complaint·April 5, 2025

LPA reviewed R1’s facility file. Upon admission, R1 had a general body rash and dermatitis. After summary reports on file from 8/16/24 – 10/24/24 indicated that R1 had either a bacterial skin condition or dermatitis. Staff interviewed stated they suspected R1 to have scabies due to increased itch and observation of skin. R1’s family member agreed to take resident to the doctor’s appointments. The after summary reports did not mention scabies, however, it was noted that on 9/18/24, the doctor prescribed Permethrin cream to treat dermatitis. Staff indicated that the family member later called and reported that R1 has scabies while at the hospital. Allegation - Resident sustained an injury from an unwitnessed fall due to lack of supervision. It is alleged that Resident #1 (R1) fell and sustained a bruise to the hip area down to the calf. Staff and Residents were interviewed regarding this allegation. The administrator stated there are 2 care staff per shift in the memory care unit and 1 care staff and a med tech in the other cottages. Staff indicated they are frequently checking on the resident, at least 1 to 2 hours. Staff stated that when a resident falls, they contact the med tech to inform them of the fall. The med tech and Resident Care Coordinator will assess the resident and contact 911. Regarding R1, Staff stated that the resident had fallen while at the facility. However, staff attended to the resident and assessed right away. Per resident interviews, staff are always supervising residents and those who have fallen at the facility were helped immediately. Allegation - Facility staff did not notify resident’s authorized representative of the resident’s injury. LPA Chan interviewed the administrator and staff regarding this allegation. Per administrator and staff, anytime there is a fall or injury to a resident, they would contact the authorized representative to inform them of the incident. Care staff stated that they do not notify families of the incident. The administrator, resident care coordinator, or med techs are responsible for notifying the authorized representatives. Per staff, R1’s authorized representative was notified of all known falls and/or injuries. Five of the residents interviewed indicated that their families are notified if anything happens to them. (Continue on LIC9099C) Allegation - Facility is not reporting contagious outbreak to residents and/or their authorized representatives. It is alleged that the scabies outbreak was not reported to the residents and their authorized representatives. The administrator and staff stated that the scabies outbreak was reported to the public health department, licensing, residents, and authorized representatives. The outbreak occurred back in November 2024 in the memory care unit. LPA observed a line list of residents with the onset of scabies symptoms and the doctor’s diagnosis. Per the administrator, there was no letter provided by the public health department. Staff stated they notified the all the families/authorized representatives via telephone and the affected residents’ physicians. They also stated visitors were informed of the outbreak during visitations. 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 with Staff B. Walsh. A copy of this report, along with the appeal rights, was provided.