Health inspection·November 26, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to follow their surveillance plan (oversight plan to prevent the spread of infection) for scabies (an infection that causes an itchy skin rash when mites [tiny insects] burrow under the skin) prevention and control for one of four sampled residents (Resident 1) when, the Infection Preventionist (IP) did not implement the required six-week contact identification list and failed to train and notify all key healthcare personnels on how to recognize and report signs and symptoms consistent with scabies infestation.These failures had the potential to result in continued transmission of scabies among staff and residents within the facility. Findings:During a review of Resident 1's clinical record titled, admission Record, the record indicated Resident 1 was admitted to the facility in 2020 with a diagnosis which included respiratory failure. A review of Resident 1's clinical record titled, Order Summary, dated 8/26/25 at 11:33 AM, indicated the medical provider ordered permethrin cream (medicine that kills mites) and Ivermectin tablets (medicine that kills tiny bugs or worms that live in or on the body) to be administered to Resident 1. A review of Resident 1's clinical record titled, Scabies Examination, dated 8/30/25, indicated, .scabies mites seen.During a concurrent phone interview and record review on 9/23/25 at 2:05 PM with the Infection Preventionist (IP), the facility's surveillance plan titled, PREVENTION AND CONTROL OF SCABIES IN CALIFORNIA HEALTHCARE SETTINGS, was reviewed. The IP stated the PREVENTION AND CONTROL OF SCABIES IN CALIFORNIA HEALTHCARE SETTINGS was intended to guide the facility's response to a scabies infestation. The IP stated she verbally notified the following individuals of Resident 1's scabies diagnosis; the staff during a huddle (a quick and informal meeting), Resident 1's responsible party (RP), and the RPs of Resident 1's three roommates. The IP also stated that she did not follow the submitted surveillance plan when instead of conducting contact identification for six weeks as outlined, she only did for six days (8/21/25 through 8/26/25). Additionally, the IP stated she did not assign a dedicated care team member to provide care for Resident 1 as specified in the plan. During a phone interview on 9/23/25 at 2:30 PM, with the Director of Staff Development (DSD), the DSD stated the facility had not provided a stand-up meeting to all of the staff regarding Resident 1's scabies diagnosis.During a phone interview on 9/23/25 at 2:40 PM, with the IP, the IP stated that the risk of the facility not following their submitted surveillance plan was that the scabies infection could have spread within the facility. During interview on 9/24/25 at 3:05 PM with the Janitor (J) 1, J 1 stated that he heard from other janitors and housekeeping staff that there was a case of scabies in the facility; however, he did not know which resident was affected and believed the affected resident was only under observation for scabies and the case had not been confirmed.During an interview on 9/24/25 at 3:14 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was not part of a huddle when scabies was discussed, and that the huddle was only conducted with the staff who cared for Resident 1 (on the north hallway). CNA 1 stated that all staff should have been informed of the scabies diagnosis because staff were sometimes required to work in other hallways of the facility and could have been exposed. Residents Affected - Few Page 1 of 3 555164 555164 11/26/2025 Arbor Rehabilitation & Nursing Center 900 North Church Street Lodi, CA 95240

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few CNA 1 stated that she learned of Resident 1's diagnosis after she was assigned to deliver meal trays to the north hallway and was advised by other staff to wear Personal Protective Equipment (PPE, gown, gloves, mask, booties) when going into Resident 1's room. CNA 1 also stated she had not attended an in-service about scabies. During an interview on 9/24/25 at 3:31 PM with CNA 2, CNA 2 stated that she normally worked at the north station and was unaware that Resident 1 had tested positive for scabies. CNA 2 stated she learned of it only when another CNA informed her while passing meal trays. CNA 2 denied attending a huddle or being notified by the IP regarding the Resident 1's positive scabies case and could not recall receiving any scabies in-services. CNA 2 stated that if anyone who cared for Resident 1 (who was positive for scabies) should have worn a gown, washed hands before and after care, and thrown the gown in the trash can located inside Resident 1's room.During an interview on 9/24/25 at 3:44 PM, with Housekeeper (H) 1, H 1 stated that her duties included cleaning inside the resident rooms. H 1 stated she became aware of Resident 1's diagnosis of scabies after she observed an isolation sign posted by the door (a sign that indicates what PPE was necessary to wear before entering the room) and after a nurse informed her of the scabies. H1 stated she did not attend a huddle or receive in-service training regarding scabies. During an interview on 9/24/25 AT 3:53 PM with CNA 3, CNA 3 stated she was unaware that any resident (Resident 1) at the facility had scabies in 8/25 and did not know of any staff huddles that were conducted. During an interview on 9/24/25 at 3:57 PM with Licensed Nurse (LN) 1, LN 1 stated he was not informed of any staff huddle or of a positive case of scabies in the building. LN 1 stated he recalled receiving a scabies in-service in the year 2023 or 2024, but nothing in the year 2025. During an interview on 9/24/25 at 4:06 PM with LN 2, LN 2 stated that she knew about a positive scabies case because another nurse from north station informed her. LN 2 stated no in-service training on scabies was provided. During an interview and record review, on 9/24/25 at 4:11 PM with the IP, Resident 1's progress notes, the facility's huddle sign in sheets, the facility's in-service training records, and the facility's line lists (lists of residents/staff who have been tested or have signs and symptoms of an infection) were reviewed. The IP stated that she conducted a staff huddle on 8/26/25 at the north station only, during a shift change (one set of nurses end their shift and a new set of nurses come on shift). The IP stated there was no sign-in sheet for the huddle, so she did not have a record of who attended the huddle. The IP also stated she did not document any communication or education regarding scabies education in Resident 1's progress notes. The IP stated that no in-service training on scabies was provided after Resident 1's positive scabies diagnosis. The IP stated she did not create a line list and reiterated that contact identification was conducted for only one week and not the six weeks required by the surveillance plan. A review of the facility's surveillance plan titled, PREVENTION AND CONTROL OF SCABIES IN CALIFORNIA HEALTHCARE SETTINGS, dated 8/20, indicated, .All Healthcare facilities (HCF) should develop, implement, and periodically evaluate a scabies prevention control , and outbreak management program.the IP should be responsible for preventing or managing an outbreak.outbreak management program should include training all physicians, nurses and other HCP to recognize and report.signs and symptoms consistent with scabies infestation.All HCP and volunteers should be instructed to report any potential exposure to scabies in the home or community.An outbreak of scabies.might be defined as. 1 confirmed case and at least 2 suspect cases. An outbreak should be assumed to be occurring following diagnosis of a single case, until screening of all new patients and staff for scabies has been completed without identifying additional suspect cases. An outbreak cannot be conclusively excluded for at least 6 weeks following the last unprotected exposure to the case.the IP should develop a contact identification list. This list should identify every patient/resident , HCP, volunteer and 555164 Page 2 of 3 555164 11/26/2025 Arbor Rehabilitation & Nursing Center 900 North Church Street Lodi, CA 95240

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few visitor who may have direct, physical contact with the case within the previous 6 weeks.Notification of Key Personnel. should include representatives from all departments including.environmental services, and laundry.All HCP and volunteers should be notified as soon as possible. Initially, a communication memo should be distributed to all departments. should briefly describe. the symptoms, a brief description of the treatment.and whom to call if there are questions.CONTROLLING THE OUTBREAK.failure to identify and treat even one contact can result in continued propagation of the outbreak.Isolation of Patients/Residents.A team of HCP should be assigned to care only for patients/residents with atypical or crusted scabies during isolation period. A review of the facility's policy titled, Transmission-Based (Isolation) Precautions, dated 8/1/2025, indicated, .'Contact precautions' refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident of the resident's environment.8. Prompt recognition of need: a. All staff receive training on transmission-based precautions upon hire and at least annually.b. Nursing staff receive training on signs and symptoms of infection, common organisms that require additional control measures, and considerations for residents who are colonized with infectious organisms. 555164 Page 3 of 3