Health inspection·August 20, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain its infection control/prevention surveillance program for two of two sampled residents (Resident 1 & Resident 2) by failing to: Residents Affected - Some a. Initiate a scabies line list immediately after Resident 1 was confirmed to have scabies from a positive skin scrapping test result. b. Ensure that Infection Control measures were implemented when Resident 2 was identified to be highly suspicious of scabies. This deficient practice compromised infection control measures to prevent the potential spread of infections. Findings: a. During a review of Resident 1's admission Record (Face sheet), dated 8/16/2024, the facility admitted the resident on 6/6/2022, with diagnoses that respiratory failure, transient ischemic attack (a temporary disruption in the blood supply to part of the brain), epilepsy (a common condition that affects the brain and causes frequent seizures), and quadriplegia (a form of paralysis [the loss of the ability to move some or all of the body] that affects all four limbs, plus the torso). A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 6/5/2024, indicated Resident 1's cognition was severely impaired, and Resident 1 was dependent with activities of daily living. During a concurrent interview and record review on 8/16/2024 at 1:33 PM with Licensed Vocational Nurse (LVN) 1, Resident 1's Change of Condition Evaluation dated 8/12/2024, was reviewed. LVN 1 stated that she noticed the generalized rash on Resident 1 and notified the Medical Doctor (MD) on 8/12/2024. CNA 1 stated the MD ordered a skin scrapping test (allows collection of the superficial skin cells and further evaluation of the cells under microscope or cultured environment in the laboratory), and results confirmed a positive scabies result. CNA 1 stated that the resident was placed on contact isolation and the family was notified. During an interview on 8/16/2024 at 2:43 PM with Infection Preventionist (IPN) 1, IPN 1 stated only Resident 1 was confirmed and identified to have scabies. IPN 1 nurse stated that no line listing was initiated for this incident, as they did with their COVID outbreak, because the recommendation of the line listing for their COVID outbreak was directed from the Public Health Department. Page 1 of 4 055104 055104 08/20/2024 Sunset Manor Conv Hosp 2720 Nevada Avenue El Monte, CA 91733

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 8/16/2024 at 3 PM with the Director of Nursing (DON), the DON stated the scabies incident was not reported to the Public Health Department, because it was an isolated incident. The DON stated that Resident 1 was confirmed to have scabies after skin scrapping test results were positive. The DON stated the resident's primary clinicians were notified. The DON stated based on the Dermatologist's physical assessment other residents were started on treatment prophylactically (to prevent or guard against something, such as disease or infection) in the sub-acute unit. The DON stated she did not know if there was a line listing initiated, she would need to ask the IPN. During a review of the line listing e-mailed dated 8/16/24 at 5:40 pm and a concurrent interview, the IPN 1 stated she just completed the line listing today when requested. IPN 1 stated the line listing is incomplete and did not include the list of staff who were potentially exposed to Resident 1. IPN 1 stated it was important to identify both residents and staff who were exposed to Resident 1 to monitor them for signs and symptoms of scabies. During a review of the local guidelines for Scabies Prevention and Control and a concurrent interview on 8/19/24 at 12:55 pm, Infection Prevention Nurse 2 (IPN 2) stated she referred to the local guidelines for scabies Prevention and Control. IPN 2 stated based on the guidelines she needed to identify both the staff and residents who were exposed to Resident 1 so the IPN could be provided education about scabies and to monitor both the residents and staff for rash or itching. b. During a review of Resident 2's admission Record, the record indicated the facility initially admitted Resident 2 to the facility on 2/1/24, and readmitted the resident on 7/15/24, with diagnoses that included functional quadriplegia (complete immobility due to severe disability or frailty,) aphasia (a communication disorder that affects speech, writing, and language understanding.) During a review of Resident 2's Change of Condition (COC) dated 6/4/24, the COC indicated Resident 2 had a generalized body rash. The COC indicated the attending physician was notified and there was an order for triamcinolone acetonide (corticosteroid - anti-inflammatory) external cream to be applied to general body topically two times a day for rash. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was severely impaired with making decisions regarding tasks of daily life and was dependent with all activities of daily living. During a review of Resident 2's Dermatology Progress Notes dated 7/23/24, the progress notes indicated a diagnosis of generalized dermatitis, unspecified. The notes indicated an order for the following medications: 1. Elimite - (Permethrin cream) is a topical scabicide agent for the treatment of infestation with scabies. 2. Ivermectin - unlabeled use for treatment of scabies. During a review of Resident 2's typewritten orders dated 7/23/24, the order indicated the following: 1. Permethrin 5% cream, apply from neck to toes. Leave for 12 hours then rinse, repeat once a week for 4 weeks. 055104 Page 2 of 4 055104 08/20/2024 Sunset Manor Conv Hosp 2720 Nevada Avenue El Monte, CA 91733

F 0880 2. Ivermectin 3 milligram (mg) tablet, take 12 mg. po once a week for 4 weeks. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 2's Nurse Progress Notes dated 8/6/24, the notes indicated FM requested a dermatology consult for Resident 2 because FM was diagnosed with scabies. Residents Affected - Some During an interview on 8/19/24 at 1:40 pm, Resident 2's Family Member (FM) stated Resident 2 had a rash for months. Resident 2's FM stated it started on the left arm and it had moved to the arms, legs, and abdomen. Resident 2's FM stated she had been diagnosed with possible scabies and requested from Resident 2's licensed nurses to test Resident 2 for scabies. The FM stated she was informed Resident 2 was already getting treatment for scabies and for the itching. During an interview on 8/20/24 at 2:20 pm, the Dermatology Nurse Practitioner (NP) stated during his assessment of Resident 2's rash last July, the rash was highly suspicious for scabies and treatment was started right away. The NP stated he had notified Treatment Nurse 2 about the high suspicion for scabies and because there was no scraping to confirm the diagnosis of scabies, he wrote a diagnosis of dermatitis. The NP stated it was the facility's responsibility to initiate control measures and implement interventions to prevent the spread of scabies. During an interview on 8/20/24 at 2:50 pm, Treatment Nurse 2 (TN 2) stated during the NP rounds with Resident 2, the NP never told TN 2 Resident 2's rash was highly suspicious for scabies. TN 2 stated the order indicated the order for Elimite and Ivermectin was for dermatitis and carried out the order as written. During an interview on 8/20/24 at 3:15 pm, Infection Prevention Nurse 2 (IPN 2) stated when she saw the new orders of Elimite and Ivermectin for Resident 2, IPN 2 stated she asked TN 2 if the NP suspected scabies. IPN 2 stated TN 2 informed her the written diagnosis was for unspecified dermatitis. IPN 2 stated the facility's process with new orders for antibiotics, antifungals, antivirals, and in this case anti-scabies, the nurse who received the new order would need to clarify the proper indication and ask the NP if there was a suspicion for scabies since Resident 2 was started on treatment for scabies. During this same interview, IPN 2 stated Resident 2 was in the subacute unit so Resident 2 was already on enhanced standard precautions. IPN 2 stated if it was determined from the NP that there was suspicion for scabies then IPN 2 would put Resident 2 in a separate room with contact isolation, initiated in-services to all staff, room disinfection, initiated contact tracing and investigated possible exposures. During an interview on 8/20/24 at 4:00 pm, the Director of Nursing (DON) stated she was not informed by TN 2 she carried out an order for scabies treatment and she was not notified by the NP about Resident 2 being highly suspicious for scabies. The DON stated if she was notified regarding the dermatologist assessment and diagnosis of Resident 2 was highly suspicious for scabies then the facility would initiate a plan to prevent and control scabies infestation. The DON stated she would expect her licensed nurses to carry out physician orders. The DON stated Permethrin is used to treat various skin conditions so she would not have questioned the NP orders. During a review of the drug information sent by the facility's contracted pharmacy on 8/20/24 at 5:06 pm, the information indicated Elimite was a topical scabicidal agent. During a review of the drug information from a drug handbook provided by the DON, the information 055104 Page 3 of 4 055104 08/20/2024 Sunset Manor Conv Hosp 2720 Nevada Avenue El Monte, CA 91733

F 0880 indicated Ivermectin had an unlabeled use for the treatment of scabies. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's Policy and Procedure titled Infection Control Prevention Surveillance dated January 2018, the facility employs an infection surveillance program to help prevent to the extent possible the development and transmission of disease and infection. The P&P indicated outcome surveillance examples include the collection of signs and symptoms data as well as laboratory data and comparing to standard written definitions (criteria) of infections. Residents Affected - Some During a review of the local Public Health Guidelines dated July 2019, titled Scabies Prevention and Control Guidelines for Healthcare Settings. The guidelines indicated scabies can be diagnosed clinically or via skin scraping. The guidelines indicated to prepare a line listing of symptomatic patients/residents and healthcare workers with a separate line list of their contacts. Evaluate contacts for scabies. 055104 Page 4 of 4