**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care, treatment, and services for five of five sampled residents (Residents 1, 2, 3, 4, and 5) in accordance with professional standards of practice in order to meet the residents' physical, mental, and psychosocial needs, by failing to: 1. Conduct proper assessment to identify what was causing generalized and severely itchy skin rashes despite two separate treatments for Resident 1 and generalized dry crusted skin rashes for Resident 5. Resident 1's rash and itching was first identified by the facility on 11/06/2023. 2. Notify a physician that treatment ordered for skin itchy rashes was ineffective according to the resident's care plan. Residents 1, 2, 3, 4, and 5 had no pre-existing skin conditions/rashes upon admission/readmission to the facility. These deficient practices resulted in: 1. Resident 1 experiencing unrelieved generalized and severely itchy body rashes, itchy skin, discomfort despite two separate treatments since 8/10/2023, and inability to sleep. 2. Zoloft (medication to treat mood disorders) was increased from 50 milligrams (mg- unit of measurement) to 100 mg daily for crying for Resident 1. 3. Resident 1 was referred for psychiatry (is the medical specialty devoted to the diagnosis, prevention, and treatment of deleterious mental conditions) services on 1/5/2024 due to intermittent episodes of crying. 4. Residents 2, 3, 4, and 5 were not assessed for generalized itchy skin rashes, and a physician not notified about the generalized itchy skin rashes. These deficient practices placed Residents 1, 2, 3, 4, and 5 at increased risk for significant decline in the residents' physical, mental, or psychosocial well-being, disfigurement, avoidable excruciating pain, and discomfort. On 4/1/2024 at 7:40 p.m., an Immediate Jeopardy (IJ - a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was identified in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's lack of a system in providing a timely diagnosis, appropriate treatment, care and services to protect all 158 residents, staff, and community. On 4/3/2024 at 2:21 p.m., while onsite at the facility, the IJ was removed in the presence of the ADM and the DON, after the ADM submitted an acceptable IJ Removal Plan (interventions and implementation to correct the deficient practices) which was verified and confirmed through observation, interview, and record review. A review of the IJ removal plan included the following: 1. On 4/1/2024, the licensed nurse contacted Resident 1's physician and obtained orders for a skin scraping (is a bedrock technique in dermatology that is applied in a high proportion of cases. It enables both the full thickness of the epidermis and the contents of the hair follicles to be sampled) to identify the presence of scabies mites (scabies causing parasite), the test was completed and sent the specimen to the laboratory for processing. The licensed nurses began immediate cleaning and disinfection of all multi-use resident care equipment to reduce the potential to transmit contagious skin rashes to the extent possible. 2. On 4/1/2024, The Clinical Consultant inserviced (educated) the DON, Infection Prevention Nurse (IPN), and the Administrator on the facility's policy and procedures (P &P) and the guidelines for Prevention and Control of Scabies in California Healthcare settings. 3. On 4/1/2024, The DON and IPN began in servicing (educating) licensed nurses working in the facility during the 3 pm-11pm shift on the facility's P & P and the guidelines for Prevention and Control of Scabies in California Healthcare settings including weekly assessments of each residents skin, completion of change in condition assessments for all resident rashes identified, notification of the resident's physician and representative and under the direction and guidance of the physician, place the resident on contact precautions (Precautions intended to prevent transmission of infectious agents by use of gloves, gowns, masks), complete a skin scraping to identify the presence of scabies mites, and proper use of PPE (Personal Protective Equipment, protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission). 4. On 4/1/2024, The licensed nurse completed head to toe body assessments of Residents 2, 3, 4, and 5 to identify the presence of a skin rash. 5. The DON and Registered Nurse (RN) Supervisors reviewed and revised Residents 3 and 4's care plans effective 4/1/24 to address the changes in condition, potential exposure to a resident with possible scabies rash and to ensure continued care and services to maintain their highest practicable outcomes. 6. On 4/2/2024, Physical Plant and Environmental Services Consultants in-serviced housekeeping supervisor and housekeeping staff regarding Housekeeping Disinfection Plan which includes using EPA (Environmental Protection Agency, approved disinfectant for cleaning), wearing gloves and long sleeve gown while conducting disinfection, changing gloves and long-sleeve gown between affected resident rooms, performing handwashing between rooms and tasks, changing water, mop, and rags between resident rooms or between disinfection tasks, and when possible complete cleaning and disinfection of each affected room while the resident is showering. On 4/2/2024, the housekeeping staff deep cleaned Resident l, 2, 3, 4, and 5's room. On 4/2/2024, 3rd and 4th Floor were deep cleaned to reduce potential for transmission of contagious pathogens. 7. On 4/2/2024, the DON and the IPN completed 144 of 158 resident body assessments to identify the presence of rashes on other residents to prevent harm to affected residents. Dermatologist (a medical practitioner specializing in the diagnosis and treatment of skin disorders) also completed an assessment of all 158 residents to identify residents who are likely to suffer, a serious adverse outcome because of the facility's noncompliance. The [NAME] and the dermatologist, identified 17 of 158 residents were identified with rashes. 15 of the 17 residents already had on-going treatment orders for identified skin rashes. Two of the 17 residents are newly identified with diagnosis of unspecified dermatitis (a group of conditions in which the skin becomes inflamed, forms blisters, and becomes crusty, thick, and scaly). The licensed nurses completed change in condition assessments for the 17 residents identified with skin rashes and the roomates for the 17 residents. The residents' physicians and resident representatives were notified.17 residents that were newly identified with unspecified dermatitis, were placed on isolation. Skin scraping was performed on 16 of 17 residents and Elimite (a medicated skin cream that treats scabies) treatments per physician were completed. 8. On 4/2/2024, Clinical Consultant continued evaluation through interview of available staff to identify any staff with skin conditions. To reduce the potential for transmission of contagious rashes, employee interviews were continued in person and via the telephone, prior to staff working with residents during their next assigned shift, to identify any staff members with skin conditions. 149 of 200 staff were contacted and interviewed. Three staff who reported itchiness and identified with rashes were offered Elimite. 9.The IPN revised new employee and annual infection prevention and control training to include education of Scabies prevention in Healthcare Settings and reporting the development of new skin rashes identified to their physician, especially when known to have provided direct care with residents diagnosed with contagious skin rashes effective 4/2/2024. Findings: a. A review of Resident 1's admission record indicated the facility admitted Resident 1 on 2/27/2023, with diagnoses that included hemiplegia (loss of strength in the arm, leg, and sometimes the face on one side of the body) and hemiparesis (loss of use in the arm, leg, and sometimes the face on one side of the body) following cerebral infarction (stroke) affecting right dominant side, aphasia (difficulty speaking), dysphagia (difficulty swallowing), dependence on supplemental oxygen (use of extra oxygen to breathe in), and anxiety. The admission record did not indicate Resident 1 was admitted with any skin rashes and major depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.). A review of Resident 1's Minimum Data Set (MDS- standardized assessment and care screening tool) dated 1/4/2024, indicated the resident's cognition (relating to mental ability to make decisions of daily living) was severely impaired. The MDS indicated Resident 1 was dependent on facility staff for oral hygiene, toileting, showers/bathing, dressing, and repositioning. A review of Resident 1's care plan for The resident has multiple body discolorations (any change in your natural skin tone), dated 8/10/2023, did not indicate the location, size, color, or appearance of the multiple discoloration skin discolorations. The care plan interventions included facility staff to carry out to address the discolorations included Educate resident/family/caregiver of causative factors and measures to prevent skin injury. A review of Resident 1's Wound Weekly Monitoring Assessment-Non-Pressure dated 11/2/2023 at 7:59 AM, indicted the resident did not have any skin concerns other than a bump/lymphoma (tumor) on the left shoulder. A review of Resident 1's Assessment Summary dated 11/6/2023 at 1:33 PM, indicated the resident had a change in condition. The change in condition was documented as: skin dermatitis [rash: redness and inflammation of the skin] to Left cheek, right lower chin, and left forearm. Nursing assessment done with no itchiness, pain, or drainage noted to site. A review of Resident 1's situation background assessment and recommendation (SBAR- is a structured communication tool that helps teams share information about the condition of a patient or team member or about another issue the team needs to address) form dated 11/6/2023 at 1:33 PM, indicated the resident had skin dermatitis [rash: redness and inflammation of the skin] to left cheek, right lower chin, and left forearm. The SBAR interventions to improve the skin condition included, Tx [treatment] as ordered, monitoring, and possible derma consult. The SBAR indicated an order received for Triamcinolone (medication used to treat a variety of skin conditions) 0.5% cream for 14 days until healed and reassess and Claritin (medication to treat allergies) 10 milligrams (mg- unit of measurement) daily for one week. A review of Resident 1's complete Medical Records for 11/6/2023, did not indicate the facility conducted a body assessment on Resident 1. A review of Resident 1's SBAR dated 11/6/2023 at 3 PM, indicated on 11/6/2023 at around 3 PM, Resident 1's physician examined the resident's skin and ordered Acyclovir (medication to treat shingles [(also known as herpes zoster, is a viral disease characterized by a painful skin rash with blisters in a localized area], a painful rash caused by a virus, that may appear as a stripe of blisters). The SBAR indicated Resident 1 had no pain but was noted with itchiness (unspecified). The SBAR indicated treatment cream administered to affected areas, and Claritin 10 mg one time (x 1) administered as ordered and same tolerated with no adverse side effect (ASE). A review of Resident 1's care plan for Resident has Left Forearm unspecified skin dermatitis dated 11/6/2023, did not indicate the size, color, or appearance of the dermatitis. The care plan interventions included facility staff to address the dermatitis included apply treatment as ordered, keep skin clean and dry, monitor effectiveness of tx (treatment), monitor any skin changes, inform MD if tx not resolved . A review of Resident 1's Health Status Note dated 11/8/2023 at 11:29 AM, indicated a physician's order to discontinue the Acyclovir. A review of Resident 1's SBAR dated 11/12/2023 at 10:46 AM, indicated, noted resident with left thigh skin scratch with 5-centimeter (cm, unit of measurement) x 0.8 centimeters (cm - unit of measurement). The SBAR interventions included to administer antiviral medications (medications help the body fight off harmful viruses). A review of Resident 1's Interdisciplinary Team (IDT, a team of health care professions who work together to establish plans of care for residents) dated 11/15/2023 at 8:47 PM, indicated, skin care treatment rendered as ordered. However, the IDT notes did not indicate if IDT discussed conducting assessment about the skin rashes for Resident 1. A review of resident 1's Health Status Note dated 11/16/2024 at 2 PM, indicated a physician's order to increase Zoloft (medication to treat depression) from 50 mg to 100 mg via gastrostomy tube (GT- a surgical procedure to insert a tube through the abdomen and into the stomach used to administer nutrition, hydration, and or medication) daily for depression manifested by (M/B) episode of crying. A review of Resident 1's admission record indicated on 11/16/2023, a diagnosis of Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) was added to Resident 1's medical record. A review of Resident 1's care plan for Resident has left thigh unspecified skin dermatitis dated 12/4/2023, indicated interventions facility staff needed to carry out to address the dermatitis included cleanse with normal saline (wound care solution) and apply Triamcinolone cream 0.05% every (Q) shift x 14 days, keep clean and dry, and monitor for signs and symptoms of infection and adverse changes. The care plan did not indicate the facility reviewed and updated the current interventions, after the 14 days of treatment with Triamcinolone cream 0.05%. A review of Resident 1's Physician Order Note dated 12/13/2023 at 1:26 PM, indicated Resident 1 to continue Zoloft due to episode of crying. A review of Resident1's IDT Progress Note-Behavior Management dated 1/5/2024 at 2:02 PM, indicated Resident 1 was referred to psychiatry services due to use of Zoloft 50 mg daily for depression manifested by (m/b) crying. Pt's (patient's -Resident 1) medication was initiated at the facility due to (d/t) intermittent episodes of crying observed by staff and family. A review of Resident 1's MD Progress Notes dated 1/9/2024 at 12:21 PM., indicated Resident 1 was diagnosed with dermatitis, noted with rashes in armpit area, and started on nystatin (medication to treat fungal infection/s) twice a day and hydrocortisone cream (medication used to reduce pain, itching, and swelling (inflammation) twice a day. The MD progress note indicated Resident 1 did not have decision making capacity. A review of Resident 1's After Visit Summary report from the outpatient clinic Neurologist (a medical doctor with specialized training in diagnosing, treating, and managing disorders of the brain and nervous system) dated 3/5/2024 at 1:15 PM, indicated the reason for the visit was nonspecific paroxysmal spell (alteration in consciousness that look like seizures) and rash, and that on 3/5/2024, the neurologist referred Resident 1 to outpatient dermatologist (doctor who specializes in disorders of the skin). A review of Resident 1's Assessment Summary note dated 3/5/2024 at 9:15 PM, indicated General Skin Conditions: Rash Itching. The note did not indicate the location and size of the rash or if a physician was notified. A review of Resident 1's care plan for The resident has rash trunk, legs, arms, armpit rash, general body rash Thin and fragile skin, initiated on 3/5/2024, indicated interventions included the facility will address the rash, avoid scratching, daily shower as tolerated, derma (dermatologist) consult, and monitor skin for signs and symptoms of infection. A review of Resident 1's Assessment Summary Note, dated 3/12/2024 at 2:04 PM, indicated General Skin Conditions: Rash Itching. The note did not indicate the location and size of the rash, or if the facility notified a physician about the itchy skin rash. A review of Resident 1's Health Status Note, dated 3/27/2024 at 1:30 PM, indicated Resident 1 left the facility to a dermatology appointment. A review of Resident 1's After Visit Summary from the outpatient clinic dated 3/27/2024 at 2 PM, indicated the reason for the visit was Scabies (an infestation of the skin where mites (small bugs) dig its way into the top layer of the skin where it will live and lay eggs). A focal skin examination was performed of the face, head, neck, chest, right upper extremity (RUE-arm), left upper extremity (LUE - arm), right lower extremity (RLE-leg), left lower extremity (LLE -leg) . Pertinent findings: -Bilateral (both) palms with erythematous papules (solid elevation of skin with no visible fluid that is reddish (erythematous) in color), single pustule (a bulging patch of skin that's full of a yellowish fluid called pus), scaly -Few linear (resembling a line) burrows in interdigital (in between fingers and toes) areas -Erythematous papules on bilateral upper and lower extremities The same After-Visit Summary further indicated the Assessment and Plan SCABIES Note: Favor scabies given clinical, also notable scybala (feces) and ovum (eggs) on mineral oil prep scraping . The same After-Visit Summary further indicated the plan included: -Start Permethrin (medication used to treat infestations of small parasites) 5 % Topical (TOP-apply to skin) Cream to entire body (include face since involved) at night today and wash off in morning - REPEAT in 7 days . -Start Ivermectin (medication used to treat diseases caused by parasites like head lice and for skin conditions) 3 mg oral (by mouth) TAB (tablet) -4 pills (12 mg) total once today -Start Triamcinolone Acetonide 0.1 % Topical (TOP) Ointment (OINT) tomorrow to affected areas except face and skin folds -Wash all bedding/clothing -Discussed that may remain itchy for 4-6 weeks after treatment. A review of Resident 1's admission record for 3/27/2023, did not indicate the scabies diagnosis was added to the resident's medical record. A review of Resident 1's care plan for The resident has rash (general body) at risk for recurrent skin problems secondary to diagnosis of diabetes, anxiety, anemia (low blood count), quadriplegia (paralysis from the neck the neck to the legs), incontinent, bedbound status, thin and fragile skin dated 3/27/2024, did not indicate the diagnosis of scabies. The care plan interventions included the facility to Deep clean room (volves cleaning objects or surfaces that may not be routinely cleaned, such as walls, ventilation ducts, curtains, carpets) [Resident 1's] after emilite application. The care plan did not have an indication for the emilite. A review of Resident 1's Infection Note dated 3/28/2024 at 2:54 PM, indicated On 3/27/24, Resident returned from doctor's appointment with orders for Ivermectin and Elimite (medication used to treat scabies). The Infection indicated Resident 1's was explained to that Resident 1 has a history of on and off rashes, and that Resident 1's physician was aware and was actively treating and addressing the resident's skin concerns. b. A review of Resident 2's admission Record indicated the facility readmitted Resident 2 on 9/17/2023 with diagnoses that included hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebrovascular accident (damage to the brain from interruption of its blood supply), aphasia (A language disorder that affects a person's ability to communicate), dysphagia (swallowing difficulties) and type 2 diabetes (is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). The admission record did not indicate Resident 2 was readmitted with any skin rashes. A review of Resident 2's History and Physical (H&P) dated 10/16/2023, indicated the resident did not have the capacity to understand or make decisions. A review of Resident 2's MDS dated [DATE], indicated the resident's skin was intact with no abnormalities, rashes, or sores. A review of Resident 2's Weekly Summary: Nursing note dated 3/25/2024 at 9:49 PM, indicated General skin conditions: normal (Assessment not applicable), dermatitis. The note did not indicate where the dermatitis was located. A review of Resident 2's care plan for The resident is at risk for recurrent skin rashes, itching, skin eruption related to: dermatitis dated 12/27/2023, indicated interventions included to observe Resident 2 for skin irritations, signs and symptoms of infection, and trimming fingernails. The care plan indicated a new problem was identified on 3/26/2024 Xerosis [abnormally dry skin] skin generalized body. A review of Resident 2's Weekly Summary: Nursing note dated 3/4/2024 at 10:42 PM, indicated, General Skin Conditions: Skin Normal (Assessment Not Applicable, Dermatitis. A review of Resident 2's Weekly Summary: Nursing note, dated 3/12/2024 at 3:40 PM, indicated, General Skin Conditions: Skin Normal (Assessment Not Applicable, Dermatitis. A review of Resident 2's Weekly Summary: Nursing note dated 3/25/2024 at 9:49 PM, indicated, General Skin Conditions: Skin Normal (Assessment Not Applicable, Dermatitis. A review of Resident 2's Health Status note, dated 3/27/2024 at 12:35 PM, indicated the resident had an unspecified dermatology follow up at bedside on 3/25/2024. The note indicated new orders were received and carried out. However, the health status note did not indicate what the orders were. c. A review of Resident 3's admission record indicated the facility admitted Resident 3, on 9/9/2022 with diagnoses that included hemiplegia and hemiparesis following cerebrovascular accident and aphasia. The admission record did not indicate Resident 3 was admitted with any skin rashes. A review of Resident 3's H&P dated 7/31/2023, indicated the resident did not have the capacity to understand and make decisions. d. A review of Resident 4's admission record indicated the facility admitted Resident 4 on 7/22/2023 with diagnoses that included right femur (thigh bone) fracture (break in a bone), high blood pressure, and diabetes (elevated blood sugar). The admission record did not indicate Resident 4 was readmitted with any skin rashes. A review of Resident 4's H&P dated 7/31/2023, indicated the resident had the capacity to understand and make decisions. e. A review of Resident 5's admission record indicated the facility admitted Resident 5, on 12/14/2023, with diagnoses that included injury of the blood vessels in the head, history of falling, and muscle weakness. A review of Resident 5's H&P dated 12/15/2023, indicated the resident did not appear to have full decision-making capacity. During observation in Resident 1's room and concurrent interview with Licensed Vocational Nurse 1 (LVN 1) on 3/30/2024 10:51 AM, Resident 1 was observed with multiple tiny red spots around Resident 1's torso, arm pits, bilateral legs, arms, web of fingers, and palm of hands with burrow marks on the hands and was observed scratching areas the resident was able to reach. LVN 1 confirmed and stated Resident 1 had generalized itchy rashes and that the Treatment Nurse (TN) and IPN were the only nurses responsible to assess the resident and determine if the resident had scabies or not. LVN 1 confirmed and stated Resident 1 had all the classic symptoms of scabies (Severe itching, especially at night, is the earliest and most common symptom of scabies. A pimple-like itchy scabies rash of the body or be limited to between the fingers). During a concurrent observation In Resident 2's room and interview with Certified Nurse Assistant 3 (CNA 3) on 3/30/2024 at 11:26 AM, CNA 3 stated Resident 2 has had itchy skin rashes for several months. Resident 2 was observed scratching the resident's abdominal area where the resident could reach. Resident 2 had tiny red spots to chest, back, abdominal area, waist thighs, legs, between webs of feet & hands, and arms. Resident 2 also observed with scarring like marks from scratching as well as burrowing (to make a hole or tunnelling) on the resident's hands and feet. During an interview and concurrent record review with TN 3/30/2024 at 12:11 PM, Resident 1's medical chart was reviewed. TN stated there was a Change in Condition (COC) for generalized body rash on 3/28/2024 for Resident 1. TN stated a dermatologist evaluated Resident 1 on 3/27/2024 and ordered Ivermectin oral medication and Permethrin to be applied on Resident 1. The TN stated that the order indicated to administer to Resident 1per physician's request. TN stated that she (TN) would have questioned the order because every order needs to have an indication/diagnosis. TN stated that that the order should have been questioned because the regimen ordered was for scabies. TN stated contact isolation (are steps that healthcare facility visitors and staff need to follow before going into a patient's room) must be placed as soon as suspicions for scabies arise. TN admitted there were neither prophylactic treatments for Resident 1's roommate nor skin assessments completed. There was no documented evidence of scraping orders for Resident 1 of which TN stated would have increased further spread to other residents not only in Resident 1's roommates, but for other residents though staffing working other unaffected residents. TN stated the treatment nurse should have assessed the other residents because scabies is highly contagious. During a telephone interview with the IPN on 3/30/2024 at 12:54, IPN stated that Resident 1 had an ongoing rash on and off but does not recall how long ago it started. IPN stated that she (IPN) had assessed Resident 1 after the 3/27/2024 appointment and noted that she (Resident 1) had scattered rashes under armpits and back. IPN admitted that she (IPN) had not assessed the hands to check in the web of fingers and hands where the burrowing was mostly located. IPN admitted that every medication ordered must have a diagnosis to be a complete order per nursing professional standards. Stated that Resident 1 should have been isolated right away to prevent further spread to other residents as well as staff. IPN stated that symptoms of scabies included: itching, scattered rashes, crevices, hands, folds, crusting. IPN admitted that the primary physician should have been notified and scrapings ordered. During a telephone interview with Family Member 1 (FM 1) on 4/1/2024 at 9:45 AM, FM 1 stated that FM 1 had noticed the rash to Resident 1's left upper arm and thought the rashes were bug bites. FM 1 stated Resident 1 has been scratching intensely and cried a lot. FM 1 stated that before long, the rashes had spread to Resident 1's whole arm, and that the facility's in house dermatologist had evaluated Resident 1. FM 1 stated that in 11/2023, facility staff (unidentified) contacted FM 1 and told FM 1 that Resident 1 had shingles. FM 1 stated two days later, FM 1 received another call by facility staff (unidentified) notifying FM 1 that the rashes on Resident 1 was not shingles. FM 1 stated the facility staff informed FM 1 that the facility did not know what the rashes were and would start applying hydrocortisone. FM 1 stated, IPN told FM 1 that the facility did not have a dermatologist to evaluate Resident 1. FM 1 stated she was shocked. FM 1 stated that on 3/5/2024, FM 1 brought Resident 1 for neurologist appointment. FM 1 stated the neurologist made a dermatology appointment concerning scabies for Resident 1. FM 1 stated that on 3/7/2024, the dermatologist scraped Resident 1's skin and confirmed that Resident 1 had scabies. FM 1 stated that when Resident 1 returned from the dermatologist appointment, FM 1 gave the Social Services Director (SSD) and IPN copies of Resident 1's positive scabies results as well as the physicians notes, and it was then that the IPN included the diagnosis for scabies on Resident 1's medical chart. During a telephone interview with the facility's MD on 4/1/24 at 5:35 PM, MD stated the facility informed the MD two at 3:35 PM, that Resident 1 had scabies. MD stated nursing staff should have notified Resident 1's Primary Care Physician (PCP) as well as the facility's MD as soon as possible, that Resident 1's generalized itchy skin rashes were not responding despite administering acyclovir and nystatin. MD stated dermatology consults must be made and followed up within a few hours or days to prevent Resident 1 from suffering. During an interview with Registered Nurse Supervisor (RNS) on 4/2/24 at 12:48 PM, RNS stated that scabies is very infectious and serious diagnosis which needs to be reported to the PCP, and properly assessed. RNS stated the signs and symptoms of scabies includes itchiness, red spots on the back, chest areas, web of fingers (covered areas). RNS stated scabies are diagnosed by skin scraping. During an interview with DON on 4/2/24 at 1p.m., DON confirmed and stated that the facility did not implement the skin assessment policy, the facility did not routinely conduct assessment of residents' skin. The facility's P&P titled NOTIFICATION OF CHANGES, revised 3/2023 was reviewed with the DON. The P & P indicated: 1. The facility notifies the physician and resident representative of: b. A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). The facility's P&P titled DEVELOP-IMPLEMENT COMPREHENSIVE CARE PLANS, revised, 3/2023, was reviewed with the DON. The P & P, indicated, The facility develops a person-centered comprehensive care plans that are culturally competent and trauma-informed, developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical. mental and psychosocial needs. The guidelines included the following: The facility must establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. The facility's P&P titled SKIN ASSESSMENT, revised 3/2023, was reviewed with the DON. The P & P indicated, To provide guidelines for routine assessment of residents' skin to maintain skin integrity and promote healing in accordance with standard of care practice guidelines. The same P&P indicated, skin observations may be documented according to facility preference on a Weekly Summary, narrative documentation or an assessment developed specifically for the skin.