Health inspection·March 23, 2026

72311. Nursing Service – General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A)Identification of care needs based upon an initial written and continuing assessment of the patient’s needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (2) Implementing of each patient’s care plan according to the methods indicated. Each patient’s care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B)Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. 72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physician and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in written by the patient care policy committee. 72525. Required Committees (a) Each facility shall have at least the following committees: patient care policy, infection control and pharmaceutical service (2) Infection control committee. (A) An infection control committee shall be responsible for infection control in the facility. (B) The committee shall be composed of representatives from the following services: physician, nursing, administration, dietetic, pharmaceutical, activities, housekeeping, laundry and maintenance. (C) The committee shall meet at least quarterly. (D) The functions of the infection control committee shall include, but not be limited to: 1. Establishing, reviewing, monitoring and approving policies and procedures for investigating, controlling and preventing infections in the facility. 2. Maintaining, reviewing and reporting statistics of the number, types, sources and locations of infections within the facility. An infection control committee shall be responsible for infection control in the facility. The committee shall be composed of representatives from the following services: physician, nursing, administration, dietetic, pharmaceutical, activities, housekeeping, laundry and maintenance. The committee shall meet at least quarterly. The functions of the infection control committee shall include, but not be limited to: Establishing, reviewing, monitoring and approving policies and procedures for investigating, controlling and preventing infections in the facility. § 72541. Unusual Occurrences. Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of residents, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. Note: Authority cited: Sections 208(a) and 1275, Health and Safety Code. Reference: Section 1276, Health and Safety Code. F880 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv) When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (iv) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi) The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct On 2/11/26 at 11:25 AM, an unannounced complaint investigation was conducted regarding infection control. The facility failed to implement the facility’s infection prevention and control program (IPCP) for Residents 1, 2, 3, and 4 by failing to: 1.Initiate and monitor a Line List (a tool used for data collection and systemic case tracking and surveillance during outbreaks) for residents and staff suspected of having scabies on 2/4/26.   2. Maintain an updated infection surveillance log to track and monitor infections among residents and staff to detect a potential scabies (a contagious skin infestation by mites causing intense itching and rash) outbreak on 10/21/25 when Resident 1 was suspected of having scabies and treated with Permethrin cream (Elimite - a medicated cream used to treat scabies), and again on 2/5/26 when Residents 1, 2, 3, and 4 were suspected of having scabies and treated with Permethrin cream in accordance with the facility’s P&P for IPCP).   3. Report a suspected outbreak of scabies to California Department of Public Health (CDPH) when Residents 1, 2, 3, and 4 were placed on contact precautions for a “suspicious rash” and tested for scabies on 2/4/26. The facility reported a possible scabies outbreak to the LA DPH on 2/12/26, eight (8) days later.     As a result, the facility delayed the implementation of outbreak control measures and increased the potential for continued transmission of scabies among residents and staff. CDPH was not aware of the suspected scabies outbreak at the facility and could not conduct a timely on-site investigation to ensure the facility was taking proper precautions to ensure the welfare of the residents and staff   Findings: A review of Resident 1’s Admission Record indicated Resident 1 was a 63 year old male admitted to the facility on 7/22/24 with diagnoses including neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).     A review of Resident 1’s Minimum Data Set (MDS- a resident assessment tool) dated 1/2/26 indicated Resident 1 had intact cognition (the resident had good orientation, memory recall, and attention) and was fully dependent on staff for bathing, lower body dressing, and putting on/taking off footwear.     A review of Resident 1’s Progress notes on 10/21/25 at 1:07 PM signed by the Infection Preventionist (IP) indicated, “[Resident] verbalizes complaints of ‘mild itchiness’ associated with rashes on the left arm and left lateral torso… Assessment of skin reveals localized, non-vesicular rashes on the left arm and left lateral torso. No fluid-filled blisters, discharge, or scaling noted. Rashes appear contained in the initial areas. MD has assessed the [resident] and new orders have been received…  [Resident] presents with a rash of unknown etiology, posing a potential risk for transmission. The prescribed treatment with Permethrin cream suggests a possible differential diagnosis of scabies. Due to the unknown nature and potential for contagion, infection control measures are warranted to prevent potential cross-contamination to roommates and healthcare staff… [Resident] and current roommates have been placed on contact isolation for a planned duration of [seven] days. Signage has been posted on the door. This measure is implemented to prevent the potential spread of the undiagnosed condition… Will administer medications as per [medical doctor, MD] orders: Permethrin cream, Hydroxyzine HCL 25 mg (milligrams- a unit of measurement) [by mouth] for pruritic, and Hydrocortisone cream 1% for inflammation…”   A review of Resident 1’s Medication Administration Review (MAR) for the month of 10/2026, indicated Resident 1 was administered Permethrin External Cream 5% on 10/28/26.   A review of Resident 1’s untitled care plan (CP) initiated on 2/5/26 indicated Resident 1 had impaired skin integrity related to generalized rash of unknown etiology and a risk for infection transmission related to potential parasitic or fungal infestation. The CP further indicated nursing interventions to maintain Resident 1 in an isolation room with Contact Precaution signage clearly posted; ensure the availability of PPE at the room entrances for all staff and visitors; perform skin assessments every shift to monitor for changes in the rash, signs of excoriation, or secondary infection; monitor for skin scrape results and notify the physician immediately upon receipt to adjust the treatment plan; and to continue staff in-servicing on scabies/fungal protocols and the importance of hand hygiene and environmental cleaning.    A review of Resident 1’s Order Recap Report dated 2/11/2026 indicated physician’s orders dated 2/5/26 for contact precaution including for staff and visitors to don (put on) gloves and gowns prior to entering the room and remove them before exiting room. Orders also included for dietary services to provide meals using single-use disposable trays and utensils. Additionally, a review of Resident 1’s physician’s orders dated 2/5/26 indicated orders to apply Elimite External Cream 5% (Permethrin) apply from neck to toe topically at bedtime every seven days for prophylaxis (empiric) for seven days (ensure coverage under fingernails, skin folds, and between toes, and on 2/7/26, orders to do skin scrape on three to four sites. A review of Resident 1’s MAR for the month of 2/2026 indicated Resident 1 was administered Permethrin on 2/5/26.   A review of Resident 1’s Progress Notes for the month of 2/2026 indicated on 2/7/26 timed at 3:33 PM and signed by the IP indicated that on 2/4/26 a dermatology consultation was conducted by MD 1 regarding a generalized body rash. Following the assessment, Resident 1 was transferred to an isolation room and contact precautions were initiated as a prophylactic measure. To mitigate environmental transmission risks, deep cleaning was completed and privacy curtains were replaced in the transition from the unoccupied to the occupied room. A skin scrape was performed to rule out parasitic infestations, fungal infections, or yeast. The procedure was successfully performed on 2/6/26 upon the arrival of the necessary kits. Results pending. A review of Resident 1’s Progress Notes then indicated on 2/7/26 timed at 3:53 PM and signed by the IP indicated skin scrape number one completed and packaged for lab pick up, remainder of the scrapes to be completed when kits arrive. A review Resident 1’s Progress Notes further indicated on 2/8/26 timed at 10:41 AM and signed by the IP indicated Resident 1’s skin scrape test was left at the front desk since Friday (2/6/26) and the IP communicated with lab dispatch. The notes further indicated Resident 1’s skin scrape test performed on 2/6/26 was picked up from the facility on 2/8/26 at 10:30 AM.   2. A review of Resident 2’s Admission Record indicated Resident 2 was a 75 year old male, originally admitted to the facility on 5/21/26 with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing) and congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).   A review of Resident 2’s MDS dated 1/16/26, indicated Resident 2 had moderate cognitive impairment (the resident may commonly experience forgetfulness, difficulty recalling information, or occasional confusion). The MDS also indicated that Resident 2 was dependent on staff for toileting hygiene, bathing, lower body dressing, and putting on/taking off footwear.     A review of Resident 2’s Change in Condition Evaluation (CIC) dated 2/7/26 at 1:19 PM and signed by Licensed Nurse (LN) 2 indicated, “Upon being changed by CNA [certified nursing assistant], noticed generalized rash. Charge nurse notified and upon assessment noted with rash and spoke with IP about generalized rash. Reported to dermatologist and given skin cream orders. Orders noted and carried out”     A review of Resident 2’s Progress Notes for the month of 2/2026 indicated that on 2/7/26 at 3:17 PM and signed by the IP indicated a dermatology consultation was completed on 2/4/26 regarding Resident 2’s generalized body rash. All new clinical orders were noted and implemented. To mitigate the risk of potential transmission, Resident 2 was placed on contact precaution pending a definitive diagnosis. Environmental interventions were initiated immediately, including deep cleaning of Resident 2’s room and replacement of privacy curtains. A skin scrape test was performed on 2/6/26 following the arrival of collection kits to evaluate parasitic infestations such as scabies, fungal, or yeast infections. A review of Resident 2’s Progress Notes then indicated on 2/7/26 at 3:52 PM and signed by the IP, indicated Resident 2’s skin scrape was completed and packaged for pick up. A review of Resident 2’s Progress Notes further indicated on 2/8/26 at 10:44 AM and signed by the IP, indicated Resident 2’s skin scrape test was done on three sites: the left arm, right arm, and abdomen on 2/6/26 and picked up by lab dispatch from the facility on 2/8/26.   A review of Resident 2’s untitled CP initiated on 2/7/26, indicated Resident 2 had impaired skin integrity related to generalized body rash as evidenced by skin lesions and dermatology consult, and a risk for infection transmission related to unidentified skin etiology and potential for parasitic or fungal spread. The CP further indicated nursing interventions to maintain contact precautions strictly and to ensure PPE was available and to perform skin assessments every shift to monitor for changes in the rash distribution or signs of secondary bacterial infection.   A review of Resident 2’s Order Recap Report written by MD 3 on 2/5/26 indicated orders to perform skin scraping upon kit arrival to three to four sites. A review of Resident 2’s physician’s order written by MD 3 on 2/6/26 also indicated to apply Elimite External