Other·May 29, 2026

73535-Reporting of Outbreaks Each facility having knowledge of any outbreak or undue prevalence of infectious or parasitic disease or infestation shall report the facts promptly to the local health officer. 72537. Reporting of Communicable Diseases. All cases of reportable communicable diseases shall be reported to the local health officer in accordance with Section 2500, Article 1, Subchapter 4, Chapter 4, Title 17, California Administrative Code. Note: Authority cited: Sections 208(a) and 1275, Health and Safety Code. Reference: Section 1276, Health and Safety Code. 72539. Reporting of Outbreaks. Any outbreak or undue prevalence of infectious or parasitic disease or infestation shall be reported to the local health officer in accordance with Section 2502, Article 1, Subchapter 4, Chapter 4, Title 17, California Administrative Code. During an annual recertification survey conducted from 4/20/2026 to 4/23/2026, the California Department of Public Health (CDPH) initiated an onsite investigation into reported allegations of a scabies outbreak. The facility failed to report to CDPH an outbreak of scabies (a contagious skin condition caused by tiny insects called mites that infest and irritate your skin by intense itching, inflammation, and red patches) when two of 2 sampled residents (Residents 87 and Resident 66) had rashes with severe itching and tested positive for skin scraping (a quick, minimally invasive diagnostic procedure used to sample the outer layer of skin, usually with a scalpel blade, to detect fungal infections using potassium hydroxide [KOH] or parasites like scabies/mites [using mineral oil] under a microscope) for scabies, which affected their quality of life, while being treated for suspected scabies. This deficient practice resulted in CDPH inability to investigate the outbreak timely, placing all residents, staff, vendors, and visitors at risk to acquire and be exposed to the scabies infection. A review of Resident 87's Admission Record indicated the facility admitted Resident 87, a 67-year-old female, on 11/23/2025 with diagnoses including hypertension (high blood pressure), diabetes mellitus (DM-high blood glucose), and acute respiratory failure with hypoxia (dangerous condition where body tissues do not receive enough oxygen). A review of Resident 87's Minimum Data Set (MDS-a resident assessment) dated 2/8/2026 indicated Resident 87 has no speech, and with short term and long-term memory problem. The MDS indicated Resident 87 is dependent on all activities of daily living (ADLs). A review of Resident 87's Skin Scraping for scabies dated 1/20/26 indicated Resident 87 is positive for sarcoptes scabiei (microscopic, parasitic mite that burrows into the upper layer of human skin to live and lay eggs, causing a contagious skin infestation known as scabies). A review of Resident 66's Admission Record indicated the facility admitted Resident 66, a 76-year-old male, on 3/20/2024 with diagnoses including hemiplegia (complete paralysis) and hemiparesis (weakness) following unspecified cerebrovascular disease affecting right dominant side, acute respiratory failure with hypoxia, cardiac arrest (life-threatening emergency where the heart abruptly stops beating and pumping blood), pneumothorax (collapsed lung), acute embolism (thrombus or foreign substance that breaks off and travels through the bloodstream, getting lodged in a smaller vessel) and thrombosis (stationary clot formed in a vein or artery) of unspecified deep veins of right lower extremity. A review of Resident 66's MDS dated 1/27/2026 indicated Resident 66 has no speech, with short term memory problem and long-term memory problem. The MDS indicated Resident 66 is dependent with staff on all ADLs. A review of Resident 66's Skin Scraping for scabies dated 2/28/2026 indicated Resident 66 is positive for sarcoptes scabiei. A review of Resident 66's Dermatologist (a medical practitioner specializing in the diagnosis and treatment of skin disorders) Visit Note dated 3/3/2026 indicated Resident 66 was seen for a chief complaint of a rash located throughout the body, rash is itchy, red, scaly and moderate in severity, has had this rash for weeks, pertinent history includes difficulty sleeping at night due to itch. The note indicated the Dermatologist prescribed ivermectin (prescription medication used to treat human infections caused by parasitic worms [strongyloidiasis, onchocerciasis] and external parasites like head lice and scabies) and permethrin cream (prescription topical medication used primarily to treat scabies by killing sarcoptes scabiei mites and their eggs), apply from neck down to the toes, leave for 12 hours then rinse, repeat once a week x for 4 weeks, and perform skin scraping. A review of the undated line listing (a table that contains key information about each case in an outbreak) indicated on 1/16/2026 that Resident 87 has positive skin scraping. The line list indicated that, on 2/25/2026, Resident 66 tested positive for skin scraping of scabies which is within 4 to 8 weeks of incubation period (the time elapsed between exposure to an infectious disease and the first appearance of the symptom). During a concurrent interview and record review conducted on 4/23/2026 at 9 a.m. with the Infection Preventionist Nurse (IPN), the IPN stated that a report was not made to the Local Public Health Department (agency) because there were not yet two positive residents to qualify as an outbreak. The IPN stated they had been waiting for a response from the Public Health Agency, but no response was received until 3/2026. The IPN stated that the report should have been submitted when two residents tested positive on 2/25/2026. The IPN stated that the agency must be notified so CDPH can visit the facility and ensure appropriate measures are being taken care to contain the spread of infection. The IPN stated that the report should have been made sooner. During an interview on 4/23/2026 at 11 a.m. with the Director of Nursing (DON), the DON stated first positive was on 1/20/2026 (Resident 87) and the second positive was 2/25/2026 (Resident 66). The DON stated the facility did not report when there was already second positive scabies in the facility. The DON stated it is important to report if there are two positive cases within 4 to 6 weeks incubation, so that CDPH staff can come and investigate the outbreak. A review of facility's P&P on Scabies Identification, Treatment and Environmental Cleaning dated 8/2022 indicated, incubation period can be 2 to 6 weeks before onset of itching for persons with no previous exposure. The facility failed to report to CDPH an outbreak of scabies (a contagious skin condition caused by tiny insects called mites that infest and irritate your skin by intense itching, inflammation, and red patches) when two of 2 sampled residents (Residents 87 and Resident 66) had rashes with severe itching and tested positive for skin scraping (a quick, minimally invasive diagnostic procedure used to sample the outer layer of skin, usually with a scalpel blade, to detect fungal infections using potassium hydroxide [KOH] or parasites like scabies/mites [using mineral oil] under a microscope) for scabies, which affected their quality of life, while being treated for suspected scabies. This deficient practice resulted in CDPH inability to investigate the outbreak timely, placing all residents, staff, vendors, and visitors at risk to acquire and be exposed to the scabies infection. This violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.