The resident, identified only as Resident 1 in federal inspection records, was admitted with cellulitis of her right lower leg, peripheral vascular disease, and dermatitis. Her July assessment showed she had severe cognitive impairment affecting daily decision-making and required substantial help with basic activities like dressing, bathing, and using the toilet.
Staff witnessed the destructive behavior repeatedly. Certified Nursing Assistant 1 told inspectors during an October 22 interview that she had seen the resident "scratched her legs, ears, and almost her entire body." Licensed Vocational Nurse 1 confirmed the next day that the resident "had the behavior of scratching on her arms and legs and picking on her dressing."
The facility's Director of Nursing admitted the oversight during an October 24 interview with federal inspectors. She stated the resident "did not and should have had a care plan to address resident's behavior of scratching her legs and picking on her dressing."
More concerning, the nursing director acknowledged that the resident's wounds "could have been prevented from getting exposed due to the dressings coming off if the facility had a specific care plan intervention on the resident's behavior."
Federal regulations require nursing homes to develop comprehensive, person-centered care plans with measurable objectives and timetables for each resident's physical, psychological, and functional needs. The facility's own policy, revised in March 2022, explicitly states this requirement.
Yet no such plan existed for this resident's compulsive scratching and dressing removal, despite her multiple skin conditions and cognitive impairment that prevented her from understanding the consequences of her actions.
The resident required supervision even for eating and substantial assistance with personal hygiene tasks. Her cognitive impairment meant she couldn't make daily decisions independently, yet staff provided no structured intervention to prevent her from damaging her own medical treatment.
Cellulitis, the skin infection affecting the resident's right lower leg, causes swelling and redness and can become serious if not properly managed. When wound dressings are removed or disturbed, the risk of bacterial contamination increases significantly.
The resident also suffered from dermatitis, which causes inflammation, itching, dryness, and rashes. This condition likely intensified her urge to scratch, creating a cycle where her cognitive impairment prevented her from understanding that scratching would worsen her skin problems.
Federal inspectors found the facility failed to meet care planning requirements for this resident during their complaint investigation. The deficiency carried a determination of minimal harm or potential for actual harm, affecting few residents.
However, the nursing director's own admission suggests the potential consequences were more serious. By failing to address the resident's behavior, the facility allowed ongoing risk of wound exposure and possible infection complications.
The inspection revealed a fundamental breakdown in individualized care. While the facility had detailed assessments documenting the resident's cognitive limitations and physical needs, staff failed to connect those findings into actionable interventions.
Care plans serve as roadmaps for daily care, telling staff exactly how to address each resident's specific challenges. Without such a plan, different staff members might handle the resident's scratching inconsistently or not at all.
The resident's case illustrates how cognitive impairment can compound physical health problems when facilities don't develop appropriate interventions. Her severe decision-making deficits meant she couldn't participate in her own care or understand why picking at dressings was harmful.
Staff observations alone weren't enough. Multiple employees witnessed the problematic behavior over time, but their awareness never translated into systematic intervention or prevention strategies.
The facility's March 2022 care planning policy clearly outlined requirements for comprehensive, measurable care plans. Yet eight months later, inspectors found this basic standard wasn't being met for a vulnerable resident with multiple interrelated conditions.
Federal inspectors completed their investigation on November 18, documenting how the facility's failure to plan left a cognitively impaired resident at risk of worsening her own medical conditions through behaviors she couldn't control or understand.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Infinity Care of East Los Angeles from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
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