California Healthcare And Rehabilitation Center
CALIFORNIA HEALTHCARE AND REHABILITATION CENTER in VAN NUYS, CA — inspection on November 18, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of Resident 3's Wound Care Notes documented by the Wound Care Specialist dated 9/17/2025, the Wound Care Notes indicated that on 9/17/2025, Resident 3 was seen, evaluated and treated Resident 3's wound.
The Wound Care Notes indicated that Resident 3 had an unstageable pressure-induced tissue injury to the sacral (located near the sacrum) coccyx (tailbone) area measuring 7 cm in length, 6.2 cm in width and unable to determine (UTD) depth. A sharp excisional debridement (removes unhealthy tissue by cutting it off) of necrotic subcutaneous tissue (contains dead tissue, which is caused by a lack of blood flow, severe injury, or infection, and can appear black, brown, or yellow) was performed.
During a concurrent interview and record review on 10/31/2025 at 3:30 p.m., with LVN 1, the Skin and Wound Evaluation forms dated 9/6/2025 timed at 4:58 p.m.; 9/15/2025 timed at 10:41 a.m.; and 9/22/2025 timed at 11:36 a.m. were reviewed. LVN 1 stated that on 9/15/2025, he (LVN 1) performed and completed the skin and wound evaluation for Resident 3 and documented his (LVN 1) findings on the Skin and Wound Evaluation form. LVN 1 stated that based on the wound's appearance and characteristics including the presence of exudate, Resident 3's wound on the sacrum area should have been identified as an unstageable PU rather than a DTI. LVN 1 stated that he (LVN 1) was unable to assess Resident 3's wound accurately. LVN 1 stated that appropriate interventions for an unstageable PU were not implemented; instead, interventions for a DTI were provided. LVN 1 further stated that he (LVN 1) should have assessed the resident (Resident 3) for pain as well, developed a care plan, and provided appropriate wound care management and treatment for Resident 3's unstageable PU. LVN 1 stated he (LVN 1) failed to recognize and document Resident 3's wound accurately, documenting it as a DTI instead.
During an interview on 11/4/2025 at 3:20 p.m., with the Director of Nursing (DON), the DON stated that LVN 1 should have accurately identified and assessed Resident 3's wound.
The DON stated that as a result of the inaccurate assessment, Resident 3 did not receive appropriate interventions, management and care for an unstageable PU, placing Resident 3 at risk for PU deterioration.
During a review of the facility's policy and procedure (P&P) titled Staging Pressure Sores last reviewed on 10/20/2025, the policy indicated that it is the facility's policy to provide appropriate staging of pressure sores (pressure ulcers).
During a review of the facility's P&P titled Pressure Sore Management, last reviewed on 10/20/2025, the policy indicated that all available measures shall be taken to reduce skin breakdown and pressure sores.
Individual care plans for management of skin condition will be developed as indicated.
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