North Starr Postacute Care
Inspection Findings
F-Tag F0686
F 0686 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
nurse should have looked for redness and changes in skin color, or texture, when doing Resident 1's skin assessments. The DON stated the nurse should have looked at areas more prone to pressure during their assessments, which included Resident 1's heels. The DON stated a DTI occurs over time and is the result of prolonged pressure. The DON stated a DTI would not develop overnight. The DON stated the CNAs and nurses should have noticed Resident 1's pressure injury prior to 6/3/25. The DON stated CNAs should have noticed any skin changes for Resident 1 during shower times or repositioning. The DON stated nurses should have identified skin changes for Resident 1 during assessments. The DON stated she expected the CNAs and nurses to look at bony prominences for signs of pressure injury. The DON stated 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. The DON stated the facility should have identified the pressure injury sooner, before it progressed. The DON stated Resident 1 was not admitted to the assistive living facility due to his stage 3 pressure injury. During an interview on 8/20/25 at 12:33 p.m. with the Administrator (ADM), the ADM stated pressure injuries should be prevented in the facility. The ADM stated staff should have assessed residents' skin before a pressure injury developed. The ADM stated that staff should have been more careful in identifying pressure injuries for Resident 1 since he was immobile due to hip surgery and because of his type 2 DM. During a review of Resident 1's Skin Monitoring: Comprehensive CNA Shower Review (CSR), dated 6/2/25, the CSR indicated, .Resident: Resident 1 . Perform a visual assessment of a resident's skin when giving the resident a shower . Use this form to show the exact location and description of the abnormality . The CSR indicated Resident 1's heels had no redness or discoloration. During a review of the facility's policy and procedure (P&P) titled, Pressure Injuries Overview, dated January 2018, the P&P indicated, This injury results from intense and/or prolonged (continuing for a long time) pressure . at the bone-muscle interface (junction where muscle tissue connects to bone). During a review of the facility's P&P titled, Repositioning, dated January 2018, the P&P indicated, General Guidelines: Evaluation of a resident's skin integrity after pressure has been reduced (lower pressure on specific body areas) or redistributed (more evenly spread pressure across a larger surface area) should give the development and implementation of repositioning plans . Evaluation: Evaluate the resident for an existing pressure ulcer.
During a review of the facility's P&P titled, Shower, dated January 2018, the P&P indicated, Observe the resident's skin for any redness . reddish or blue-gray area of skin over a pressure point .
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NORTH STARR POSTACUTE CARE in TURLOCK, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TURLOCK, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from NORTH STARR POSTACUTE CARE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.