Incident investigation·April 23, 2026

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and initially met with Josephine Ellonye and then with Administrator, Vera Okyere. LPA stated the reason for the inspection. LPA observed a family member depart after visiting with a resident in their room. All other residents were resting in their rooms during the inspection. LPA discussed the letter received from the Administrator on April 22, 2026 noting resident (R1) completed treatment for suspected scabies on April 13, 2026. The administrator explained that (R1) moved in on December 31, 2025 and noticed redness in their upper chest area, which is also documented on a skin assessment conducted that day. The Administrator stated that (3) days after (R1) moved in, she spoke to a social worker who suggested (R1) be evaluated by a skin specialist, since they had previously contracted scabies but was cleared prior to move in. The Administrator stated (R1) continued to use the creme they moved in with , but the rash had not improved, so the doctor prescribed a different creme, Permethrin 5% creme, to be applied twice daily, effective 1/25/2026, which was logged on facility records. The Administrator stated (R1) would itch and only had redness on their chest and buttocks; however, the redness/rash did not resemble scabies rash. (R1) went to the emergency room on March 26, 2026 related to their catheter and returned the next day. The Physician's Report (3/27/26) is complete except for regarding any skin conditions. Medication orders (3/27/26) list Permethrin Topical 5% creme to be given twice daily. LPA reviewed medications for (R1), including the creme Triamcinolone Acetonide .1%, that (R1) has been using since on/around January 2026- and has shown no rash since it's been refilled every (2) weeks, instead of monthly. *cont on 809C-1.. 809C-2... (R1) was not awake during today's inspection so LPA was not able to speak to them. The administrator stated (R1) does not currently have a rash, and no other resident ever acquired a similar looking rash. LPA previously conducted an inspection for February 10, 2026 regarding resident (R1) who showed a rash on their chest starting on February 9, 2026. A video appointment was conducted yesterday and (2) prescription creams were prescribed . (R1) began using the first cream in February 9, 2926, and the rash looks much better and is not itchy. A second prescription creme was started on February 10, 2026. The administrator agreed to change laundry detergents for (R1) to see if there was a possible allergy or (R1) has sensitive skin and wash (R1's) laundry separately. LPA and the Administrator discussed resident (R2) and getting them evaluated for a possible Guardian. The administrator stated (R2) has an in-person appointment with their primary care physician in May 2026 and she will discuss this matter and ask the physician to complete a new referral so (R2) can be evaluated again since they did not qualify over a year ago. The facility notified the Department timely of the skin rash and medical appointments made. There are no deficiencies issued in this report. Exit interview. Copy of report provided.