Health inspection·December 18, 2025

Code of Federal Regulations, Title 42, Section 483.25 Quality of Care. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices, including but not limited to the following: California Code of Regulations, Title 22, Section 72311. Nursing Services-General. (a) Nursing service shall include, but not be limited to, the following: (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: (E) Any untoward response or reaction by a patient to a medication or treatment. California Code of Regulations, Title 22, Section 72313. Nursing Services-Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. California Code of Regulations, Title 22, Section 72315. Nursing Services-Patient Care. (d) Each patient shall be provided care which shows evidence of good personal hygiene, including care of the skin, shampooing and grooming of hair, oral hygiene, shaving or beard trimming, cleaning and cutting of fingernails and toenails. The patient shall be free of offensive odors. On 10/15/2025 at 11:28 am, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to investigate an anonymous complaint regarding quality of care. The facility failed to provide care and services to treat the skin and itching for Resident 1 in accordance with the facility’s policies and procedures (P&P) titled, “Wound Assessment and Treatment” and “Skin Assessment” by failing to ensure: 1. Resident 1 was given diphenhydramine (medication used to treat allergies, sneezing, runny nose, and itching) for itching according to the physician’s orders. Resident 1 had multiple open skin scratches all over the body from itching. 2. Resident 1’s Medical Doctor/Primary Care Provider (MD) 1 was notified on 10/6/2025 that Resident 1 continued to have itching and had multiple open scratches all over the body even after being treated with hydrocortisone cream (medication used to relieve inflammation, itching, and redness caused by various skin conditions) from 8/7/2025 to 8/21/2025 and from 9/22/2025 to 10/6/2025. 3. Licensed Nurses assessed Resident 2’s skin weekly to monitor Resident 2’s wounds for signs of infection and to evaluate how Resident 2 responded to hydrocortisone cream. As a result, Resident 1 continued to itch and scratch and became at risk for infection due to multiple open skin scratches on the body. A review of Resident 1’s Admission Record (AR) indicated the facility admitted Resident 1, an 82-year-old male, on 7/3/2023 with diagnoses that included unspecified psychosis, unspecified abnormalities of gait and other mobility, and muscle wasting and atrophy. A review of Resident 1’s untitled Care Plan (CP), initiated on 8/7/2025 and revised on 9/22/2025, indicated Resident 1 had actual impairment to skin integrity of the back extending to left and right buttocks related to dry skin and scratches and had an open tear to the right lower back. The CP goals indicated Resident 1 would maintain or develop clean and intact skin by the review date (12/24/2025). The CP interventions included to encourage good nutrition and hydration to promote healthier skin, follow facility protocols for treatment of injury, provide treatment as ordered, and identify/document potential causative factors, and eliminate/resolve where possible. A review of Resident 1’s Order Summary Report (OSR), dated 8/1/2025 to 10/15/2025, indicated Resident 1 had a physician’s order for: 1. Extreme dryness/scratches to back extending to left and right buttocks- cleanse with soap and warm water. Pat Dry. Apply hydrocortisone one percent (1%) cream to area. Leave open to air two times a day for 14 days. The order dates indicated 8/7/2025 was the start date and 8/21/2025 was the end date. 2. Extreme dryness/scratches to back extending to left and right buttocks- cleanse with soap and warm water. Pat Dry. Apply hydrocortisone one percent (1%) cream to area. Leave open to air two times a day for 14 days. The order dates indicated 9/22/2025 was the start date and 10/6/2025 was the end date. A review of Resident 1’s Minimum Data Set (MDS - a resident assessment tool), dated 9/25/2025, indicated Resident 1 had moderately impaired cognition. The MDS indicated Resident 1 required substantial/maximal assistance with toileting hygiene, showering/bathing, and dressing. During a concurrent observation and interview with Resident 1 on 10/15/2025 at 2:06 pm, inside Resident 1’s room, Resident 1 was observed scratching both forearms. There were visible areas of open skin that were bright red on Resident 1’s arms, legs, chest, and top of head. Resident 1 had visible signs of healed and scarred scratches on the chest, on the top of the head, and on the legs. Resident 1 stated, “It does bother me but yeah, as you can see, I itch a lot, all the time.” During a concurrent observation and interview with Certified Nurse Assistant (CNA) 4 on 10/15/2025 at 2:22 pm, inside Resident 1’s room, Resident 1 was observed. CNA 4 stated, “[Resident 1] is always itchy. The physician hasn’t told us what the reason is.” During a concurrent interview and record review on 10/15/2025 at 2:34 pm, Licensed Vocational Nurse (LVN) 3 reviewed Resident 1’s skin assessments. LVN 3 stated Resident 1 had not had a skin assessment completed since September 2025. LVN 3 stated, “I’ve been (working) here for three weeks and [Resident 1’s] skin has been the same.” During a concurrent observation and interview on 10/15/2025 at 2:49 pm, inside Resident 1’s room, LVN 3 observed Resident 1’s skin. Resident 1 was scratching Resident 1’s back and buttocks. LVN 3 stated all the red scratches on Resident 1’s body were new opened wounds. LVN 3 stated, “[Resident 1] has too many new open skin scratches on [Resident 1’s] body to count.” LVN 3 stated, “They (the wounds) are everywhere; from the top of [Resident 1’s] head to [Resident 1’s] feet.” LVN 3 stated Resident 1 had brown discoloration on Resident 1’s back that extended from Resident 1’s sacrum to the mid-back. LVN 3 stated Resident 2 had two, one-half inch by one-fourth inch wounds on Resident 1’s buttocks. LVN 3 stated the wounds were excoriations from scratching. LVN 3 stated LVN 3 thought a wound consultant looked at Resident 1’s excoriations but was not sure when and was not sure what the recommendations for treatment were. LVN 3 stated, “All the red open marks you see on [Resident 1’s] body are skin excoriation from scratching.” LVN 3 stated the dark marks on Resident 1’s body, from head-to-toe were healed/healing scratch marks and the red ones were new open scratches. LVN 3 stated, “We don’t know why [Resident 1] is so itchy.” Resident 1 stated, “I’m really itchy and I don’t like it. All I do is itch.” During a concurrent interview and record review on 10/15/2025 at 3:08 pm, with Registered Nurse (RN) 1, Resident 1’s medical records were reviewed. RN 1 stated, according to Resident 1’s medication administration record (MAR- a report that serves as a legal record of the medications administered to a resident), dated 10/1/2025 to 10/31/2025, Resident 1 had a physician’s order for diphenhydramine but had not received any diphenhydramine to relieve the itching. RN 1 stated Resident 1’s physician’s order for hydrocortisone ended on 10/6/2025 and Resident 1 was no longer receiving the medication. RN 1 stated, “I’m not sure why [Resident 1] is not (receiving hydrocortisone cream). I know [Resident 1] is still itchy.” RN 1 stated there were no Situation-Background-Assessment-Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents) or change of condition notifications (COC- a change in the resident’s health or functioning that requires further assessment and intervention) found in Resident 1’s medical record to inform Resident 1’s physician (MD 1) regarding Resident 1’s continued itching and scratching. During a concurrent observation and interview on 10/15/2025 at 3:25 pm, inside Resident 1’s room, RN 1 observed Resident 1’s skin. Resident 1 was observed scratching Resident 1’s skin on the head and chest. RN 1 stated Resident 1 had areas of open skin from Resident 1’s head to toes. RN 1 stated, “It’s generalized, meaning it’s everywhere, and there are too many to count.” RN 1 stated MD 1 should have been notified and that RN 1 would have to find out what happened and why Resident 1 was still experiencing itchiness. During a concurrent observation and interview on 10/15/2025 at 3:39 pm, inside Resident 1’s room, LVN 3 was observed with Resident 1. LVN 3 stated LVN 3 was applying a brand name petrolatum (thick, jelly-like substance used to protect the skin as a moisturizer and to soothe and protect from irritants or after minor injuries) on Resident 1’s skin because Resident 1’s skin treatment (hydrocortisone cream) ended nine days ago. LVN 3 stated, “We haven’t addressed the itching yet. Generally, when treatment ends, we need to reach out to the physician to let them know what’s going on with the resident.” LVN 3 stated Resident 1 had skin tears all over Resident 1’s body from itching. During a concurrent interview and record review on 10/16/2025 at 11:44 am with the Director of Nursing (DON), the DON reviewed Resident 1’s medical records. The DON stated Resident 1 did not have wound consultant treatment notes. The DON stated the last skin assessment performed on Resident1 was a post-fall skin assessment on 9/20/2025. The DON stated the skin assessment, dated 9/20/2025, was incomplete and did not indicate Resident 1 had open skin scratches all over the body. During a telephone interview on 10/16/2025 at 11:59 am, with Physician Assistant/Wound Consultant (PA) 1, PA 1 stated PA 1 had never seen Resident 1 as a patient and Resident 1 had never been treated by PA 1. PA 1 stated if PA 1 had assessed or treated Resident 1 there would have been wound consultant treatment notes in Resident 1’s medical record. PA 1 stated if PA 1 observed Resident 1 with itchiness and covered in scratch marks, PA 1 would want to know if Resident 1 was having an allergic reaction to medication or the environment to see if those variables were causing the itchiness. PA 1 stated, “I would want to know why [Resident 1] is so itchy and then perhaps treat it with systemic corticosteroids to see if that helps.” PA 1 stated PA 1 would want to know if the physician had treated Resident 1 with a topical medication, and if that was not effective, what the physician had to say regarding recommendations. PA 1 stated Resident 1 could need a referral to a specialist. PA 1 stated having so many open skin scratches on the body and continuing to be itchy placed Resident 1 at risk for infection. During a telephone interview on 10/17/2025 at 9:19 am, with MD 1, MD 1 stated Resident 1 had been having, “on and off episodes of itchiness.” MD 1 stated, “I don’t know why it’s happening, but I have some theories.” MD 1 stated MD 1 prescribed Resident 1 hydrocortisone cream but it did not resolve Resident 1’s itchiness. MD 1 stated, “[Resident 1] hasn’t had a dermatologist (medical doctor who specializes in the skin and skin conditions) referral. [Resident 1] is conserved and [Resident 1’s] insurance changed which makes things more challenging.” MD 1 stated MD 1 could give Resident 1 a referral to a dermatologist but because Resident 1 was unable to recall Resident 1’s stories, MD 1 was not sure how much the specialist could help. MD 1 stated, “These specialists want their patients to be able to recount things.” MD 1 stated, “Because of [Resident 2’s] dementia, the specialists don’t want to deal with him.” MD 1 stated MD 1 extended the hydrocortisone and diphenhydramine orders on 10/8/2025 or 10/9/2025 after the orders ended however it was possible the facility did not receive them. MD 1 stated the most concerning issue with Resident 1 continuing to be itchy and scratching Resident 1’s skin was a risk for cellulitis (an infection of the deeper layers of skin and underlying tissue. This infection can spread quickly and become life threatening). During a concurrent interview and record review on 10/17/2025 at 9:53 am, with the DON and LVN 3, the facility’s communication with MD 1 were reviewed. LVN 3 stated, “We (licensed nurses) did not get a new order for hydrocortisone or diphenhydramine on 10/8/2025 or 10/9/2025; trust me, I would have been putting it on [Resident 1].” The DON stated, “We reached out to MD 1 regarding Resident 1’s itching after you (surveyor) were here on 10/15/2025.” The DON stated that was the only communication the facility had with MD 1 or MD 1’s nurse practitioner regarding Resident 1’s persistent scratching. During an interview on 10/17/2025 at 11:31 am, with the DON, the DON stated charge nurses (LVNs) were supposed to be observing residents for any changes in their skin every day. The DON stated treatment nurses (licensed nurses who treat wounds) must conduct weekly skin assessments on all residents and document the assessment, any treatment, and a skin note that indicates any changes to the current skin condition. The DON stated licensed nurses should have informed Resident 1’s physician when Resident 1’s skin condition did not improve. A review of the facility’s P&P titled, “Skin Assessment,” revised 7/2025, indicated, “A full body, or head to toe, skin assessment will be conducted by a licensed nurse upon admission/re-admission, daily for three days, and weekly thereafter.” The P&P indicated to note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions and to document the assessment. A review of the facility’s P&P titled, “Wound Assessment and Treatment,” revised 7/2025, indicated the facility was committed to the prevention, early identification, accurate assessment, and appropriate assessment of all wounds. The P&P indicated, “All wounds must be assessed and documented upon identification and at least weekly thereafter, or more frequently if ordered or clinically indicated…Wounds must be monitored at least weekly for changes in size, depth, signs of infection, or other changes in condition.” The P&P indicated licensed nurses were responsible for identifying, assessing, treating and documenting wounds, reporting changes to the physician, and following physician’s order. The P&P also indicated the wound care nurse was responsible for leading wound rounds, providing staff training, monitoring wound trends, and recommending care adjustments. The facility failed to provide care and services to treat the skin and itching for Resident 1 in accordance with the facility’s P&P titled, “Wound Assessment and Treatment” and “Skin Assessment” by failing to ensure: 1. Resident 1 was given diphenhydramine for itching according to the physician’s orders. Resident 1 had multiple open skin scratches all over the body from itching. 2. Resident 1’s MD 1 was notified on 10/6/2025 that Resident 1 continued to have itching and had multiple open scratches all over the body even after being treated with hydrocortisone cream from 8/7/2025 to 8/21/2025 and from 9/22/2025 to 10/6/2025. 3. Licensed Nurses assessed Resident 2’s skin weekly to monitor Resident 2’s wounds for signs of infection and to evaluate how Resident 2 responded to hydrocortisone cream. As a result, Resident 1 continued to itch and scratch and became at risk for infection due to multiple open skin scratches on the body. The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resi