complaint·December 26, 2024

During the subsequent visit conducted on 12/26/24, LPA Khurshudyan collected staff and resident rosters, toured the physical plant at 10:00am and interviewed Memory Care Director Alma Fuentes. Review of medical records confirmed that two (2) residents were seen by their primary physicians and diagnosed with scabies on 11/15/24 and 11/21/2024. Topical medication was prescribed for treatment. Additionally, three (3) staff members reported having skin irritation and itching during the same time frame. Records review showed that the first Incident Report submitted to CCL regarding a resident with body itching was received on 9/5/2024 and per SIR an anti-itch powder applied. Further interviews with staff members confirmed that the skin rash issue started about five (5) months ago, and almost every resident in Memory Care unit had rash and itchy skin. Documentation review indicated that although the facility was aware of two (2) confirmed scabies diagnosis, and at least seven (7) residents with skin rash problems, staff did not follow Universal Precautions at the facility. The facility failed to immediately notify all staff of the confirmed scabies cases and did not ensure that appropriate infection control measures were implemented throughout the affected unit. Interviews with the Memory Care Director revealed that the facility relied solely on the facility’s doctor’s evaluation and did not implement preventive measures as required by Universal Precautions reporting to Department of Public Health on time. Based on interviews, records review, and observations, there is sufficient evidence to support that staff did not utilize universal precautions while caring for residents affected with skin rash which posed rash epidemic within the Memory Care unit. Therefore, the allegation is substantiated. Deficiency issued on LIC9099-D. Exit interview conducted, appeal rights explained and copy of this report delivered.