Health inspection·August 7, 2025

§ 72321. Nursing Service -Patients with Infectious (1) A patient suspected of or diagnosed as having an infectious or reportable communicable disease or being in a carrier state who the attending officer determines is a potential danger, shall be accommodated in a room, vented to the outside, and provided with a separate toilet, hand-washing facility, soap dispenser and individual towels. (2) There shall be: (A) Separate provisions for handling contaminated linens. (B) Separate provisions for handling contaminated dishes. (b) The facility shall adopt, observe and implement written infection control policies and procedures. These policies and procedures shall be reviewed at least annually and revised as necessary. § 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 physicians 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 writing by the patient care policy committee. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (3) Infection control policies and procedures. 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. (v) 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. On 6/26/20205, at 10:22 AM the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding quality of care. 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 to prevent the spread of scabies (an itchy skin condition caused by a tiny bug, mite, that burrows into the skin), by failing to: 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 5/13/2025 when Resident 1 was diagnosed with scabies. Resident 1 was not placed under contact precaution until 5/15/2025, two days after confirmed diagnosis. 2. Monitor and assess close contact residents for rashes, 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 1 order 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 to Resident 1. 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. As a result, there was a 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." Resident 1 was transferred to the General Acute Care Hospital (GACH) for further evaluation on 6/17/2025 due to “extensive skin rashes and probable secondary infection.” A review of Resident 1's Face Sheet, indicated Resident 1 was a 90 year old male resident admitted to the facility on 2/22/2024 with a diagnosis of but not limited to Type 2 diabetes mellitus (inability to use insulin properly) with hyperglycemia (too much sugar in blood). A review of Resident 1's Dermatology Report, dated 5/15/2025, indicated Resident 1 was evaluated for a rash on the trunk, abdomen, and legs. The Report indicated the 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. A review of Resident 1's Physician order Report, dated 5/16/2025 indicated an order to place Resident 1 was to be on contact precautions for scabies on 5/16/2025 to 5/23/2025. A review Resident 1's Care Plan titled "Infectious disease: Scabies Type of infection: Contact Isolation," dated 5/16/2025 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). A review of Resident 1's Change of Condition (COC) Notes, dated 5/17/2025 indicated Resident 1 was being monitoring for scabies and general body scattered and distributed open nodules with ongoing treatment. The COC indicated contact isolation was implemented. 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. A review of Resident 1's Progress Note dated 5/22/25 at 3:31 PM 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. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/28/2025 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 A review of Resident 1's History and Physical (H&P)," dated 6/11/2025, indicated, Resident 1 does not have the capacity to understand and make decisions. A review of Resident 1's Care Plan titled "Whole Body Rash, not controlled by Derma Consult," dated 6/17/2025 indicated to send Resident 1 to the GACH ER for therapy. A review of Resident 1's Transfer Form, dated 6/17/2025 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. A review of Resident 1's Physician order Report, dated 6/17/2025, indicated no new orders for Permethrin on 5/24/25, one 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. A review of Resident 2's Face Sheet indicated Resident 2 was an 86 year old male admitted to the facility on 1/13/2025, with a diagnosis of but not limited to Metabolic encephalopathy (general term that means damage or disease affecting the brain). A review of Resident 2's H&P dated 1/15/2025 indicated the resident has the capacity to understand and make decisions. A review of Resident 2's MDS dated 4/18/2025 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. 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. A review of Resident 3's Face Sheet indicated Resident 3 was a 91 year old male admitted to the facility on 11/24/2023, with a diagnosis of but not limited to fractures of the ribs and heart disease. A review of Resident 3's H&P dated 8/22/2024, indicated the resident does not have the capacity to understand or make decisions. 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. A review of Resident 3's MDS dated 5/26/2025, 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 rashes 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 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 since facility staff did not wear personal protective equipment (PPE equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses), 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 for scabies. 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 for scabies 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 1"Does 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 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 as