F0636

B

Failure to Timely Reassess Resident’s Occipital Area Obscured by Matted Hair

Lake Forest, California Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The facility failed to complete a timely and thorough assessment of a newly admitted resident’s occipital (back of head) area when it was initially unable to be visualized due to matted hair. Facility policy titled “admission of a Resident” required a licensed nursing assessment and development of a plan of care upon admission. The resident was admitted and a nurse’s progress note, entered late and dated 3/12/24, documented that the resident’s hair was matted to the occipital area and the scalp could not be visualized. Despite this, there was no documented reassessment of the occipital area until 3/27/24, 16 days later, when a family member worked through the matted hair and observed dry blood on the scalp. In an interview, an LVN stated that at admission staff could only see the matted hair, that the family member wanted to work through the matted hair, and that the scalp was only seen once the hair was worked through, confirming the delay in reassessment and complete assessment of the resident’s occipital area.

The Administrator and DON were later informed of and acknowledged these findings, and the surveyor concluded that the failure to reassess the occipital area in a timely manner had the potential to negatively impact the resident.