**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program for scabies (a contagious, intensely itchy skin condition caused by a tiny, burrowing mite) for eight of eight sampled residents (Resident 1, Resident 2, Resident 3, Resident 7, Resident 8, Resident 19, Resident 21 and Resident 26) afterfacility was informed Resident 1 (who was transferred from the facility to a general acute care hospital [GACH] on 3/25/2023 with rashes) was diagnosed and treated for scabies on 3/26/2023 and returned to the facility on 4/4/2023. The facility failed to: 1. Inform the dermatologist ( [Medical Doctor (MD) 2 ] a medical practitioner specializing in the diagnosis and treatment of skin disorders), to report Resident 1 was diagnosed and treated with scabies on 3/26/2023 at the GACH, to further investigate and treat other six Residents (Resident 1, Resident 3, Resident 7, Resident 8, Resident 19, and Resident 21) who were exhibiting symptoms of scabies. 2. Address the rashes noted for six of six sampled residents (Resident 1, Resident 3, Resident 7, Resident 8, Resident 19, and Resident 21) who were exhibiting symptoms of scabies. 3. Treat Resident 2 (Resident 1' s roommate) prophylactically (a medicine or course of action used to prevent disease), after being exposed to Resident 1, who was treated and diagnosed with scabies. 4. Ensure Certified Nurse Assistant (CNA) 1, (who did not receive prophylactic treatment after exposure to residents who were suspected of having scabies), wore personal protective equipment ([PPE] protective clothing or equipment worn to protect against infectious materials) when providing care to residents, Resident 1 and Resident 26, who were in a contact isolation (precautions taken when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled). CNA 1 placed Resident 1 and 26 at high risk for exposure to scabies. 5. Adhere to the facility's policy and procedure titled, Scabies Prevention and Control, which stipulates to identify possible cases of scabies infection as soon as possible, skin scrapings will be performed as ordered for suspected cases, place all residents and staff suspected of scabies in contact precaution, wear PPE when providing care to residents to prevent the potential spread of scabies. These deficient practices placed 109 Residents, all staff, vendors, and visitors at risk for scabies exposure. On 4/25/2023, at 4:30 p.m., the Department identified an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident and the situation created a need for an immediate corrective action situation). The Administrator (ADM), the Director of Nursing (DON), and Clinical Manager (CM 1) were notified at this time of the immediate actions that needed to be taken and the seriousness of the residents ' health and safety threatened due to the facility's failure to ensure infection control practices were implemented during scabies outbreak. The facility failed to address the rashes of six residents (Residents 1, Resident 3, Resident 7, Resident 8, Resident 19, and Resident 21) who were exhibiting symptoms of scabies, ensure the facility ' s policy and procedure for scabies was followed, treat Resident 2 prophylactically, and ensure CNA 1 wore PPE while providing care. On 4/27/2023 at 3:05 p.m., the ADM provided an acceptable IJ removal plan. The IJ removal plan included the following: 1. On 4/17/2023, 21 residents with rashes were seen and evaluated by the Dermatologists. 2. On 4/18/2023, all 21 residents with rashes received treatment orders for Permethrin ([Elimite] an insecticide, used to treat scabies). 3. On 4/18/2023, the facility implemented monitoring of facility staff and resident for skin rashes/scabies. Any staff or resident with a new rash will be included in the scabies outbreak line list. 4. On 4/19/2023, Permethrin was applied for residents with rashes, and 8 roommates received prophylactic treatment. 5. On 4/19/2023, all 29 resident's responsible parties were notified of the new orders. 6. On 4/19/2023, all 29 residents were placed on contact precautions during the duration of initial Permethrin. 7. On 4/19/2023, and 4/20/2023 Staff utilized PPE (gowns, gloves, masks) when showering residents. 8. On 4/19/2023, belongings of 29 residents were bagged and kept sealed for seven days. 9. 16 rooms of resident's that received treatment were all deep cleaned, all linens were bagged and washed separately. All beds were disinfected. All curtains were replaced, and all bathrooms were terminally cleaned on 4/19/2023, and 4/20/2023. 10. 21 residents with rashes will continue to be treated with Permethrin once a week for 3 weeks to complete course of treatment. 11. On 4/21/2023, all 21 residents with skin rashes were skin scraped (a test to confirm or rule out scabies). 12. On 4/21/2023, Los Angeles Public Health conducted an on-site visit to the facility giving the facility verbal guidance on the Scabies Toolkit (contains materials to assist health care facilities in managing scabies outbreaks and educating health care workers on identification, transmission, signs and symptoms, and treatment of scabies) to manage rashes at the facility. 13. On 4/21/2023, Resident 2 was offered prophylaxis treatment, after being one of the residents exposed to scabies. 14. On 4/21/2023, CNA 1 was given one on one reeducation by the DON, about following the scabies prevention, control, and managing protocol, and the use of PPE. 15. On 4/18-4/19/2023, 4/21-4/22/2023, 4/25-4/26/2023, the DON, Director of Staff Development (DSD), and Infection Preventionist Nurse (IPN) gave in-services to staff about scabies prevention and management, which included good hand hygiene for residents, hand hygiene for staff, proper PPE use, and contact precaution protocol. PPE training included utilization of gowns, gloves, and masks. 16. On 4/25/2023, the housekeeping supervisor trained four (4) housekeepers about proper infection control, proper cleaning of isolation rooms, room cleaning process, bathroom cleansing process and deep clean process. 17. On 4/19/2023, staff were offered Permethrin cream as prophylaxis. 18. On 4/24/2023, all staff were notified and educated about the use of Permethrin cream as scabies prophylaxis. Permethrin was provided to all staff from 4/24-4/26/2023. 90 staff members received the Permethrin. In the event of refusal, the staff will be required to wear gowns when in the facility. 19. On 4/21/2023, the DON, DSD, IPN, and RN conducted rounds and observed staff donning (to put on) and doffing (to remove) PPE. 20. On 4/25/2023, the DSD, IPN, and RNs completed body check for all residents to ensure that there were no residents with new rashes. 21. On 4/25/2023, the Dermatologist agreed to conduct telehealth consults so residents with rashes will be evaluated timely, and dermatology to follow-up after completion of treatment as needed. 22. On 4/26/2023, monitoring started, the DON and/or designee will conduct clinical meetings daily, for 30 days to review and identify any resident with a new rash and conduct daily rounds to ensure staff adhere to infection prevention precautions and procedures, including hand washing and appropriate use of PPE. 23. On 4/28/2023, the medical records staff will start to conduct weekly audits for medication and treatment for any new residents with rashes for six (6) weeks. The audit will be reviewed by the DON and Clinical Manager weekly to ensure appropriate interventions were in place. 24. The DON and the DSD will present the recapitulation (summary) of the plan of action to the QA (Quality Assurance)/Utilization Group on 4/26/2023. Findings shall be reviewed and discussed monthly for three (3) months to ensure corrections were achieved and sustained during QA/Utilization Group quarterly meetings. The QA/Utilization Group shall thereby decide if further reviews/audits need to be extended for another quarter to ensure compliance. On 4/27/2023, at 3:05 p.m., after an onsite verification of the facility's IJRP implementation through observation, interview, and record review, IJRP was not found implemented, the IJ was not lifted and an exit was conducted for the investigation. The Facility was placed on a 23-day fast track (enforcement action when immediate jeopardy exists where the IJ must be removed no later than 23 days from the last day of the survey or the provider agreement will be terminated). On 4/28/2023, at 3:58 p.m., the IJ Removal Plan was verified as implemented through observation, interviews, and record review. The ADM was notified that the IJ was removed. Findings: 1. During a review of Resident 1's admission Record (Face Sheet), dated 4/25/2023, the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Resident 1's diagnoses included Raynaud ' s syndrome (a condition in which some areas of the body feel numb and cool in certain circumstances), alcoholic liver disease (liver damage caused by excess alcohol intake), chronic obstructive pulmonary disease ([COPD] a group of lung diseases that block airflow and make it difficult to breath) and anemia (a condition in which blood does not have enough healthy red blood cells). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 2/3/2023, the MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was intact. Resident 1 required extensive assistance in dressing, limited assistance in personal hygiene, and limited assistance in bed mobility. During a review of Resident 1's document, titled Change of Condition ([COC] a clinical deviation from a resident's baseline) Assessment Form, dated 2/20/2023, at 9:30 p.m., indicated, Resident 1 expressed concerns over a new onset rash with redness, scabbing, and extreme itchiness on the trunk of her body, and upper extremities. COC indicated Resident 1 denied being exposed to any known allergens (iodine, and sea food). COC indicated Licensed Vocational Nurse (LVN) 1 notified Resident 1 ' s primary physician (MD) 1. MD 1 ordered Triamcinolone Acetonide Cream (used to treat the itching, redness, dryness, crusting, scaling, inflammation, and discomfort of various skin conditions) for generalized (all over the body) rash. During a review of Resident 1's Physician Order, dated 2/21/2023, indicated an order for Triamcinolone Acetonide Cream 0.1 % topically every morning and evening shift for 30 days for generalized body rash. During a review of Resident 1's Physician Order, dated 2/28/2023, indicated an order for Hydrocortisone External Gel (used to treat skin conditions by suppressing the immune response, relieving itch) every morning and evening shift for generalized body rash for 30 days. During a review of Resident 1's Physician Order, dated 2/28/2023, indicated, a dermatology consult was ordered eight days after onset of rash. During an interview on 4/20/2023, at 12:45 p.m., with Registered Nurse (RN) 2, RN 2 stated, Resident 1 originally had the rash on 2/20/2023, was readmitted to the facility on [DATE] from the GACH, and was treated for scabies (3/26/2023) during her hospitalization, prior to readmission on [DATE]. During a concurrent observation and interview on 4/21/2023, at 11:35 a.m., inside Resident 1 ' s room, Resident 1 was observed with a pimple like red rash and residual scarring on arms, legs, and chest. Resident 1 stated her rash started approximately on 2/20/2023, eight weeks before she was hospitalized on [DATE]. Resident 1 stated that the physician in the hospital told her she had scabies. Resident 1 stated she still felt itchy today (4/21/2023). During a review of Resident 1 ' s Physician Order, dated 4/4/2024, indicated an order for Benadryl (used to treat sneezing, runny nose, watery eyes, hives, skin rash, itching, and other cold or allergy symptoms) 25 mg ([milligram] unit of measurement) every 6 hours as needed for itchiness. During a concurrent interview and record review on 4/21/2023 at 2:15 p.m., with CM 1, Resident 1's Physician Orders, Dermatology Notes, and Nurses Notes from 2/20/2023 to 4/21/2023 were reviewed. CM 1 stated a dermatology consult was ordered for Resident 1 on 2/28/2023. CM 1 stated Resident 1's clinical record indicated she was only seen by MD 2 on 4/17/2023. CM 1 stated there was no dermatology notes from 2/20/2023 up until 4/17/2023 to address Resident 1 ' s new onset rash on 2/20/2023. CM 1 was unable to explain why a dermatology consult was not done for Resident 1 as ordered. During record review of Resident 1's documents from MD 2, Resident 1's dermatology records indicated MD 2 did a consult for Resident 1 was on 4/17/2023. Resident 1 ' s Dermatology Order, dated 4/17/2023, indicated the folowing orders: · Permethrin 5% cream, apply one tube from neck to toes, leave for 12 hours then rinse. Repeat once a week times four weeks. · Ivermectin (an anti-parasite medication used to treat parasitic diseases, and scabies) 12 mg once a week times four weeks. During a review of Resident 1's Medication Administration Record (MAR), dated 4/2023, the MAR indicated, Permethrin 5% cream was administered on 4/19/2023 to Resident 1, by RN 2. During a review of Resident 1's MAR, dated 4/2023, the MAR indicated, Ivermectin 12 mg was administered on 4/20/2023 to Resident 1, by LVN 2. During a review of Resident 1's Physician Order, dated 4/21/2023, indicated an order for a skin scraping (a definitive scabies test that identifies mites, eggs, or eggshell fragments embedded in the skin) for Resident 1. During an interview on 4/20/2023, at 10:50 a.m., with Treatment Nurse (TN) 1, TN 1 stated Resident 1 had a history of the generalized body rash since 2/20/2023. During a review of Resident 1's GACH record, titled Physian History and Physical, dated 3/26/2023, indicated Resident 1 was admitted on [DATE] at 10:54 p.m. Resident 1 ' s history of present illness / chief complaint included a scabies appearing rashes. The Infectious Disease note indicated a diagnosis of Ectoparasitic infestation (condition in which organisms live primarily on the surface of the host) scabies and Permethrin, Ivermectin and contact isolation were ordered. During a review of Resident 1's GACH record, titled, Physician ' s Progress Note Infectious Diseases, dated 3/30/2023, indicated Resident 1 was itching, had scattered diffused papules (a raised, pimple-like growth on the skin that does not produce pus) and burrows (a tunnel made in or under the skin) on upper extremities, chest, abdomen, lower extremities and skin excoriation (linear erosion of skin tissue resulting from mechanical means) of bilateral buttocks. The GACH record indicated Resident 1's diagnosis included Ectoparasitic Infestation, scabies . Resident 1 was treated with Permethrin, Ivermectin on 3/26/2023, and was placed on contact isolation. During a concurrent interview and record review on 4/21/2023, at 2:29 p.m., with CM 1, CM 1 reviewed Resident 1's GACH discharge summary record indicating Resident 1 was treated for scabies at the GACH on 3/26/2023. CM 1 stated she does not know if the hospital informed facility staff, upon readmission, that Resident 1 was treated for scabies during her hospitalization. During an interview on 4/25/2023, at 3:35 p.m., with the DON, the DON stated she screened all residents prior to admission, and reviews the GACH records for the residents ' diagnosis and what kind of treatment residents received from the GACH. The DON stated Resident 1 ' s GACH records indicated Resident 1 was treated for scabies on 3/26/2023. The facility should had initiated an investigation of other residents with skin rashes and scabies exposure upon knowledge of Resident 1's scabies treatment during hospitalization to prevent the potential spread of scabies. 2. During a review of Resident 2's Face Sheet, dated 4/25/2023, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 ' s diagnoses included diabetes mellitus (body has high sugar levels for prolonged periods of time), hypertension (blood pressure that is higher than normal), and muscle weakness (lack of muscle strength that affects mobility). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 ' s cognitive skills for daily decision making was intact, and Resident 2 required extensive assistance in dressing, toileting, personal hygiene and bed mobility. During an interview on 4/21/2023, at 10:50 a.m., with Resident 2, Resident 2 stated she and Resident 1 were roommates prior to Resident 1's transfer to the GACH on 3/25/2023. They (Resident 1 and Resident 2) were also roommates when Resident 1 returned to the facility on 4/4/2023 until 4/15/2023. Resident 2 stated Resident 1 had told her the doctor in the hospital said she (Resident 1) had scabies. Resident 2 stated she suspected that scabies had been why all the showers have been taking place for other residents the past couple of days, but the facility staff have not communicated anything to her regarding the potential exposure to scabies. Resident 2 stated she did not receive or was offered any creams or treatments for scabies. During a concurrent interview and record review, on 4/21/2023, at 2:15 p.m., with CM 1, the Facility Census dated 3/25/2023 to 4/21/2023 was reviewed. CM 1 stated that Resident 1 and Resident 2 were roommate on 3/25/23, prior to Resident 1 ' s transfer to GACH, where Resident 1 was treated for scabies. CM 1 also stated Resident 1 and Resident 2 were roommates from 4/4/2023 to 4/15/2023. During a review of Resident 2's Dermatology Order, dated 4/17/2023, indicated an order for Permethrin 5% cream, apply one tube from neck to toes, leave for two hours then rinse for prophylactic treatment. During a review of Resident 2's Dermatology Progress note, dated 4/17/2023, MD 2 progress note indicated Resident 2 was seen by MD 2, who determined no skin pathology was seen on general body, and treatment plan was to administer Elimite prophylaxis (precautionary measure taken to prevent the onset of scabies). During review of document, titled, Scabies Outbreak Line List for Healthcare Facilities: Patients, dated 4/18/2023, indicated that Resident 2 who was exposed to Resident 1, was not on the line list. During an interview, on 4/21/2023, at 2:30 p.m., with the DON, the DON stated she was not sure why Resident 2 was not added to the line list and treated prophylactically for scabies. During a review of Resident 2's Change of Condition Assessment Form (COC), dated 4/21/2023, the COC indicated on 4/21/2023 at 4 p.m., RN 2 discussed recommendation from dermatologist with the primary physician (MD1) to treat Resident 2 for dermatitis [sic]prophylactically and obtained an order for prophylactic treatment on 4/21/2023. COC indicated Resident 2 was notified of a new order for prophylactic treatment but refused treatment. COC did not indicate the physician was notified Resident 2 was refusing treatment to determine what other orders could be done to mitigate potential spread of scabies. During a review of Resident 2's Physician Order, dated 4/21/2023, indicated, Permethrin External Cream was ordered on 4/21/2023 at 2:31 p.m., by MD 2. During a review on of Resident 2's MAR, dated 4/2023, indicated, Permethrin External Cream (5%) was administered on 4/24/2023 to Resident 2, by LVN 3. During an interview on 4/25/2023, at 12:57 p.m., with the DON, the DON stated the facility should have identified Resident 2 did not receive prophylactic treatment on 4/17/2023, and Resident 2 could have spread scabies to other staff or residents since she was exposed to Resident 1 on 4/15/2023. The DON was unable to explain why Resident 2 did not receive prophylaxis treatment for scabies when MD 2 ordered Elimite on 4/17/2023. 3. During a review of Resident 3, Resident 7, Resident 8, Resident 19, and Resident 21's clinical records, the records indicated the residents did not receive treatment for scabies when Resident 1 returned to the facility on 4/4/23, with a disgnosis of scabies. The records indicated the following: a. During a review of Resident 3's Face Sheet, dated 4/18/2023, the Face Sheet indicated Resident 3 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Resident 3 ' s diagnoses included functional quadriplegia (complete immobility and inability to move due to severe physical disability), ventilator dependence (inability to breath independent of a machine device), and hypertension. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 ' s cognitive skills for daily decision making was severely impaired, and had total dependence (full staff performance) on personal hygiene and bathing. During an observation on 4/21/2023, at 11:40 a.m., inside Resident 3 ' s room, Resident 3 was observed lying in bed, unable to move, and nonverbal. Resident 3 had red skin lesions on her back and left lateral torso (side of trunk of the body), with red scarring, both raised and flat, some of which were greater than 1-centimeter ([cm] unit of measurement) in diameter, with surrounding skin showing darkened discolored, and eczematous (patches of skin become rough and inflamed with blisters that cause itching and bleeding) blotches (irregular patch or unsightly marks on surfaces). During a review of Resident 3's Physician Order dated 4/1/2023, indicated an order for Clobetasol Proprianate External Foam (used to treat the itching, redness, dryness, crusting, scaling, inflammation, and discomfort of various scalp and skin conditions) 0.05%, apply to affected areas topically every day shift for rash. During a review of Resident 3's Dermatology Progress Note, dated 4/17/2023, indicated Resident 3 had generalized body dermatitis. During a review of Resident 3's Dermatology Order, dated 4/17/2023, indicated the following orders: · Permethrin 5 % cream, apply one tube from neck to toes, leave for 12 hours then rinse. Repeat once a week times four weeks. · Ivermectin 12 mg via gastrostomy tube ([g-tube] a tube that allows nutrition and medication to bypass the mouth and go directly into the stomach) every week times four weeks. During a review of Resident 3's MAR, dated 4/2023, the MAR indicated, Permethrin Cream 5% was administered on 4/18/2023. During a review of Resident 3's MAR, dated 4/2023, the MAR indicated, Ivermectin 12 mg was administered on 4/20/2023 to Resident 3. During an interview on 4/20/2023, at 10:50 a.m., with TN 1, TN 1 stated Resident 3 had rashes since 3/13/2023, but was determined by MD 2 to be dermatitis (inflammation of skin), and was treated with topical corticosteroids (a topical immune suppressorant to reduce inflammation of skin). b. During a review of Resident 7's Face Sheet, dated 4/19/2023, the Face Sheet indicated Resident 7 was originally admitted to the facility on [DATE], and was readmitted to the facility on [DATE]. Resident 7's diagnoses included traumatic brain injury (a head injury causing damage to the brain by external force or mechanism)), quadraplegia (whole body paralysis), Urinary Tract Infection (an infection in any part of the urinary system), rash and other nonspecific eruption. During a review of Resident 7's MDS , dated 3/27/2023, the MDS indicated Resident 7 ' s cognitive skills for daily decisions was severely impaired. Resident 7 required total dependence with bed mobility, dressing, eating, toilet use and personal hygiene. During a review of Resident 7's Dermatology Progress note, dated 1/16/2023, indicated Resident 7 has prurigo nodularis (a chronic skin disorder characterized by the presence of hard, extremely itchy bumps known as nodules) on left arm, left flank and left trunk and was treated with topical steroids. During a review of Resident 7's Dermatology Progress Note, dated 2/13/2023 indicated Resident 7 had general body tinea corporis (a rash caused by a fungal infection) and was treated with topical steroids, oral steroids, and oral antifungal. During a review of Resident 7's GACH record, titled Physician H&P General, dated 2/24/2023 (admission date) at 1:12 p.m., indicated physician was concerned about Resident 7 ' s widespread rash and suspecting scabies. The GACH records further indicate he was placed on contact isolation for scabies, and treated with Permethrin twice on 2/24/2023. During a review of Resident 7's admission Reassessment note, dated 3/8/2023, indicated Resident 7 had a generalized body rash. During a review of Resident 7's Dermatology Progress Note, dated 4/17/2023, indicated Resident 7 had a generalized dermatitis. During a review of Resident 7's Dermatology Order, dated 4/17/2023, indicated the following orders: · Permethrin 5 % cream, apply one tube from neck to toes, leave for 12 hours then rinse. Repeat once a week times four weeks. · Ivermectin 12 mg by mouth every week times four weeks. During an interview on 4/20/2023, at 12:25 p.m., with TN 1, TN 1 stated Resident 7 was readmitted to the facility with the generalized body rash on 3/8/2023, and that dermatology visited him on 1/16/2023, 2/13/2023, 3/13/2023, and 4/17/2023. TN 1 stated that prior to 4/17/2023 when MD 2 suspected Resident 7 had scabies, his rash was diagnosed as prurigo (skin condition characterized by multiple nodules on the back of the arms and legs, and was extremely itchy) and tinea corpus. c. During a review of Resident 8's Face Sheet, dated 4/19/2023, the Face Sheet indicated Resident 8 was admitted to the facility on [DATE]. Resident 8 ' s diagnoses included ventilator dependence, dysphagia (difficulty swallowing), and traumatic brain injury. During a review of Resident 8's MDS, dated [DATE], the MDS indicated the cognitive skills for daily decisions was severely impaired, and Resident 8 required total dependence with personal hygiene and bathing. During a review of Resident 8's Physician Order dated 3/18/2023, indicated an order for Clotrimazole Cream 1%, apply to groin topically every morning and evening shift for Tinea Cruris ([Jock itch] a [NAME] infection that causes a red and itchy rash in warm and moist areas of the body). During a review of Resident 8's Physician order dated 4/3/2023, indicated an order for Triamcinolone Acetonide External Cream 0.1%, apply to general body topically every day shift for dermatitis unspecified for 30 days. During a review of Resident 8's Dermatology Progress Note, dated 4/17/2023, indicated Resident 8 had a generalized dermatitis. During a review of Resident 8's Dermatology Order, dated 4/17/2023, indicated the following orders: · Permethrin 5 % cream, apply one tube from neck to toes, leave for 12 hours then rinse. Repeat once a week times four weeks. · Ivermectin 12 mg via gastrostomy tube (g-tube) every week times four weeks. During an interview on 4/20/2023, at 10:51 a.m., with TN 1, TN 1 stated Resident 8 had a rash since 4/4/2023, and antifungal and antiinflammatory creams were ordered for the rash by MD 1. Resident 8 was seen by dermatologist, MD 2, on 4/17/2023 for the first time. During an observation on 4/21/2023, at 11:15 a.m., inside Resident 8 ' s room, Resident 8 was observed lying in bed, unable to move, and nonverbal. Resident 8 had a red rash of raised bumps on his back, abdomen, both arms, and legs. d. During a review of Resident 19's Face Sheet, dated 4/18/2023, the Face Sheet indicated Resident 19 was admitted to the facility on [DATE]. Resident 19 ' s diagnoses included diabetes mellitus, dysphagia, and left-sided hemiplegia (paralysis of the left side of the body). During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19's cognitive skills for daily decisions was intact. Resident 19 required extensive assistance with bed mobility, dressing eating, personal hygiene, and total dependence with toilet use. During an observation on 4/21/2023, at 10:30 a.m., inside Resident 19's room, Resident 19 was awake, alert, and refused observation of rash, and interview. During a review of Physician Order dated 11/9/2022, indicated an order for Triamcinolone Acetonide External Cream 0.1%, apply to left upper thigh topically every morning for dermatitis unspecified for 30 days. During an review of Resident 19's Physician Order dated 12/20/20222, indicated an order for Bethamethasone Diprolonate External Cream 0.05%, apply to general body topically every morning shift for dermatitis unspecified for 30 days. During a review of Dermatology Progress Note dated 1/16/2023, indicated Resident 19 was status post dermatitis unspecified general body and treat for topical steroids. During a review of Resident 19's Physician order dated 1/17/2023 indicated an order for Triamcinalone Acetonide External Cream 0.1%, apply to general body topically every morning shift for status post dermatitis unspecified for 30 days. During a review of Resident 19's progress note dated 2/13/2023 indicated Resident 19 has dermatitis unspecified general body topical steroids. During a review of Resident 19's Physician Order dated 2/16/2023, indicated an order for Clobetasol Propionate External Cream 0.05%, apply to generalized body topically two times a day for dermatitis unspecified for four weeks. During a review of Resident 19's Physician Order dated 3/16/2023, indicated an order for Clobetasol Proprionate External Cream 0.05%, apply to generalized body topically, two times a day for 4 weeks. During review of Resident 19's Treatment Administration Record (TAR), dated 4/2023, the TAR indicated Resident 19 was receiving Clobetasol Propionate 0.05% cream since 4/1/2023 for generalized body rash. During a review of Resident 19's Dermatology Progress Note, dated 4/17/2023, indicated Resident 19 had a generalized dermatitis. During a review of Resident 19's Dermatology Order, dated 4/17/2023, indicated the following orders: · Permethrin 5 % cream, apply one tube from neck to toes, leave for 12 hours then rinse. Repeat once a week times four weeks. · Ivermectin 12 mg by mouth every week times four weeks. f. During a review of Resident 21's Face Sheet, dated 4/18/2023, the Face Sheet indicated Resident 21 was admitted to the facility on [DATE]. Resident 21 ' s diagnoses included dementia (a group of symptoms that affects memory, thinking and interfers with daily life) COPD, and diabetes mellitus. During a review of Resident 21' s MDS, dated [DATE], the MDS indicated Resident 21 was cognitively impaired, and required extensive assistance for personal hygiene and toileting. The MDS indicated Resident 21 did not have any skin issues. During a review of Resident 21 ' s GACH record dated 3/10/2023, indicated, Resident 21 was admitted to the GACH on 3/6/2023 with complaints of itchy rash that she had for the last several months. Resident 21 ' s GACH assessment indicated Resident 21 had possible scabies and plan was to treat with Elimite and Ivermectin trial. Clinical summary indicated Resident 21 received Permethrin 5% topical on 3/7/2023 with discharge summary indicating to continue taking the following medications: · Triamcinolone 0.1% topical cream, apply topically to affected area two times a day. · Triamcinolone 0.5 % topical cream, apply topically to affected area once a day. During an interview on 4/20/2023, at 12:45 a.m., with RN 2, RN 2 stated Resident 21 had a new generalized rash discovered by MD 2 on 4/17/2023. During a [TRUNCATED]