F0686

D

Failure to Reposition High-Risk Resident Every Two Hours

Pasadena, California Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pressure ulcer prevention care by not turning and repositioning a high‑risk resident every two hours as required by the resident’s care plan and the facility’s positioning policy. The resident had diagnoses including diabetes mellitus and protein‑calorie malnutrition, was assessed as high risk for pressure injuries on a Braden Scale assessment, and the MDS documented dependence for all mobility and ADLs, as well as participation in a turning and repositioning program. The resident’s care plan, revised 7/14/2024, directed staff to turn and reposition the resident every two hours and as needed. The facility’s Positioning and Body Alignment policy, reviewed 1/1/2026, required position changes every two hours.

On the survey date, the resident was observed at 10:40 AM lying on her right side. At 11:12 AM and again at 1:20 PM, the resident was still on her right side, and the responsible party and roommate reported that staff had not changed or repositioned the resident since 10:40 AM. The responsible party stated CNAs typically turned the resident only twice during the morning shift, around 8:00 AM and 2:00 PM. CNA 1 later reported she had changed/repositioned the resident at 8:00 AM and 2:00 PM, acknowledging this was not consistent with the every‑two‑hour requirement. The DSD and DON both stated residents should be repositioned every two hours, and the continence management guideline indicated pad/brief changes every 2–4 hours, while the DON noted the policy did not clearly state “every 2 hours and as needed” for changes. This combination of observations, staff statements, and record review showed the resident was not turned every two hours as required, creating the potential for skin tears and pressure injuries.