Complaint·March 13, 2024

Allegation: Staff is not preventing the spread of scabies On 3/13/24 LPA Shirley reviewed resident’s files and incident reports. LPA observed 2 incident reports that were sent to CCLD for scabies. The first report indicated there to be one incident that occurred 6/9/22, reported 6/14/22. Assessment of all the residents in Memory care unit proved signs of possible scabies on a few other residents. The Physician was notified, the community was locked down and quarantined. All residents were treated for possible scabies. Family, POA and Public health were all notified. LPA observed the second report that indicated a scabies outbreak in Memory Care unit that occurred 3/28/23. Four residents were diagnosed and treated for scabies. Measures were put into place to help mitigate the spread and keep it contained. Families and public health were notified. LPA reviewed response from public health in which guidance on Outbreak Management was provided along with an attached Scabies Toolkit. On 2/29/24 LPA Shirley interviewed Staff 1 – Staff 10 (S1-S10). LPA asked, did residents in the Memory Care unit have scabies? Of those interviewed, 5 out of 10 answered yes. LPA asked residents, did you know about an outbreak of scabies. Of those interviewed, 10 out of 10 was not aware of an outbreak. Based on information gathered, the department did not find sufficient evidence to support allegation "Staff is not preventing the spread of scabies.” This facility was not negligent, residents were tested and public health was contacted as is protocol. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Staff are not preventing residents from engaging in inappropriate behaviors It was reported that a resident from the assisted living side of the facility digs in the trash and the dog disposal and takes things out the trash and touches things within the facility. On 3/13/24 LPA Shirley reviewed resident’s file, which included yearly Appraisal/Needs and services plans and assessments. Upon review of documents, LPA observed that R1 has had this behavior their whole life and that their behavior has been documented on several needs and services plans and also provided what precautions that the staff were taking. Resident was moved from the assisted living side and placed in the Memory Care Unit of this facility. Con'd on 9099-C On 2/29/24 LPA Shirley interviewed Staff 1 – Staff 10 (S1-S10). LPA asked, did a resident from the assisted living side dig in the trash every day which also contained a dog disposal in the trash can? Of those interviewed, 8 out of 10 answered yes. LPA asked residents, have you ever seen a resident that use to dig in the trash everyday? Of those interviewed, only 2 out of 10 remembered the incident and answered yes. Based on information gathered and interviews conducted, the department did not find sufficient evidence to support the allegation, staff are not preventing residents from engaging in inappropriate behaviors. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted and a copy of the LIC 9099 was provided to Executive Director Janie Acosta.