Health inspection·June 27, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices (IPCP, a set of measures designed to protect patients and healthcare workers from avoidable infections) was implemented for one of three sampled residents (Resident 1) who was diagnosed with scabies (an itchy skin condition caused by a tiny bug, mite, that burrows into the skin), by failing to: Residents Affected - Few 1. Place Resident 1 under contact precaution (infection control measures used to prevent the spread of infectious agents that can be transmitted through direct or indirect contact with a patient or their environment) on 5/13/25 when Resident 1 was diagnosed with scabies. Resident 1 was not placed under contact precaution until 5/15/25, two days after confirmed diagnosis. 2. Monitor and assess close contact residents who were exposed to Resident 1, that included, Resident 1's roommates, Resident 2 and Resident 3 and facility staff who had direct contact with Resident 1. 3. Implement MD 1order to administer Ivermectin (antiparasitic medication used to treat a variety of parasitic infections, including scabies) 3 mg oral tablets and Permethrin (topical medication used to treat scabies, a skin condition caused by mites) 5% cream as ordered on 5/15/25. 4. Notify Medical Doctor (MD) 2 after Ivermectin and Permethrin was not administered on 5/17/25 and 5/18/25. 5. Establish a surveillance system that included an accurate line listing of symptomatic residents and healthcare workers that allowed the facility to track, analyze and interpret the data, and identify concerns such an unusual increasing number of residents and employees with new and ongoing rashes. These deficient practices had the potential to spread infection to Resident 2, Resident 3, and all other residents, staff and visitors of the facility, and had the potential for worsening of skin condition and infection by not treating scabies as ordered by the physician. Resident 1 was described by certified nurse assistant (CNA) 1 as looking very uncomfortable. As a result, Resident 1 was transferred to the General Acute Care Hosptial (GACH) for further evaluation on 6/17/25. The General Acute Care (Gach) discharge summary indicated Resident 1 was transferred to the GACH due to extensive skin rashes with probable secondary infection. Finding: 1. During a review of Resident1's Face Sheet, the Face Sheet indicated the resident was admitted to Page 1 of 5 055288 055288 06/27/2025 Autumn Hills Health Care Center 430 N.Glendale Ave Glendale, CA 91206

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the facility on [DATE] with a diagnosis of but not limited to Type 2 diabetes mellitus (inability to use insulin properly) with hyperglycemia (too much sugar in blood). During a review of Resident 1's Dermatology Report, dated 5/15/2025, the Dermatology Report indicated Resident 1 was evaluated for a rash on the trunk, abdomen, and legs. The Report indicated a reason for visit was for the presence of red, itchy lesions that had been present for over five months. The Report indicated Resident 1 was assessed as having scabies, on the trunk, back, and legs. The Report documented that the lesions were itchy and persistent and Resident 1 was prescribed treatment with Ivermectin 3mg oral tablets and Permethrin 5 % cream to start on 5/15/25. During a review of Resident 1's Physician order Report, dated 5/16/2025, the Report indicated an order to place Resident 1 was to be on contact precautions for scabies on 5/16/2025 to 5/23/2025. During a review Resident 1's Care Plan titled Infectious disease: Scabies Type of infection: Contact Isolation, dated 5/16/2025, the Care Plan indicated Permethrin Cream 5% applied externally from neck down to toes at night on 5/17/2025 then repeat in 1 week on 5/24/2025 then wash off in AM 5/25/2025. During a review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR) Notes, dated 5/16/2025, indicated orders for Ivermectin 3mg oral to give 5 tablets today (5/16/2025) and Permethrin Cream 5% topical to be administered on (5/17/2025) and wash off on (5/18/2025). Then repeat in 1 week 5/24/2025 then wash off in AM (5/25/2025). During a review of Resident 1's Change of Condition (COC) Notes, dated 5/17/2025, the COC indicated Resident 1 was on monitoring for scabies and general body scattered and distributed open nodules with on going treatment. The COC indicate contact isolation was implemented. During a review of Resident 1's Treatment Administration History (TAR), for May 2025, the TAR indicated the following: 1. On 5/17/25, Permethrin 5% cream was not administered. The TAR indicated a note indicating, spoke to family, she will bring medication tomorrow. 2. On 5/18/2025, Permethrin 5% cream was not administered. The TAR indicated a note indicating, Spoke to family, she said she would bring medication tomorrow. The TAR indicated the first dose of Permethrin 5% cream was not administered until 5/25/2025 at 8 PM,12 days after Resident 1 was diagnosed with scabies and 8 days after the physician ordered Permethrin 5% cream. During a review of Resident 1's Progress Note dated 5/22/25 at 3:31 PM, the Note indicated MD 1 ordered to 'apply cream from head to toe and shower on 5/23/25. The Note indicated a diagnosis of scabies and to keep on contact precaution. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/28/2025, the MDS indicated Resident 1 has limited ability to understand, process, and recall information, and unable to answer questions about time, place, or memory. MDS also indicated Resident 1 required Maximal assistance with toileting, showering and walking 055288 Page 2 of 5 055288 06/27/2025 Autumn Hills Health Care Center 430 N.Glendale Ave Glendale, CA 91206

F 0880 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1's History and Physical (H&P), dated 6/11/2025, the H&P indicated, Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Care Plan titled Whole Body Rash, not controlled by Derma Consult, dated 6/17/2025, the Care Plan indicated to send Resident 1 to the GACH ER for therapy. Residents Affected - Few During a review of Resident 1's Transfer Form, dated 6/17/2025, the Transfer form indicated reason for transfer was for further evaluation of generalized body rash and intravenous antibiotics. There as no mention of Resident 1's history of scabies, diagnoses on 5/ 15/2025. During a review of Resident 1's Physician order Report, dated 6/17/2025, the Report indicated no new orders for Permethrin on 5/24/25, on week after Resident 1's initial treatment on 5/17/25. The Report indicated Resident 1 was transferred to the GACH emergency room (ER) for further Evaluation. 2. During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was admitted on [DATE], with a diagnosis of but not limited to Metabolic encephalopathy (general term that means damage or disease affecting the brain). During a review of Resident 2's H&P dated 1/15/2025, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 demonstrates adequate memory and recall abilities and was capable of participating in care planning and making informed decisions. Requiring moderate assistance (helper does less than half the work) when using manual wheelchair. During a review of Resident 2's Progress notes from 5/15/2025 to 6/17/2025, there was no documented evidence that indicated monitoring, or assessment was conducted for Resident 2 who was in close contact of Resident 1 who had a confirmed diagnosis of scabies. 3. During a review of Resident 3's Face Sheet, the Face Sheet indicated Resident 3 was admitted on [DATE], with a diagnosis of but not limited to fractures of the ribs and heart disease. During a review of Resident 3's H&P dated 8/22/2024, the H&P indicated the resident does not have the capacity to understand or make decisions. During a review of Resident 3's Progress Notes from 5/15/2025 to 6/17/2025, there was no documented evidence that that indicated monitoring, or assessment was conducted for Resident 3 who was in close contact of Resident 1 who had a confirmed diagnosis of scabies. During a review of Resident 3's MDS dated [DATE], the MDS indicated resident 3 has very limited mental functioning and requires maximum assistance when up in wheelchair. During an interview on 6/26/2025 at 8:47AM with Family Member (FM2), FM 2 stated Resident 1 was hospitalized approximately two weeks ago for open, severe skin wounds. FM 2 stated Resident 1's skin condition had worsened, so FM 2 requested for Resident 1 to go to the GACH. FM 2 stated Resident 1 had the skin condition for about a month and described Resident 1's skin condition as nonstop scratching and that the skin looked like chicken pox. FM 1 and FM 2 while visiting observed Resident 1' s skin looking completely raw with blood present everywhere. FM 2 stated after speaking to Resident 1's 055288 Page 3 of 5 055288 06/27/2025 Autumn Hills Health Care Center 430 N.Glendale Ave Glendale, CA 91206

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Primary Physician and expressing concerns about Resident 1's condition, the resident was transferred to the GACH on 6/17/2025 for evaluation. During an interview on 6/26/2025 at 10:39 AM with Director of Nursing (DON), the DON stated on 5/15/2025, Resident 1 was seen by an outside Dermatologist. The DON stated the facility received a prescription for Permethrin cream for scabies. The DON stated when Resident 1 returned from the Dermatology appointment on 5/15/2025, Resident 1 was placed back into the same room with the roommates (Resident 2 and Resident 3). The DON stated the facility did not have an available room for isolation for Resident 1. The DON stated Resident 1 was on one side of room and Residents 2 and 3 were on the other side of room. The DON stated only Resident 1 was on isolation precautions while Residents 2 and 3 were permitted to move around within the room and around the facility. During a concurrent interview and record review on 6/26/2025 at 12 PM with the DON, Resident 2 and Resident 3's Progress notes from 5/15/2025 to 6/17/2025 were reviewed. The DON stated Resident 1's Progress Notes did not indicate Resident 1 was placed on isolation precautions or was monitored for scabies. During an interview on 6/26/2025 at 1:17 PM with CNA1, CNA1 stated Resident 1 had scabies and that only Resident 1 was placed on isolation inside the same room as Resident 2 and 3. CNA 1 stated Residents 2 and 3 were not placed on isolation, even though Resident 1 shared the same room. Resident 1 scratched a lot and that his arms would bleed from scratching. CNA 1 stated Resident 1 and looked very uncomfortable. During an interview on 6/26/2025 at 1:30 PM with Licensed Vocational Nurse (LVN 1), LVN 1 stated she was informed by the facility's infection preventionist (IP) that Resident 1 had a diagnosis of scabies. LVN 1 stated Resident 1 shared a room with Residents 2 and 3, but LVN 1 only monitored Resident 1. LVN 1 stated Residents 2 and 3 were not assessed or monitored for scabies exposure from Resident 1. During a concurrent interview and record review on 6/26/26/2025 at 1:44 PM with the DON, DON stated no monitoring, or assessment was conducted on Residents 2 and 3 for the exposure of scabies. During a concurrent interview and record review on 6/27/2025 at 9 AM with LVN 2, Resident 1's Short Message Service (SMS) communication between Licensed Vocational Nurse (LVN 2) and the in-house Dermatology Nurse practitioner (NP1) was reviewed. The SMS indicated on 5/13/ 2025 at 12:10 PM, LVN 2 sent a photograph via SMS of Resident 1's torso, arms, and legs to NP 1 for dermatological evaluation. The SMS indicated LVN 1 asked NP 1Does this look like scabies to you? The SMS indicated NP 1's response was Highly suspicious for Scabies and instructed to Treat as scabies - Need weight and face sheet. LVN 2 stated Resident 1's Primary Physician and the IP were notified on 5/13/25 of Resident 1's suspected scabies with no new order was received. During an interview on 6/27/2025 at 9:59 AM with IP, the IP stated that on 5/13/2025, Resident 1 was suspected to have scabies based on a visual review by the in-house dermatology provider who received a text photograph of Resident 1's skin. IP stated the dermatologist instructed staff to Treat as scabies. IP stated Resident 1's isolation was delayed because the resident's family requested to seek an outside dermatologist for a second opinion. IP stated contact isolation was not initiated until 5/16/2025, three days after the initial recommendation to treat as scabies. During an interview on 6/27/2025 at 9:59 AM with IP, IP stated that exposure tracking began on 055288 Page 4 of 5 055288 06/27/2025 Autumn Hills Health Care Center 430 N.Glendale Ave Glendale, CA 91206

F 0880 Level of Harm - Minimal harm or potential for actual harm 5/13/2025, after resident 1 was suspected of having scabies. IP stated she obtained information from a form titled Stop and Watch that would be filled out by either the CNA's or the LVN's. IP stated if no form was submitted, she documented no changes.' IP stated no formal documentation, or assessments were being conducted daily or on each shift. IP stated the facility did not perform any diagnostic testing to verify whether any residents had scabies. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled Scabies, Unknown date, indicated Scabies is defined as an infestation with a mite. Prevention and risk minimization accomplished by early detection, prompt isolation and implementation of transmission- based precautions. Infection control interventions should include residents undergoing treatment for scabies should be confined to their room, including appropriate personal protective equipment and evaluation of all resident contacts, including residents on the affected unit or wing, all nursing staff, and other facility staff who have had close resident contact. Documentation should include a comprehensive plan of care, progress notes describing signs, symptoms, treatment, and follow - up and an updated infection control log to track cases and interventions. During a review of the Facility's Policy and Procedure (P&P) titled infection Control Program, (No date), the P&P indicated outbreak management is a process that includes determining the presence of an outbreak, managing affected residents, preventing the spread to other resident, documenting information related to the outbreak, and educating staff. The policy also describes infection prevention measures, which include to identify possible infections or complications from existing infections, enhanced screening and to follow established general and disease specific guidelines, including those from the Centers for Disease control and prevention (CDC). According to the Centers for Disease Control and Prevention (CDC) publication titled Public Health Strategies for Scabies Outbreaks in Institutional Settings (Published December 18, 2023), prevention of scabies outbreaks requires early detection, prompt treatment, and the implementation of appropriate isolation and infection control practices. These are essential components in preventing the spread of scabies within healthcare facilities. The CDC recommends that facilities establish an active surveillance program to promote early detection of infested Residents and Staff. Facilities should maintain detailed records that include Resident names, skin scraping results, names of all staff members who provided hands on care and documenting dates of symptoms onset and medication administration. Assessing the extent of the outbreak is based on data to guide isolation protocols, treatment coordination, and further preventive measures. 055288 Page 5 of 5