complaint·February 19, 2026

In regard to the allegation “Staff did not ensure that the facility was free of scabies”, It is alleged that R1 was admitted to emergency for an unwitnessed fall and upon exam it was discovered R1 had scabies. During interview with Administrator, and staff five (5) out of seven (7) stated that they did not observe R1 to have any rash. Administrator stated that the Dermatologist came on 11/19/2025 and only treated R1 for redness around sacral/buttocks. S1 and S3 stated there was a little rash on back but was not reported only documented on body assessment chart. During interviews with residents four (4) out of five (5) residents stated that they have had no rash. LPA obtained documents that facility has ongoing pest services on a monthly basis. There is no evidence of a current scabies outbreak or documentation or evidence obtained that any other resident is currently diagnosed with scabies. LPA did not obtain any evidence that R1 obtained the scabies due to staff neglect and/or lack of care and supervision. It is undetermined how R1 contracted the scabies. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was proved. In regard to the allegation “Staff did not address resident's change in condition”, It is alleged that R1 was not treated for skin condition prior to be admitted to hospital on an unrelated manner. Treating physician reported R1 had scabies and treatment was initiated due to the resident's skin condition/symptoms. During interview with Administrator, and staff seven (7) out of seven (7) stated that there was no report of a change of condition. Administrator stated that dermatologists are at facility weekly and no report of rash was reported. During interviews with residents five (5) out of five (5) residents stated that they have had no problems with rashes. During record review it was revealed that on 11/18/2025 body assessment chart taken by caregiver indicated little red spots on lower neck. On 11/19/2025 there was no evidence that R1’s NP addressed the redness caregiver observed as notes provided do not discuss this new red area observed or addressed. On 11/24/2025 R1 was discharged to facility with PIH document with scabies diagnosis. NP notes dated 11/26/2025 once again do not mention anything about the redness around the back neck or scabies. NP finally documents potential scabies on 12/03/2026 notes after R1 had been discharged from hospital with scabies diagnosis. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of this report was provided.