Health inspection·January 14, 2026

Amended 1/15/2026 §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 §483.70(e) 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. §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 10/27/2025, the California Department of Public Health (CDPH) received a complaint alleging an unidentified resident and an unknown number of unidentified staff acquired scabies (a contagious skin condition caused by tiny insects called microscopic mites which infest and irritate the skin causing intense itching, red patches and inflammation) and the facility did not disclose this information. On 10/28/2025, the CDPH conducted an unannounced visit to the facility to investigate the complaint allegations. Upon investigation, the CDPH determined the facility suspected and treated Resident 1 on 8/4/2025, Resident 2 on 10/22/2025, and Resident 3 on 10/20/2025 for scabies. The facility failed to: 1. Report a suspected scabies outbreak (two or more clinically subsector confirmed cases identified in patients/residents, healthcare workers, volunteers and/or visitors) to the CDPH. 2. Follow its undated Policy and Procedure (P/P), titled "Unusual Occurrence Reporting" which indicated the facility would report outbreak of any communicable disease or unusual occurrence affecting the welfare, safety or health of residents, via telephone to the appropriate agency within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. This deficient practice resulted in a delay in the investigation by the CDPH and placed residents, staff, visitors and the community at risk for acquiring and spreading scabies. Resident 1, a 96-year-old female, was admitted to the facility on 8/12/2016 with a diagnosis of an anxiety disorder (mental health condition characterized by excessive worrying). A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 10/16/2025, indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding ability) was severely impaired and Resident 1 was dependent (helper does all) on staff for hygiene, and to shower/bath. A review of Resident 1's Order History (Physician's Orders) dated 8/14/2025 indicated to apply Permethrin 5% cream (a topical cream used to treat an infestation like scabies) to Resident 1's neck, down to the sole of his feet times one, shower the resident in eight to 14 hours, then repeat the process in one week for prophylaxis (action taken to prevent disease). Resident 2, a 100-year-old female, was admitted to the facility on 12/18/2020 with a diagnosis of an anxiety disorder. A review of Resident 2's MDS dated 10/5/2025, indicated Resident 2's cognition was severely impaired, and she was dependent on staff to shower/bathe. A review of Resident 2's Physicians Order Report dated 10/22/2025, indicated to apply Permethrin 5% cream to Resident 2, from the neck, down to the toes, leave it on for eight to 12 hours then rinse or give a shower in the a.m. Apply a second dose due to suspicious rashes. Give Ivermectin (oral medication used to treat scabies) 3 milligrams ([mg] a metric unit of measurement, used for medication dosage and/or amount) 4 tablets to equal 12 mg then repeat in two weeks for suspicion of scabies. Resident 3, a 64-year-old female, was admitted to the facility on 12/19/2023 and readmitted on 12/28/2024 with a diagnosis of an anxiety disorder. A review of Resident 3's MDS dated 7/29/2025, indicated Resident 1 was dependent on staff to shower/bathe. A review of Resident 3's Physician's Order dated 10/20/2025 indicated to give Resident 3 Ivermectin 3 mg, 4 tablets to equal 12 mg once a day on Sunday at 9 a.m., for scattered rashes and repeat in two weeks for suspected scabies. During an interview on 10/28/2025 at 1:08 p.m., the Infection Prevention Nurse (IPN) stated she was not aware that she had to report a suspected scabies outbreak to the CDPH. During an interview on 10/28/2025 at 1:45 p.m., the Director of Nursing (DON) stated the IPN reported to her (DON) that the Public Health Nurse (PHN) told her (IPN) she (PHN) would call CDPH, that was why she (DON) did not report the suspected scabies outbreak to CDPH. A review of the facility's undated P/P titled "Unusual Occurrence Reporting" indicated the facility would report the following events to the appropriate agency: An outbreak of any communicable disease Other occurrences that interfere with the facility operations and affect the welfare, safety or health of residents, employees or visitors. Unusual occurrences shall be reported via telephone to the appropriate agency as required by current laws and/or regulations within twenty four (24) hours of such incident or as otherwise required by federal and state regulations. The facility failed to: 1. Report a suspected scabies outbreak to the CDPH. 2. Follow its undated P/P titled "Unusual Occurrence Reporting" which indicated the facility would report outbreak of any communicable disease or unusual occurrence affecting the welfare, safety or health of residents, via telephone to the appropriate agency within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. This deficient practice resulted in a delay in the investigation by the CDPH and placed residents, staff, visitors and the community at risk for acquiring and spreading scabies. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security and welfare of residents in the facility.