Other·June 2, 2026

22 CCR § 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 patients, 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 such other pertinent information related to such occurrences as the local health officer or the Department may require. Title 22 California Code of Regulations §70737. Reporting (a) Reportable Disease or Unusual Occurrences. All cases of reportable diseases shall be reported to the local health officer in accordance with Section 2500, Article 1, Subchapter 4, Chapter 4, Title 17, California Administrative Code. Any occurrence such as epidemic outbreak, poisoning, fire, major accident, disaster, other catastrophe or unusual occurrence which threatens the welfare, safety or health of patients, personnel or visitors shall be reported as soon as reasonably practical, either by telephone or by telegraph, to the local health officer and to the Department. The hospital shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. 22 CCR §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. On 4/17/2026, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding infection control and quality of care. The facility failed to report to CDPH in accordance with the facility’s policy and procedure (P&P) titled, “Unusual Occurrence Reporting,” that Resident 1 was diagnosed and treated for scabies (an infestation of the skin by a human itch mite causing intense itching and a pimple-like skin rash) at the General Acute Care Hospital (GACH) on 3/10/2026, and the Dermatologist (a medical doctor and skin specialist trained to diagnose and treat conditions affecting your skin, hair, nails, and mucous membranes) diagnosed Resident 3 with scabies on 3/16/2026 at the dermatology clinic. As a result, there was a delay in an onsite inspection by the CDPH to ensure the safety and well-being of the residents, which placed the residents at risk for harm, injury, and hospitalization. a. A review of Resident 1‘s Admission Record indicated the facility admitted Resident 1, a 67-year-old male, on 5/13/2024, with diagnoses including unspecified (unconfirmed) multiple sclerosis (MS - a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), acute panmyelosis (a very rare, aggressive form of acute myeloid leukemia [blood cancer] where the bone marrow fails rapidly), and unspecified peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs). A review of Resident 1’s History and Physical (H&P - a medical examination that involves a doctor taking a resident’s medical history, performing a physical exam, and documenting their findings), dated 9/3/2025, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS - a resident assessment tool), dated 1/2/2026, indicated Resident 1’s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact (decisions consistent/reasonable). The MDS indicated Resident 1 was dependent on staff for all activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily). A review of Resident 1’s Change of Condition (COC - a document used to record and report any significant changes in a resident's physical, mental, or psychosocial status), dated 3/9/2026, timed at 2:35 p.m., indicated Resident 1 had unimproved cellulitis (a skin infection that causes swelling and redness) and Family Member (FM) 1 requested to transfer Resident 1 to the GACH. A review of Resident 1’s GACH Hematology Oncology (medical specialty that diagnoses, treats, and prevents blood disorders and cancers [a group of diseases where abnormal body cells divide uncontrollably, ignore the body's signals to stop, and can destroy surrounding tissue or spread to other parts of the body]) Progress Notes, dated 3/11/2026, indicated scabies as one of the active hospital problems with topical (a medication applied directly to a specific body surface) application of permethrin (medication used to treat scabies) on 3/10/2026. A review of Resident 1’s GACH Infectious Disease Progress Notes, dated 3/12/2026, indicated Resident 1 was suspected of chronic (a long-lasting, persistent medical condition) scabies and had treatment. A review of Resident 1’s Order Summary Report, dated 3/16/2026, indicated the following orders: 1. Skin scraping (a quick, painless diagnostic test that uses a blunt blade to gently scrape surface skin cells to check for fungus, mites [scabies], or yeast under a microscope). 2. Ivermectin (prescription pill for treating scabies) oral tablet 3 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount), give 5 tablets by mouth every Tuesday for dermatitis (skin inflammation causing itchy, red and dry patches) for four weeks. 3. Permethrin external cream 5 percent (% - by the hundred), apply from neck to toes topically one time a day every Tuesday for dermatitis for four weeks. Apply one tube at 9 a.m., leave for 12 hours then rinse the following day. Repeat once a week every Tuesday for four weeks. A review of Resident 1’s Skin Rash Report, dated 3/16/2026, indicated that per Resident 1’s recent hospitalization, the resident received scabies treatment on 3/10/2026 and 3/11/2026. A review of Resident 1’s Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications given to a resident), dated 3/2026, indicated the resident received ivermectin on 3/18/2026, and 3/25/2026. A review of Resident 1’s Treatment Administration Record (TAR - a daily documentation record used by a licensed nurse to document treatments given to a resident), dated 3/2026, indicated Resident 1 received permethrin on 3/19/2026, and 3/26/2026. A review of Resident 1’s MAR, dated 4/2026, indicated Resident 1 received ivermectin on 4/1/2026, and 4/8/2026. A review of Resident 1’s TAR, dated 4/2026, indicated Resident 1 received permethrin on 4/2/2026, and 4/9/2026. During an interview on 4/17/2026 at 8:41 a.m. with FM 1, FM 1 stated that Resident 1 received treatment for scabies while in the GACH. FM 1 stated that upon Resident 1’s return to the facility, the facility denied that Resident 1 had a diagnosis of scabies, however, the facility continued to administer scabies treatment to Resident 1. During an interview on 4/17/2026 at 9:14 a.m. with the Infection Preventionist (IP), the IP stated that Resident 1 was transferred to the GACH on 3/9/2026 until 3/14/2026, and the GACH treated Resident 1 for scabies. The IP stated that upon Resident 1’s return to the facility, the nurses administered ivermectin and permethrin as per physician’s order. The IP stated ivermectin and permethrin are medications used to treat scabies. b. A review of Resident 3’s Admission Record indicated the facility admitted Resident 3, a 77-year-old female, on 2/29/2024, with diagnoses including Parkinson’s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), and fall. A review of Resident 3’s H&P, dated 3/5/2025, indicated Resident 3 did not have the capacity to understand and make decisions. A review of Resident 3’s MDS, dated 1/29/2026, indicated Resident 3’s cognitive skills for daily decisions were severely impaired (never/rarely made decisions). The MDS indicated Resident 3 required supervision from staff with eating, toileting, showering, and dressing. A review of Resident 3’s Dermatology Notes, dated 3/16/2026, indicated Resident 3 presented to the dermatology clinic with rashes. The Dermatology Notes indicated Resident 3 had a diagnosis of acute (new) scabies, with plan for administration of ivermectin 15 mg every week for four weeks. A review of Resident 3’s COC, dated 3/16/2026, indicated scabies. The COC indicated that Resident 3 had red raised papular (small, raised, solid bumps on the skin) rash present on the abdomen. The COC indicated that at the dermatology clinic the Dermatologist diagnosed Resident 3 with scabies and ordered ivermectin 3 mg, 5 tablets by mouth for six weeks. The COC indicated Treatment Nurse (TN) 1 called the Dermatologist who informed TN 1 that Resident 3’s clinical presentation was consistent with scabies and that Resident 3 would be treated with ivermectin and clobetasol (medication used to relieve severe skin inflammation) regardless of whether the skin scraping test results were negative. The COC indicated that TN 1 informed the Infection Preventionist (IP) of Resident 3’s rashes and diagnosis of scabies. During an interview on 4/17/2026 at 9:14 a.m. with the IP, the IP stated that Resident 3 went to the Dermatologist clinic on 3/16/2026, and TN 1 reported to her (IP) that Resident 3 returned with a new diagnosis of scabies. The IP stated that she (IP) had reported this to the Administrator (ADM) on 3/19/2026. During an interview on 4/21/2026 at 1:18 p.m. with the Director of Nursing (DON), the DON stated Resident 1 went to the GACH on 3/9/2026 and received treatment for scabies. The DON stated Resident 3 went to the dermatology clinic on 3/16/2026 and returned to the facility with a new diagnosis of scabies. The DON stated scabies is a communicable disease (an illness caused by harmful germs that spreads from one person, animal, or surface to another) that can be passed from one person to another. The DON stated that Residents 1 and 3’s diagnoses for scabies were not reported to the State Survey Agency (SSA). The DON stated having a scabies diagnosis in a long-term care facility is unusual. The DON stated that this should have been reported under unusual occurrences. The DON stated there were two chances to report it, once on 3/14/2026, when Resident 1 returned from the GACH, and the second chance was when Resident 3 returned from the dermatology clinic on 3/16/2026. The DON stated both incidents were not reported to the SSA. The DON stated the effect of not reporting timely was a delay in the investigation and could possibly cause the spread of scabies among residents, staff, and visitors. During an interview on 4/21/2026 at 1:59 p.m. with the ADM, the ADM stated that scabies is an unusual occurrence and should have been reported. The ADM stated a delay in reporting could potentially cause the spread of scabies among residents, staff, and visitors. A review of the facility’s P&P titled, “Unusual Occurrence Reporting,” dated 12/2007, and last reviewed on 2/20/2026, indicated, “As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors. 1. Our facility will report the following events to appropriate agencies: … b. An outbreak of any communicable disease; … 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. 3. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations.” A review of the facility’s P&P titled, “Reportable Diseases,” dated 9/2022, and last reviewed on 2/20/2026, indicated, “Certain infections, illnesses and conditions are reported to the appropriate city, county and/or state health department officials. 1. Reportable diseases are infections, illnesses or conditions with public health significance that must be reported to the local and/or state health department. 2. The list of reportable diseases varies slightly from state to state and over time. 3. The infection preventionist has access to the following information: a. The current contact information for the local/regional health department; b. The current list of reportable diseases for the state; and c. The current system and process for reporting cases. 4. When a resident(s) presents with a suspected or confirmed infection, illness or condition that is reportable, the administrator (or designee) notifies the local health department within the required timeframe.” A review of the facility’s P&P titled, “Reporting Communicable Diseases,” dated 7/2014, and last reviewed on 2/20/2026, the P&P indicated, “The purpose of this procedure is to guide reporting of suspected and confirmed communicable diseases to the appropriate governmental agency or authority. 1. All reportable infectious diseases (residents' or employees') must be reported to the Infection Preventionist as soon as a definite diagnosis is made or strongly suspected. 2. The Infection Preventionist is responsible for notifying the local, district, or state health department of confirmed cases of state-specific reportable diseases.” The facility failed to report to CDPH in accordance with the facility’s policy and procedure titled, “Unusual Occurrence Reporting,” that Resident 1 was diagnosed and treated for scabies at the GACH on 3/10/2026, and the Dermatologist diagnosed Resident 3 with scabies on 3/16/2026 at the dermatology clinic. As a result, there was a delay in an onsite inspection by the CDPH to ensure the safety and well-being of the residents, which placed the residents at risk for harm, injury, and hospitalization. The above violation had a direct or immediate relationship to the health, safety, or security of Resident 1, Resident 3, and the other residents in the facility.