Health inspection·May 15, 2024

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00892306. Representing the Department, HFEN # 43452. A Class B Citation was written. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations § 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: On 3/30/2024 the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident neglect. The facility failed to provide care, treatment, and services for Residents 1, 2, 3, 4, and 5 in accordance with professional standards of practice in order to meet the residents' physical, mental, and psychosocial needs, by failing to: 1. Conduct proper assessment to identify what was causing generalized and severely itchy skin rashes despite two separate treatments for Resident 1 and generalized dry crusted skin rashes for Resident 5. Resident 1's rash and itching was first identified by the facility on 11/6/2023. 2. Notify a physician that treatment ordered for skin itchy rashes was ineffective according to the resident's care plan. Residents 1, 2, 3, 4, and 5 had no pre-existing skin conditions/rashes upon admission/readmission to the facility. These deficient practices resulted in: 1. Resident 1 experiencing unrelieved generalized and severely itchy body rashes, itchy skin, discomfort despite two separate treatments since 8/10/2023, and inability to sleep. 2. Resident 1 was referred for psychiatry (is the medical specialty devoted to the diagnosis, prevention, and treatment of deleterious mental conditions) services on 1/5/2024 due to intermittent episodes of crying. 3. Residents 2, 3, 4, and 5 were not assessed for generalized itchy skin rashes, and a physician not notified about the generalized itchy skin rashes. 4. Increased risk for significant decline in the residents' physical, mental, or psychosocial well-being, disfigurement, avoidable excruciating pain, and discomfort for Residents 1, 2, 3, 4, and 5. a. A review of Resident 1's admission record indicated the facility admitted Resident 1 on 2/27/2023, with diagnoses that included hemiplegia (loss of strength in the arm, leg, and sometimes the face on one side of the body) and hemiparesis (loss of use in the arm, leg, and sometimes the face on one side of the body) following cerebral infarction (stroke) affecting right dominant side, aphasia (difficulty speaking), dysphagia (difficulty swallowing), dependence on supplemental oxygen (use of extra oxygen to breathe in), and anxiety. The admission record did not indicate Resident 1 was admitted with any skin rashes and major depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.). A review of Resident 1's Minimum Data Set (MDS- standardized assessment and care screening tool) dated 1/4/2024, indicated the resident's cognition (relating to mental ability to make decisions of daily living) was severely impaired. The MDS indicated Resident 1 was dependent on facility staff for oral hygiene, toileting, showers/bathing, dressing, and repositioning. A review of Resident 1's care plan for "The resident has multiple body discolorations (any change in your natural skin tone)," dated 8/10/2023, did not indicate the location, size, color, or appearance of the multiple discoloration skin discolorations. The care plan interventions included facility staff to carry out to address the discolorations included "Educate resident/family/caregiver of causative factors and measures to prevent skin injury". A review of Resident 1's "Wound Weekly Monitoring Assessment-Non-Pressure" dated 11/2/2023 at 7:59 AM, indicted the resident did not have any skin concerns other than a bump/lymphoma (tumor) on the left shoulder. A review of Resident 1's "Assessment Summary" dated 11/6/2023 at 1:33 PM, indicated the resident had a change in condition. The change in condition was documented as: "skin dermatitis [rash: redness and inflammation of the skin] to Left cheek, right lower chin, and left forearm. Nursing assessment done with no itchiness, pain, or drainage noted to site.". A review of Resident 1's situation background assessment and recommendation (SBAR- is a structured communication tool that helps teams share information about the condition of a patient or team member or about another issue the team needs to address) form dated 11/6/2023 at 1:33 PM, indicated the resident had "skin dermatitis [rash: redness and inflammation of the skin] to left cheek, right lower chin, and left forearm." The SBAR interventions to improve the skin condition included, "Tx [treatment] as ordered, monitoring, and possible derma consult". The SBAR indicated an order received for Triamcinolone (medication used to treat a variety of skin conditions) 0.5% cream for 14 days "until healed and reassess" and Claritin (medication to treat allergies) 10 milligrams (mg- unit of measurement) daily for one week. A review of Resident 1's complete Medical Records for 11/6/2023, did not indicate the facility conducted a body assessment on Resident 1. A review of Resident 1's SBAR dated 11/6/2023 at 3 PM, indicated on 11/6/2023 at around 3 PM, Resident 1's physician examined the resident's skin and ordered Acyclovir (medication to treat shingles [(also known as herpes zoster, is a viral disease characterized by a painful skin rash with blisters in a localized area], a painful rash caused by a virus, that may appear as a stripe of blisters). The SBAR indicated Resident 1 had no pain but was noted with itchiness (unspecified). The SBAR indicated treatment cream administered to affected areas, and Claritin 10 mg one time (x 1) administered as ordered and same tolerated with no adverse side effect (ASE). A review of Resident 1's care plan for "Resident has Left Forearm unspecified skin dermatitis" dated 11/6/2023, did not indicate the size, color, or appearance of the dermatitis. The care plan interventions included facility staff to address the dermatitis included "apply treatment as ordered, keep skin clean and dry, monitor effectiveness of tx (treatment), monitor any skin changes, inform MD if tx not resolved ..." A review of Resident 1's "Health Status Note" dated 11/8/2023 at 11:29 AM, indicated a physician's order to discontinue the Acyclovir. A review of Resident 1's SBAR dated 11/12/2023 at 10:46 AM, indicated, "noted resident with left thigh skin scratch with 5-centimeter (cm, unit of measurement) x 0.8 centimeters (cm - unit of measurement)." The SBAR interventions included to administer antiviral medications (medications help the body fight off harmful viruses). A review of Resident 1's Interdisciplinary Team (IDT, a team of health care professions who work together to establish plans of care for residents) dated 11/15/2023 at 8:47 PM, indicated, "skin care treatment rendered as ordered." However, the IDT notes did not indicate if IDT discussed conducting assessment about the skin rashes for Resident 1. A review of resident 1's "Health Status Note" dated 11/16/2024 at 2 PM, indicated a physician's order to increase Zoloft (medication to treat depression) from 50 mg to 100 mg via gastrostomy tube (GT- a surgical procedure to insert a tube through the abdomen and into the stomach used to administer nutrition, hydration, and or medication) daily for depression manifested by (M/B) episode of crying. A review of Resident 1's admission record indicated on 11/16/2023, a diagnosis of Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) was added to Resident 1's medical record. A review of Resident 1's care plan for "Resident has left thigh unspecified skin dermatitis" dated 12/4/2023, indicated interventions facility staff needed to carry out to address the dermatitis included cleanse with normal saline (wound care solution) and apply Triamcinolone cream 0.05% every (Q) shift x 14 days, keep clean and dry, and monitor for signs and symptoms of infection and adverse changes. The care plan did not indicate the facility reviewed and updated the current interventions, after the 14 days of treatment with Triamcinolone cream 0.05%. A review of Resident 1's "Physician Order Note" dated 12/13/2023 at 1:26 PM, indicated Resident 1 to continue Zoloft due to "episode of crying." A review of Resident1's "IDT Progress Note-Behavior Management" dated 1/5/2024 at 2:02 PM, indicated Resident 1 was referred to psychiatry services due to "use of Zoloft 50 mg daily for depression manifested by (m/b) crying. Pt's (patient's -Resident 1) medication was initiated at the facility due to (d/t) intermittent episodes of crying observed by staff and family." A review of Resident 1's MD Progress Notes dated 1/9/2024 at 12:21 PM., indicated Resident 1 was diagnosed with dermatitis, noted with rashes in armpit area, and started on nystatin (medication to treat fungal infection/s) twice a day and hydrocortisone cream (medication used to reduce pain, itching, and swelling (inflammation) twice a day. The MD progress note indicated Resident 1 did not have decision making capacity. A review of Resident 1's "After Visit Summary" report from the outpatient clinic Neurologist (a medical doctor with specialized training in diagnosing, treating, and managing disorders of the brain and nervous system) dated 3/5/2024 at 1:15 PM, indicated the reason for the visit was "nonspecific paroxysmal spell" (alteration in consciousness that look like seizures) and "rash," and that on 3/5/2024, the neurologist referred Resident 1 to outpatient dermatologist (doctor who specializes in disorders of the skin). A review of Resident 1's "Assessment Summary" note dated 3/5/2024 at 9:15 PM, indicated "General Skin Conditions: Rash Itching." The note did not indicate the location and size of the rash or if a physician was notified. A review of Resident 1's care plan for "The resident has rash trunk, legs, arms, armpit rash, general body rash .... Thin and fragile skin," initiated on 3/5/2024, indicated interventions included the facility will address the rash, avoid scratching, daily shower as tolerated, "derma" (dermatologist) consult, and monitor skin for signs and symptoms of infection. A review of Resident 1's "Assessment Summary Note," dated 3/12/2024 at 2:04 PM, indicated "General Skin Conditions: Rash Itching." The note did not indicate the location and size of the rash, or if the facility notified a physician about the itchy skin rash. A review of Resident 1's "Health Status Note," dated 3/27/2024 at 1:30 PM, indicated Resident 1 left the facility to a dermatology appointment. A review of Resident 1's "After Visit Summary" from the outpatient clinic dated 3/27/2024 at 2 PM, indicated the reason for the visit was "Scabies" (an infestation of the skin where mites (small bugs) dig its way into the top layer of the skin where it will live and lay eggs). A focal skin examination was performed of the face, head, neck, chest, right upper extremity (RUE-arm), left upper extremity (LUE - arm), right lower extremity (RLE-leg), left lower extremity (LLE -leg) ... "Pertinent findings: -Bilateral (both) palms with erythematous papules (solid elevation of skin with no visible fluid that is reddish (erythematous) in color), single pustule (a bulging patch of skin that's full of a yellowish fluid called pus), scaly -Few linear (resembling a line) burrows in interdigital (in between fingers and toes) areas -Erythematous papules on bilateral upper and lower extremities Note: Favor scabies given clinical, also notable scybala (feces) and ovum (eggs) on mineral oil prep scraping... The same After-Visit Summary further indicated the plan included: -Start Permethrin (medication used to treat infestations of small parasites) 5 % Topical (TOP-apply to skin) Cream to entire body (include face since involved) at night today and wash off in morning - REPEAT in 7 days ... -Start Ivermectin (medication used to treat diseases caused by parasites like head lice and for skin conditions) 3 mg oral (by mouth) TAB (tablet) -4 pills (12 mg) total once today -Start Triamcinolone Acetonide 0.1 % Topical (TOP) Ointment (OINT) tomorrow to affected areas except face and skin folds -Wash all bedding/clothing -Discussed that may remain itchy for 4-6 weeks after treatment. A review of Resident 1's admission record for 3/27/2023, did not indicate the scabies diagnosis was added to the resident's medical record. A review of Resident 1's care plan for "The resident has rash (general body) at risk for recurrent skin problems secondary to diagnosis of diabetes, anxiety, anemia (low blood count), quadriplegia (paralysis from the neck the neck to the legs), incontinent, bedbound status, thin and fragile skin" dated 3/27/2024, did not indicate the diagnosis of scabies. The care plan interventions included the facility to "Deep clean room (volves cleaning objects or surfaces that may not be routinely cleaned, such as walls, ventilation ducts, curtains, carpets) [Resident 1's] after emilite application". The care plan did not have an indication for the emilite. A review of Resident 1's "Infection Note" dated 3/28/2024 at 2:54 PM, indicated "On 3/27/24, Resident returned from doctor's appointment with orders for Ivermectin and Elimite (medication used to treat scabies). The Infection indicated Resident 1's was explained to that Resident 1 has a history of on and off rashes, and that Resident 1's physician was aware and was actively treating and addressing the resident's skin concerns. b. A review of Resident 2's Admission Record indicated the facility readmitted Resident 2 on 9/17/2023 with diagnoses that included hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebrovascular accident (damage to the brain from interruption of its blood supply), aphasia (A language disorder that affects a person's ability to communicate), dysphagia (swallowing difficulties) and type 2 diabetes (is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). The admission record did not indicate Resident 2 was readmitted with any skin rashes. A review of Resident 2's History and Physical (H&P) dated 10/16/2023, indicated the resident did not have the capacity to understand or make decisions. A review of Resident 2's MDS dated 3/5/2024, indicated the resident's skin was intact with no abnormalities, rashes, or sores. A review of Resident 2's "Weekly Summary: Nursing" note dated 3/25/2024 at 9:49 PM, indicated "General skin conditions: normal (Assessment not applicable), dermatitis". The note did not indicate where the dermatitis was located. A review of Resident 2's care plan for "The resident is at risk for recurrent skin rashes, itching, skin eruption related to: dermatitis" dated 12/27/2023, indicated interventions included to observe Resident 2 for skin irritations, signs and symptoms of infection, and trimming fingernails. The care plan indicated a new problem was identified on 3/26/2024 "Xerosis [abnormally dry skin] skin generalized body." A review of Resident 2's "Weekly Summary: Nursing" note dated 3/4/2024 at 10:42 PM, indicated, "General Skin Conditions: Skin Normal (Assessment Not Applicable, Dermatitis)". A review of Resident 2's "Weekly Summary: Nursing" note, dated 3/12/2024 at 3:40 PM, indicated, "General Skin Conditions: Skin Normal (Assessment Not Applicable, Dermatitis)." A review of Resident 2's "Weekly Summary: Nursing" note dated 3/25/2024 at 9:49 PM, indicated, "General Skin Conditi