at all times when he is in bed, she told inspectors, to prevent further breakdown. She confirmed that licensed staff are responsible for making sure it is running at the correct setting.
What nobody explained was why it wasn't.
The inspection record does not say how long the mattress had been off before the nurse and inspector found it that morning. It does not say whether anyone had checked it the previous shift, or the shift before that. The order required checks every shift. The mattress was off.
For a resident with diabetes, the stakes of that failure are not abstract. Diabetic tissue heals poorly. Prolonged pressure on already-damaged skin can deepen a wound from a surface sore into something that reaches muscle and bone. A low air loss mattress exists specifically to interrupt that process, redistributing pressure continuously so no single point bears the full weight of the body for too long.
Resident 1's assessment from May 9, 2026, noted he was fully capable of understanding others and making himself understood. He depended entirely on staff for bathing, dressing his lower body, toileting, and putting on and removing his footwear. He could not reposition himself. He could not turn the mattress on himself. He was dependent on the people around him to do it.
Inspectors rated the violation at the lower end of the harm scale, noting the potential for worsening of existing pressure injuries or development of new ones, rather than documented harm that had already occurred by the time of the inspection. The facility was one of four residents sampled for pressure injury care during the survey. Only Resident 1's records produced this finding.
North Valley Nursing Center received the inspection on May 22, 2026.
The mattress order was still in his chart. The care plan still called for pressure relief. The Director of Nursing still knew exactly what the standard was. On a Tuesday morning in May, none of that had been enough to keep the machine running while a man with a wound on his spine lay in his bed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Valley Nursing Center from 2026-05-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: November 2, 2026 · Our methodology
NORTH VALLEY NURSING CENTER in TUJUNGA, CA was cited for violations during a health inspection on May 22, 2026.
Diabetes complicates wound healing significantly.
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.