complaint·January 7, 2026

LPA interviewed AD who denied the allegation, stating that no resident or staff has been diagnosed with scabies, cleaning was increased and laundry detergent switched in response to a resident having itchiness, and all residents with itchiness are receiving proper evaluation, treatment, and care. Per AD, scabies was suspected for R1, but R1 has never been diagnosed with scabies. AD stated that R1 has had itchiness since June 2025, on and off, and R1’s doctor actually put R1 on medication for scabies, but it did not work, and R1’s doctor determined R1 does not have scabies. LPA interviewed R1’s hospice case manager who stated that, although R1 has received scabies medication three times, two of those treatments had no effect, R1 has never received a diagnosis of scabies, R1’s doctor does not think R1 has scabies, and R1 is receiving other medications to address their itchiness and is being referred to dermatology for their itchiness. LPA reviewed R1’s hospice medical records which confirm R1 has not had a diagnosis of scabies, has received scabies medication as a prophylaxis in case R1 did have scabies, has received multiple other medications to address their itchiness, and as of January 6, 2026, was referred to dermatology to evaluate for possible “underlying dermatologic or systemic causes” of R1’s itchiness. The information obtained did not corroborate that R1 had scabies. Per AD, scabies was also suspected for R2, but R2 has never been diagnosed with scabies, although R2’s doctor has put R2 on scabies medication. LPA reviewed R2’s facility progress notes which indicate that on December 31, 2025, R2 was seen by their doctor who did not notice or address any skin condition, but on January 3, 2026, facility staff noticed R2 with a rash on their arms and R2’s doctor was notified. LPA reviewed R2’s medical records, which show that R2 was prescribed scabies medication on January 6, 2026. LPA interviewed R2’s responsible party who confirmed that R2 was never tested for or diagnosed with scabies, but that R2’s doctor assumed R2 had scabies because it was reported to R2’s doctor that R2 had itchiness and that another resident at the facility had scabies. LPA interviewed R2’s doctor who confirmed that R2 was never tested or diagnosed with scabies, but that scabies was a possibility and so they prescribed the scabies medication presumptively, which is standard practice. The information obtained did not corroborate that R2 had scabies. Per AD, when the issue of scabies arose, the facility began tracking residents with itchiness. AD provided information that, in addition to R1 and R2, there are four other residents with itchiness, all are being overseen by their medical providers, and none has been diagnosed with scabies. LPA inspected the facility, conducted health and safety checks on residents, did not observe rashes or skin irritation on the residents identified as having itchiness and did not observe these residents scratching, and observed that bedding and seating surfaces were clean. AD stated the facility is following its infection control plan, has sufficient PPE, is conducting increased cleaning, is recommending scabies skin tests for affected residents, and will contact local public health for assistance and guidance. LPA provided AD with the contact information for local public health. Regarding the allegation that staff are not following infectious control requirements: it was alleged that a resident contracted scabies and the facility did not take proper infection control precautions, resulting in the scabies spreading. LPA reviewed the facility’s infection control plan, which is complete. However, the information and documents obtained did not corroborate that any resident has a positive diagnosis of scabies, although there are potential cases. LPA inspected the facility, conducted health and safety checks on residents, observed no health and safety issues, and observed the facility has a small supply of gowns, with PPE stations including gowns set up in front of the rooms of the residents identified has having itchiness. Per AD, more gowns have already been ordered and will arrive soon. LPA conducted health and safety checks on the residents affected by itchiness and did not observe any rashes or skin irritation or that the residents were scratching. Per AD, residents with itchiness are being tracked, all affected residents are receiving assessment and medical care from their medical providers, the facility is recommending scabies skin tests to affected residents, the facility is following its infection control plan, and AD will contact local public health for additional assistance and guidance. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.