Can Assisted Living Care for Wounds and Pressure Injuries in California?

MedlinePlus, the National Library of Medicine's health site, describes pressure sores as areas of damaged skin caused by staying in one position for too long. They tend to form where bone is close to the skin, such as the heels, hips, ankles and back, and a person is at risk if they are bedridden, use a wheelchair or cannot change position. California's regulations call them pressure injuries. Other sources say pressure sores, bedsores or pressure ulcers.

MedlinePlus groups them into four stages by severity. Stage I is a reddened, painful area that does not turn white when pressed. In stage II the skin blisters or forms an open sore. In stage III there is an open, sunken hole and the tissue below the skin is damaged. In stage IV the sore is deep enough to damage muscle and bone.

The stage matters for a care home because California draws its line between stage 2 and stage 3. Only a clinician can stage a wound, so ask the doctor or wound nurse which stage is documented and get it in writing.

Assisted living communities and board and care homes, licensed in California as residential care facilities for the elderly (RCFEs), are non-medical homes. Title 22, section 87612, lists wound care and stage 1 and 2 pressure injuries as restricted health conditions, allowed under section 87631. Section 87615 lists stage 3 and 4 pressure injuries as prohibited: a person who has one may not be admitted to or kept in an RCFE. The complete lists are in health conditions assisted living can accept.

The same prohibited list includes staphylococcus aureus infection or other serious infection, which can matter when a wound becomes infected. The table summarizes where each kind of wound falls.

Health and Safety Code section 1569.39 defines an appropriately skilled professional as a person trained and licensed to perform the procedure a physician has prescribed, such as a registered nurse or licensed vocational nurse. That person may work for a home health agency, for the resident or for the home.

For a healing wound in general, section 87631 allows care that is performed by, or under the supervision of, that professional. The wording for pressure injuries is tighter. A resident with a stage 1 or 2 pressure injury must have it diagnosed by a physician or an appropriately skilled professional, and shall receive care for the pressure injury from one of them. Everything the medical professional and the facility staff do must be documented in the resident's file.

Caregivers still matter. Before admission, staff who will take part must complete hands-on training from a licensed professional. They must be able to recognize a problem and contact the physician or the professional, and the home must report significant changes in the resident's condition to the physician and the resident's representative immediately.

Most small homes do not employ a nurse, so the wound care usually comes from a home health agency under a written agreement with the home. Medicare lists wound care for pressure sores or a surgical wound among the part-time or intermittent skilled nursing services its home health benefit covers for people who qualify, which includes being homebound.

The rules apply to keeping a resident as well as admitting one. If a pressure injury reaches stage 3, the resident now has a prohibited condition, and there are three possibilities.

The first is an exception. Under section 87616, the home may send the Department of Social Services a written request with current medical reports, the prognosis and expected duration, and its plan for meeting the resident's needs. The home applies, and the department decides.

The second is hospice. A home that holds a hospice care waiver needs no separate exception for a resident who is terminally ill and receiving hospice, provided the hospice care plan specifically addresses the treatment of the wound. Section 87633 still bars facility staff from performing procedures the law reserves for a licensed professional. See our page on finding a board and care home for someone on hospice.

The third is a move to a setting licensed for more care, such as a skilled nursing facility. Health and Safety Code section 1569.39 also requires a home that accepts or keeps a resident with a prohibited condition to help the resident reach home health or hospice services. See when assisted living is not enough for how that decision is usually made.

MedlinePlus says pressure sores can be prevented by keeping skin clean and dry, changing position every two hours, and using pillows and products that relieve pressure. Several California rules point the same way. A home caring for an incontinent resident must check skin exposed to urine and stool regularly, as incontinence in assisted living explains. A resident who cannot turn in bed without help is bedridden under California law, which brings fire clearance rules covered in bedridden residents in assisted living.

Under section 87611, a home that in the last two years has had a probationary license, an administrative action, a non-compliance conference that ended in a corrective plan, or certain serious deficiency notices must get Department of Social Services approval before accepting or keeping a resident with a healing wound.

A home is never required to accept a particular person, and homes differ in what they will take on. Bring the wound's documented stage and the treatment orders, and ask:

• Have you cared for a resident with a wound like this, and who did the dressing changes?
• Which home health agency do you work with, and how often does the nurse come?
• How often do staff reposition a resident who cannot move alone, day and night?
• Who checks skin, how often, and who is called when something changes?
• Do you hold a hospice care waiver?
• If the wound reached stage 3, would you ask the state for an exception?

Hamssa Benrekia is a senior living placement specialist in Torrance with a background in hospice, palliative care and home health. When a parent has a wound, often after a hospital or rehab stay, she can help a family in the South Bay and Harbor area look for a licensed board and care home that says it can manage the care with a visiting nurse, and she goes on the tours with you. She does not decide what a home may accept: the home, the doctor and the state do. To talk it through, contact Hamssa, or start with the California Assisted Living Placement Guide.