Health inspection·September 22, 2025

Code of Federal Regulations, Title 42 §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. California Code of Regulations, Title 22 § 72321.Nursing Service -Residents with Infectious Diseases (2) There shall be: (c) 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. § 72517. Staff Development (a) Each facility shall have an ongoing educational program planned and conducted for the development and improvement of necessary skills and knowledge for all facility personnel. Each program shall include, but not be limited to: (2) Prevention and control of infections. On 7/26/2025, at 4:50PM, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding infection control for Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9. CDPH determined the facility failed to implement the facility’s infection control program to prevent, identify, report, and investigate an infection outbreak ([OB] an unusual increase of disease among a specific population in a geographic area in a specific location) in accordance with the facility’s policy and procedures (P&P) and standard of professional practice by failing to: 1. Identify and report a scabies outbreak (an increase in skin infections caused by mites that burrow under the skin, leading to intense itching and rash, spread through prolonged skin-to-skin contact) to the local health department on 7/23/2025 when Resident 1 was clinically diagnosed with scabies and Residents 2 to 5 showed symptoms and were suspected and treated with a medication used to treat scabies (Permethrin 5% cream). 2. Prevent the spread of infection by not promptly placing Residents 2, 3, 4, 5, 6, 7, 8. and 9 on transmission-based precautions (a measure used in healthcare to prevent the spread of germs through direct or indirect contact) when they showed signs or were suspected of having scabies. This included delays in isolating residents with active symptoms (Residents 2, 3, 4, 5, 7) and Resident 6 who were exposed to confirmed case of scabies (Resident 1). 3.Ensure the Infection Prevention Nurse (IPN) or designee educated all staff, residents, and visitors in contact with affected individuals about the scabies outbreak (7/23/25 to 8/9/25), including specific instructions on transmission-based precautions for staff (Restorative Nurse Assistant [RNA], Certified Nursing Assistant [CNA], Social Service Assistant [SSA], and Receptionist 1) who had close contact with Residents 8 and 9 on 8/8/2025. 4. Conduct thorough surveillance and investigation of residents and staff with rashes to identify potential scabies cases, ensuring all affected residents were included in the line listing (a tool used to track and manage scabies outbreaks). The facility’s 7/28/25 line listing omitted several residents (Residents 6 to 14) with suspected symptoms. The DON, Administrator, IPN, and other designees did not perform daily monitoring of infection control practices, verify the accuracy of scabies reporting, and consistently track and evaluate signs and symptoms during the facility’s scabies outbreak. As a result, these deficient practices led to ongoing scabies transmission, resulting in a facility-wide outbreak with 21 suspected and 1 confirmed resident case between 7/23/2025 to 8/9/2025, placing the remaining 116 residents at risk. 1. A review of Resident 1’s Admission Record (AR), indicated Resident 1 was admitted to the facility on 7/31/2020. A review of Resident 1’s Minimum Data Set (MDS, a resident assessment tool) dated 6/3/2025, indicated the resident had intact cognition (thought process) that required moderate assistance to perform activities of daily living (ADLs). A review of Resident 1’s clinical record indicated the following: a. Change in Condition (COC) evaluation report, dated 1/13/2025, indicated Resident 1 had scattered erythematous papules (small, red, raised bumps on the skin) and self-inflicted excoriation (skin scraped) to left knee. b. Medication Administration Record (MAR) indicated, on 1/30/2025, Resident 1 received Ivermectin (medication used to treat scabies) by mouth for scabies. c. COC evaluation, dated 2/10/2025, indicated Resident 1 complained of itching and rashes to bilateral lower extremities. d. Dermatologist (MD 1) Consultation Note, dated 2/12/2025, indicated Resident 1 was suspected with scabies after treatment with Ivermectin. e. Nursing Progress Notes, dated 2/14/2025 timed at 6:43 PM, indicated Resident 1 was placed on transmission-based precaution for suspected scabies. f. Nursing progress notes, dated 2/19/2025 indicated Resident 1 received one dose of Ivermectin and placed on transmission-based precautions. g. MAR, dated March 2025, indicated Resident 1 received Ivermectin on 3/22/2025 and on 3/30/2025 by mouth for itchiness and rash. h. Nursing Progress notes, dated 5/24/2025, indicated Resident 1 complained of itching and rashes that was treated with Hydrocortisone cream (medication used to relieve itching and inflammation). g. MD 1 report, dated 5/30/2025, indicated Resident 1 was observed with mild dermatitis treated with Triamcinolone 0.1% cream (cream used to help relieve redness, itching, swelling) daily to affected area. h. A review of Resident 1’s MAR, dated 6/6/2025 timed 9 AM, indicated Resident 1’s Hydrocortisone cream was discontinued. The MAR note indicated Resident 1 will be started on Triamcinolone 0.1% everyday shift for 30 days until finished. i. A review of the Nurses Progress Notes, dated 7/11/2025 timed at 1:39 AM, indicated Resident 1 was seen by MD 1 and IPN during rounds and observed Resident 1 “with scattered papulosis (papules, small bumps on skin) with erythema (redness)” and MD 1 ordered Triamcinolone 0.1% daily for two weeks. j. Resident 1’s physician order dated 7/23/2025, indicated the resident was transferred out to the hospital due to extreme itching on 7/22/25 and to place the resident on contact precautions practice scabies. k. Resident 1’s Dermatology Assessment dated 7/23/2025, indicated Resident 1 to have pruritic rash (a skin rash that causes itching, often accompanied by red bumps or patches) affecting multiple areas of body. The distribution of pattern and history suggest possible contagious etiology with suspicion for possible scabietic exposure. l. A review of Resident 1’s Admission Record (AR), indicated Resident 1 was admitted to the facility on 7/31/2020, with a diagnosis that included diabetes mellitus (DM, the body does not make enough insulin to help move sugar from blood into cells for energy). A review of Resident 1’s MAR for July 2025, indicated Resident 1 received Permethrin External Cream 5% on 7/23/2025 at 5:05 AM. During an interview on 7/26/25 at 6:32 PM the ADM stated, Resident 1 was transferred to the GACH on 7/22/25, for complaint of severe itching with rashes, and diagnosed in the GACH with scabies without skin scrapings (a procedure where skin samples are collected to diagnose various skin conditions). The ADM stated that Resident 1 returned to the facility less than 24 hours on 7/23/25 and was treated with Permethrin cream 5 % topical to treat scabies and was placed on transmission-based precautions. During a record review and concurrent interview of the line listing conducted with ADM on 7/28/25 at 2PM, the ADM stated according to the line listing, Resident 1 was observed with rashes and itching on 7/11/2025 but was not placed on contact precautions until the resident was confirmed positive with scabies on 7/23/25 (12 days). During a follow up interview with the ADM on 7/28/2025 at 2:04 PM, the ADM stated, due to the facility’s history of scabies, she consulted with the facility’s dermatologist, and MD 1 recommended prophylactic treatment of Permethrin 5% to be administered to all residents in Station 2 and Station 4 and no skin scrapings or diagnostic tests were performed. During observations and interviews on 8/7/2025 at 11:01 AM and 8/8/2025 at 9:20 to 9:25 AM in Resident 1’s room, Resident 1 was repeatedly seen scratching her arms, chest, and back, which were covered in red, raised lesions and scratches. Resident 1 reported suffering from rashes and itching since April 2025, describing it as “very disturbing” and stated she had begged to be sent to the hospital. Resident 1 stated that Benadryl an unknown cream did not relieve her symptoms, and the persistent itching caused her anxiety, depression, embarrassment and a sense of helplessness.  During an interview on 8/8/2025 at 9:25 AM with CNA 8, CNA 8 stated, she was not informed by the facility what type of skin rash Resident 1 had. During an interview on 8/9/2025 at 10:20 AM in Resident 1’s room, Resident 1 reported difficulty sleeping the previous night due to “really intense” itching. Resident 1 stated she called the nursing staff at approximately 11:30 PM on 8/8/2025 to request Benadryl. Resident 1 further stated that she attempted to call the nurses again at 1 AM but did not receive a response. 2. A review of Resident 2’s AR, the AR indicated that Resident 2 was admitted on 10/26/2017 and readmitted on 4/22/2025, with diagnosis including dementia (a condition that affects the brain, causing memory loss). A review of Resident 2’s care plan titled “Possible exposure to roommate with pinpoint lesions,” dated 6/30/2025, indicated a goal for Resident 2 to be free from any signs and symptoms related to any rash to skin and interventions to follow transmission -based precautions as ordered for the resident. A review of Resident 2’s Progress Notes Situation, Background, Assessment, Recommendation (SBAR) form, dated 7/23/2025, indicated Resident 2 had a skin condition to order for the resident to receive Permethrin Cream. A review of Resident 2’s care plan titled “Rash – Pinpoint” dated 7/23/2025, indicated a goal for resident to be free from itchiness x 2 weeks and intervention for enhanced barrier precautions as needed for resident. A review of Resident 2’s Treatment Administration Record (TAR), for the month of July 2025, indicated Permethrin External Cream 5 % Apply to Body topically for rash with a start date of 7/23/2025 administered on 7/24/2025 at 9:53 PM. A review of Resident 2’s Dermatology Assessment, dated 7/25/2025, indicated Resident 2 had a generalized rash with itching, worse at night, with erythematous papules and excoriations noted diffusely on trunk, limbs, and abdomen. The distribution suggests possible infestation related dermatitis likely scabietic exposure. 3. A review of Resident 3’s AR, indicated that the facility admitted Resident 3 on 1/26/2022. A review of Resident 3’s Progress Notes “Follow up Documentation – Exposure to roommate with skin rash” dated 7/25/2025, indicated Resident 3 had pinpoint lesions and provided treatment as ordered. A review of Resident 3’s TAR for the month of July 2025, indicated the resident received Permethrin External Cream 5% (permethrin) was administered to the resident on 7/24/2025 at 9:52PM. A review of Dermatology Assessment dated 7/25/2025, indicated Resident 3 had rash over trunk with associated itching, scattered erythematous papules and linear excoriations of trunk and generalized dermatitis with concern for possible exposure to scabies. 4. A review of Resident 4’s AR, the AR indicated that Resident 4 was admitted to the facility on 1/30/2016 and readmitted on 5/2/2025. A review of Resident’s 4 care plan titled, “7/23/2025 - Exposure to roommate with pinpoint lesions,” initiated on 6/30/2025, indicated to be free from any signs and symptoms related to any rash like lesions indicated to notify the physician for any changes in condition. A review of Resident 4’s Dermatology Assessment, dated 7/25/2025, indicated Resident 4 complained of diffuse itching over body with diffuse erythematous macules and excoriations noted over trunk, limbs, and abdomen indicating generalized dermatitis (skin irritation) with concern for possible exposure to scabies. A review of Resident 4’s TAR indicated Resident 4 received Permethrin External Cream 5% was applied on 7/23/2025 at 9:52PM. On 8/7/2025 at 10:16 AM, during a concurrent observation and interview with LVN 5, Resident 4 was observed lying in bed, scratching her arms and shifting side to side. She stated her entire back was itchy, reported it to staff about two weeks ago, and expressed fatigue due to lack of sleep caused by the itchiness. Red circular spots were noted on her back, with visible scratches on both arms and left hip. Resident 4 attributed the scratches to persistent itching. During another observation and interview on 8/8/2025 at 9:36 AM, Resident 4 was seen lying in bed, scratching her arms and shifting side to side. She reported frequent nighttime awakenings due to itchiness all over the body and stated she was “feeling really bad” from lack of sleep. 5. A review of Resident 5’s AR, the AR indicated that Resident 10 was admitted to the facility on 5/21/2012 and readmitted on 3/12/2021. A review of Resident 5’s Dermatology Assessment, dated 7/25/2025, indicated Resident 5 complained of generalized itching with scattered erythematous papules and dermatitis with suspicion for scabies exposure. MD 1 recommended to apply Permethrin 5% cream from neck to toe overnight weekly for two weeks. A review of Resident 5’s care plan initiated on 7/29/2025 indicated the resident received Permethrin cream for suspected scabies case. The care plan’s interventions included to maintain clean environment and perform good and effective infection control practices. 6. A review of Resident 6’s AR, the facility admitted Resident 6 to the facility on 3/11/2019 and readmitted Resident 6 on 4/15/2025. A review of Resident 6’s care plan, dated 7/23/2025, the care plan indicated Resident 6 had possible exposure to roommate with pinpoint lesions. The care plan interventions included placing Resident 6 on contact isolation precautions for any signs and symptom