Griffith Park Healthcare: Skin Assessment Failures - CA
The resident, who had been incontinent and occasionally refused diaper changes, was admitted on August 8 with moisture-associated skin damage caused by prolonged exposure to bodily fluids. Federal inspectors found the facility violated its own policy by failing to conduct the mandated weekly skin evaluations through August 25.
"Not having a weekly skin assessment of Resident 1's MASD had the potential for further skin breakdown," the Director of Nurses told inspectors during their August 25 visit.
The resident required partial assistance with toileting and personal hygiene, was frequently incontinent of urine, and had occasional bowel incontinence. Her Braden Scale assessment rated her at high risk for pressure injuries.
Treatment Nurse 1 acknowledged the oversight during interviews. "There was no weekly assessment because it was missed," the nurse said. She emphasized the importance of regular monitoring "due to the resident's occasional refusal of diaper change."
The facility's care plan specifically called for monitoring and documenting the location and size of the skin injury, tracking treatment effectiveness, and reporting any abnormalities or signs of infection to the doctor. None of this weekly documentation occurred.
"The weekly skin assessment would determine if the current treatment was working or not, and if the MD needed to be notified," Treatment Nurse 1 explained to inspectors.
The resident's medical history complicated her care. She had diabetes, which can impair healing, and anemia, which reduces oxygen delivery to tissues. Her History and Physical examination showed she had the mental capacity to understand and make healthcare decisions.
Moisture-associated skin damage occurs when skin breaks down from prolonged contact with bodily fluids. Unlike pressure ulcers caused by sustained pressure on bony areas, MASD develops from chemical irritation and requires different treatment approaches.
The facility's own policy, last revised in April 2020, required staff to assess residents for pressure injury risk factors upon admission and repeat these assessments weekly. The policy mandated evaluating, reporting and documenting potential skin changes and reviewing intervention effectiveness on an ongoing basis.
Federal inspectors reviewed the resident's complete electronic health record from her August 8 admission through their August 25 inspection. The documentation showed the skin damage was present upon arrival but confirmed no weekly assessments had been completed.
The resident's Minimum Data Set assessment, initiated August 15 and completed August 25, documented her incontinence patterns and assistance needs. This comprehensive evaluation tool captures resident conditions and care requirements but cannot substitute for the specialized weekly skin monitoring required by facility policy.
During concurrent interviews and record reviews, both the Director of Nurses and Treatment Nurse 1 confirmed the assessment failures. The treatment nurse specifically noted the resident's occasional refusal of diaper changes as a factor that made regular skin monitoring even more critical.
The inspection occurred following a complaint about the facility's care practices. Inspectors found the violation represented minimal harm or potential for actual harm, but noted the deficient practice could negatively affect the resident's quality of life.
Moisture-associated skin damage can progress to deeper tissue injury if not properly monitored and treated. The resident's diabetes and anemia created additional risk factors that made consistent assessment particularly important for preventing complications.
The facility's policy emphasized the importance of identifying pressure injury factors and implementing targeted interventions. It required staff to assess effectiveness of treatments and modify approaches when skin conditions failed to improve or showed signs of worsening.
Treatment Nurse 1's admission that weekly assessments were "very important" for this resident underscored the significance of the oversight. The nurse's acknowledgment that assessments would determine treatment effectiveness and guide physician notification highlighted the clinical consequences of the missed evaluations.
The resident's care plan had been established within hours of admission, recognizing the skin integrity issues and outlining specific monitoring requirements. However, the systematic failure to follow through on weekly assessments left gaps in her clinical oversight during a vulnerable period.
Federal inspectors classified this as affecting "few" residents, indicating the assessment failures were not widespread throughout the facility. The violation specifically related to pressure ulcer care standards and the facility's obligation to prevent new injuries from developing.
The diabetic resident with moisture-associated skin damage remained at the facility during the inspection, her weekly assessments still incomplete seventeen days after admission.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Griffith Park Healthcare Center from 2025-08-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
GRIFFITH PARK HEALTHCARE CENTER in GLENDALE, CA was cited for violations during a health inspection on August 25, 2025.
Federal inspectors found the facility violated its own policy by failing to conduct the mandated weekly skin evaluations through August 25.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.