**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident was free from neglect for 13 of 15 residents (Resident #1, Resident #16,Resident #20, Resident #25, Resident #37, Resident #39, Resident #49, Resident #51, Resident #61, Resident #84, Resident #100, Resident #107, Resident #109) across 3 out of 3 units (100-Hall, 200-Hall and 300 Hall) reviewed for neglect. - The facility failed to take the appropriate actions of: retaining an IP with qualified training, complete tracking and trending of infections from August to October of 2023, treat diagnosed and presumptive scabies ( an infestation with the scabies mite), isolate of resident's with presumptive and diagnosed scabies, implement of environment controls to limit the spread of scabies and infection control surveillance to prevent a scabies outbreak even though the facility administration was aware that residents and staff had contracted the same unspecified rash over multiple months. This failure to take action resulted in multiple residents across multiple units experiencing itching/scratching, being diagnosed and/or treated for scabies and placed on contact isolation. - Resident #107 (100 Hall) was treated unsuccessfully for scabies from 07/2023 to 12/2023, experienced rashes/itching/discomfort and developed crusted scabies (a rare highly contagious hyper-infestation of the scabies mites that usually occurs in immune compromised patients). - Resident #39, who roomed with Resident #107, reported he was very itchy, developed rashes on his entire body, and was diagnosed/treated for scabies. - Resident #25, who roomed with Resident #107, developed rashes on his entire body, and was diagnosed/treated for scabies. - Resident #37 (100 Hall) developed rashes on his trunk, arm, and thigh eventually suffering from a secondary bacterial skin infection (cellulitis) - Resident #100 (300 Hall) developed rashes covering his entire body including his penis, was diagnosed/treated for scabies and placed on contact isolation. - Resident #51 (100 Hall) developed rashes on her abdomen and chest area, experienced itching, was placed on contact isolation and treated for scabies. - Resident #61 (100 Hall) developed rashes on his stomach and complained of itching. - Resident #81 (100 Hall) developed rashes to her arms, trunk, chest and scratching at her skin. - Resident #16 (100 Hall) developed a rash to his stomach, was treated for scabies and placed on contact isolation. - Resident #84 (100 Hall) developed a rash on his stomach, was treated for scabies and placed on contact isolation - Resident #109(100 Hall) developed a rash to his abdomen/trunk, was treated for scabies and placed on contact isolation. - Resident #20 (200 Hall) developed a rash on his arms, was treated for scabies and placed on contact isolation. - Resident #1 (300 Hall) developed a rash and was treated for scabies and was placed on contact isolation. -the facility failed to take prompt actions and identify potential issues early, without Surveyor intervention when Resident #49, who had a tracheostomy (tube inserted into the windpipe to help a person breathe) was observed to be in distress for an unknown period of time. -the facility failed to ensure the oxygen mask was in place to provide continuous oxygen flow to Resident #49 prior to leaving the resident's room. -the facility failed to maintain sterile procedure prior to tracheostomy suctioning for Resident #49. An IJ was identified on 12/18/23. The IJ template was provided to the facility on [DATE] at 04:09 PM. While the IJ was removed on 12/23/23 at 03:20 PM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that was not immediate due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures placed residents at risk for itching, discomfort, pain, secondary skin infections, acute respiratory distress and hospitalization. Findings included: Record review of the facility Infection Control Tracking and Trending for August, September and October of 2023 revealed, the tracking and trending was completed retrospectively for those months on 11/08/23 by the DON. Resident #107 Record review of Resident #107's Face Sheet dated 12/18/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of depression, difficulty swallowing, down syndrome, fluid overload, hypertension. The resident had a diagnosis of Atopic dermatitis (swelling and irritation of the skin) and congenital ichthyosis (a group of rare skin conditions that cause dry, scaly skin that individuals are usually born with) as of 11/03/23, he did not have a diagnosis of Scabies. The resident discharged to the hospital on [DATE]. Record review of Resident #107's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, substantial/maximal assistance for most ADLs, an indwelling catheter, frequently incontinent of bowel and application of ointments/medications other than to feet. Record review of Resident #107's undated care plan revealed, focus areas of - ID, DD with PASRR services, potential nutritional problems, potential for pressure ulcer development, impaired cognitive function, a communication problem and tube feeding. There was no focus area to address Resident #107's treatment/diagnosis of scabies. Record review of Resident #107's Order Summary dated 12/18/23 revealed, Resident #107 had orders for Permethrin (an insecticide used to treat scabies) on multiple occasions but was only on contact isolation once: - 06/23/23 Permethrin 5% for dermatitis for 2 days: apply to head to toe topically one time only for 2 days. Leave on for 8-145 hours. - 07/26/23 Permethrin 5% for pruritus: apply from head to toe excluding genitalia for 8-12 hours and rinse off next morning. - 08/18/23 Permethrin 5% : apply from head to toe excluding genitalia for 8-12 hours and rinse off next morning per dermatologist. - 11/03/23 Permethrin 5% for prophylactic dermatitis for 2 days: apply at bedtime and leave overnight. Rinse of in AM. - 12//11/23 Permethrin 5% apply topically one time for scabies infestation. Leave in for 8-14 hours, use strict contact precautions with protective garments. - 12/11/23 Contact Isolation- use strict contact precautions with protective garments. Record review of Resident #107's Dermatologist Note dated 07/26/23 revealed: Resident #107 was being seen as a referral from the Medical Director for a rash located on the body throughout. The rash was itchy and red and moderate in severity and it had been present for months. scaling and well demarcated, eczematous patches; differential diagnosis includes irritation dermatitis vs. scabies; plan- Plan: treat with triamcinolone 0.1% topical steroid cream, hydroxyzine 25 mg tablets as needed for itch and permethrin 5% apply topically once per week. Follow up in 6 weeks for skin check. Record review of Resident #107's Dermatologist Note dated 11/03/23 revealed: Impression: Eczema associated diagnosis: Scabies; status: worsening, Itch Numerical Rating scale:10; % body surface covered in rash: 70. Plan: treat with triamcinolone 0.1% topical steroid cream, hydroxyzine 25 mg tablets as needed for itch and permethrin 5% apply topically once per week. Record review of Resident #107's Physician Note dated 12/13/23 signed by the Medical Director revealed, Resident #107 was seen due to rash noted over the extremities and right upper shoulder that appeared crusted in nature. Diagnosis/Plan: unspecified dermatitis secondary to scabies infection, was started on permethrin cream, repeat treatment after 7 days, clean linens/clothes, deep clean room and contact isolation precautions in place. Record review of Resident #107's MARs from 06/2023 to 12/2023 revealed: - Jun 2023: Permethrin 5% apply to skin at bedtime for dermatitis for 2 days- it was only applied once on 6/24/23. - July 2023: Permethrin 5 % apply to skin for persistent dermatoses (a skin defect)- applied on 07/21/23. Permethrin 5% apply topically for pruritus- applied 7/26/23. - August 2023: Permethrin 5 %- applied 08/18/23 - November 2023: Permethrin 5 % prophylactically for dermatitis for 2 day- was only applied on 11/04/23 - December 2023: Permethrin 5% for scabies infestation use strict contact isolation- applied on 12/11/23 at 10:30 PM. Record review of Resident #107's Progress Notes from 12/22/22 to 12/23/23 revealed the resident's rash : - 06/24/23- generalized rash noted to entire body - 07/17/23- resident noted with recurrent rash to upper extremities - 07/23/23 day 7/7 of prednisone for generalized rash to torso. Area clean with red bumps noted from front/back torso. Resident scratching right front chest. - 08/24/23- generalized rash remains. - 09/12/23- Rash noted all over resident skin. - 11/02/23 at 01:30 AM: generalized rash remains pronounced, - 11/04/23 at 03:17 AM: generalized rash remains pronounced, dry, raised in some areas. - 11/04/23 at 10:15 AM : rash was still present to entire body and has new orders for permethrin 5% cream for 2 days and ammonium lactate 12% cream on shower day which will be on Monday 11/6/2023 - 12/14/23 at 02:30 AM- scaly, shedding, redness/self-inflicted scratches noted to skin. Resident on contact isolation There was only one mention of the resident having scabies on 12/12/23 at 04:01 AM- remain in contact isolation for scabies, permethrin cream applied to the entire body; and Resident #107 was first placed on contact isolation on 12/11/23. Record review of Resident #107's Hospital Progress dated 12/15/23 at 10:22 AM revealed, consult requested for cracking and flaking of skin with some deeper skin layer involvement. Dry thick crusted skin that extends from the right side of his head, neck, down the right shoulder, armpit, arm, right side of chest and left side of chest and armpit. Possible diagnosis of crusted scabies Record review of Resident #107's Hospital Wound Care Note dated 12/15/23 at 03:22 PM revealed, consult requested for cracking and flaking of skin with some deeper skin layer involvement. Dry thick crusted skin that extends from the right side of his head, neck, down the right shoulder, armpit, arm, right side of chest and left side of chest and armpit. Possible diagnosis of crusted scabies Record review of Hospital Infectious Disease Progress Note dated 12/17/23 at 07:46 AM revealed, Skin: chest, upper abdominal/upper extremity rash with skin lesions. Impression: Crusted Scabies Recommendations: Oral Ivermectin (an antiparasitic) and Topical Permethrin for crusted scabies. Record review of Hospital Infectious Disease Progress Note dated 12/18/23 at 05:32 AM revealed, Skin: chest, upper abdominal/upper extremity rash with skin lesions. Impression: Crusted Scabies Recommendations: Oral Ivermectin (an antiparasitic) for 4 days and Topical Permethrin for 3 days for crusted scabies. Record review of Resident #107's Medical Diagnoses printed 12/23/23 at 11:39 AM revealed, depression, difficulty swallowing, high blood pressure and atopic dermatitis. There was no documented diagnosis of scabies. An observation and interview on 12/13/2023 at 2:00 PM of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #107 was in the bed by the window, he was awake, receiving tube feeding, had a urinary foley catheter and was non interviewable. Resident #107 had fair colored skin with thick, dry, crusty, scaly large areas to the upper body. On both shoulders and upper arms were thick crusty, powdery white areas with red cracks. There were raised red bumps and rash to both forearms and to both upper thighs. The thighs had red scratch marks. The webbing between the thumb and pointer finger on both hands had powdery white irregular bumps. Resident #107 was scratching his groin and upper thighs. The treatment nurse stated he had dermatitis that worsened since he returned from the hospital in October 2023. The treatment nurse stated the rash on Resident #39 and Resident #107 appeared to be the same. She did not mention that Resident #107 had a presumptive diagnosis of scabies or that the resident was being treated for scabies. An observation and interview on 12/15/2023 at 4:00 PM revealed, Resident #107 in the ICU at the hospital with a diagnosis of respiratory failure and sepsis. Resident #107's room door was open and the resident was intubated(a tube into the throat to help breathing). The assigned hospital nurse stated when he was admitted on [DATE] d/t low blood pressures and elevated WBC. The hospital nurse stated they were not notified of the resident having scabies. The hospital nurse picked up her phone that was ringing and said it was the wound care nurse on the line who just told her she completed her evaluation done on 12/15/2023 and thought he might have scabies. The hospital nurses closed the resident's door and set up for contact isolation. Isolation signage was put up on the glass door. In an interview on 12/15/23 at 09:25 AM, MA A said she was present on 11/03/23 when Resident #107 saw the dermatologist. She said due to the rash being chronic and the severity of itching as well as the facility informing them other residents had similar rashes the Dermatologist wanted to treat Resident #107 for scabies. She said the MD ordered Permethrin 5% for Resident #107 to be repeated in 7 days. In an interview on 12/20/23 at 07:55 AM, the Hospital Treatment Nurse said when Resident #107 arrived to the hospital she observed thick plaques and rashes all over the parts of the body she could see (at least 1/3rd ) and she was surprised. She said the hyperkeratotic (a condition that causes skin to thicken in certain places) presentation and the residents history made her believe he had crusted scabies. Resident #39 Record review of Resident #39's Face Sheet dated 12/23/23 revealed, a 50-year-olf male who admitted to the facility on [DATE] with diagnoses of: chronic pain syndrome, contractures, lack of coordination, anemia and a scabies (onset 12/11/23). Record review of Resident #39's Annual MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 11 out of 15, dependence for most ADLs and application of ointments/medications other than to feet. Record review of Resident #39's undated Care Plan revealed, focus-impaired visual function, refusal of care (showers/shampoos and general grooming), total assistance with all ADLs except feeding. Focus- actual impaired to skin integrity r/t thick skin and callous buildup to feet, he refuses to shower routinely which precipitates dry skin formation; intervention- identify/document potential causative factors and eliminate/resolver where possible; keep skin clean and dry. Record review of Resident #39's NP Note dated 11/30/23 signed by the NP revealed, skin: chronic seborrheic dermatitis ( a chronic inflammatory disorder affecting areas of the head and trunk were glands are located)- refuses showers. Record review of Resident #39's NP Note dated 12/08/23 signed by the NP revealed, Diagnosis/Plan: seborrheic dermatitis- refuses showers. There was no documented description of the resident's rash. Record review of Resident #39's MD note dated 12/13/23 and signed by the Medical Director revealed, Resident #39 had a red rash over the extremities of both upper and lower extremities. The resident was on isolation and was started on permethrin for scabies but he continued to refuse showers and application of creams. Diagnosis/plan: unspecified dermatitis secondary to scabies infection, on contact isolation, on permethrin cream repeated after 7 days and room to be deep cleaned and linens washed. Record review of Resident #39's Clinical Census dated 12/23/23 revealed, Resident #39 shared a room with Resident #107 from 10/24/23 until Resident #107 was discharged to the hospital on [DATE]. Record review of Resident #39's Medical Diagnoses dated 12/23/23 at 12:57 PM, the diagnosis of scabies was added on 12/16/23 and the onset of the disease was 12/11/23. Record review of Resident #39's Progress notes from 12/22/22 to 12/23/23 revealed, Resident #39's had rashes dating back to 06/2023. - 6/13/23 at 04:46 PM- Resident's lower extremities are swollen with wound., Also has rash all over the body but was refusing treatment and medication. - 06/26/2023 at 10:40- The entire body skin observed with rash. There was no other mention of Resident #39 suffering from a rash until 12/14/23 (3 days after being diagnosed with scabies:) - 12/14/23- remain in contact isolation/precautions, generalized skin rash remains to the body. Record review of Resident #39's Order Summary dated 12/23/23 revealed, - 12/11/23 Permethrin 5% apply head to toe at bedtime for scabies infestation. Use strict contact precautions with protective garments. - 12/11/23 Permethrin 5% apply head to toe at bedtime for scabies infestation. Use strict contact precautions with protective garments. Start date 12/19/23. Record review of Resident #39's December 2023 MAR revealed, -Permethrin 5% topically at bedtime for scabies infestation- applied on 12/11/23 at 9:30 PM and 12/19/23 at 12:16 AM. Observation and interview on 12/13/2023 at 2:00 PM of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #39 was awake, dressed in a hospital gown and brief and was in the bed by the door. Resident #39's arms, legs and hands were contracted. Resident #39 stated it was ok to look at his skin and that areas on his skin were very itchy. Resident #39 had small, red bumps on the scalp, forehead, cheeks, on both elbows, arms and both lower legs had large red bumps. The treatment nurse stated the redness to the elbows and red areas on his back were not new. The treatment nurse stated the new red bumps appeared sometime last week (12/4/2023 to 12/08/2023). The treatment nurse stated these new red bumps occurred at the same time Resident #107's red bumps appeared. Observation and interview on 12/23/2023 at 12:00 PM, Resident#39 was in contact isolation. He had a plate of food on his chest. He had red bumps on his scalp, face and arms and was unchanged from 12/13/23. He said he did receive the treatment cream, then showers the next day. Resident #39 stated he was told the cream was for scabies. He stated that it started with Resident #107 and maybe from not having the bed linens changed and washed. He stated that the bed linens were changed out daily and his personal belongings were removed. He stated he did not feel as itchy. He stated he was able to sleep through the night but during mornings he would feel itchy when he thinks about it. He stated he will be getting out of isolation soon and was happy about that because he wanted to get his money so he can buy soda. Resident #25 Record review of Resident #25's Face Sheet dated 12/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of ID, schizophrenia, anemia, anxiety, hallucinations, depression and scabies (onset date 12/11/23). Record review of Resident #25's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, substantial to maximal assistance with most ADLs, and always incontinent of both bladder and bowel. There was no documentation of any applications of ointments/medication to the skin. Record review of Resident #25's undated Care Plan revealed, no related focus areas. There was no mention of any skin issues including rashes and scabies. Record review of Resident #25's Clinical Census revealed, Resident #25 shared a room with Resident #107 since 10/24/23. Record review of Resident #25's NP Note dated 11/27/23 revealed, no documented skin issues. Record review of Resident #25's NP Note dated 11/30/23 revealed- head to toe assessment done due to reports of patient had rash to both sides of his upper and lower extremities. He has elevated red bumps, dry scaly skin scattered to chest, abdominal area, back, both legs and arm but no rashes were observed on the web spaces of his hands, genitals or scalps. Monitor closes due to skin rash issues in the unit. Record review of Resident #25's NP Note dated 12/08/23 revealed, the resident was on hydrocortisone (steroid cream) for skin rash and the rash was unresolved. Record review of Resident #25's NP Note visit date 12/09/23 but signed on 12/18/23 revealed, Resident #25 was noted itching/scratching and had a persistent skin rash likely scabies. Resident #25 was treated with Sulfur 5% nightly for 3 days, with a plan to treat with Permethrin if the rash didn't resolve. Contact Isolation precautions and an oral medication to treat itching. Record review of Resident #25's Medical Diagnoses dated 12/23/23 at 12:57 PM, the diagnosis of scabies was added on 12/16/23 and the onset of the disease was 12/11/23. Record review of Resident #25's Order Summary dated 12/23/23 revealed: - 12/09/23- Sulfur 5% lotion for dermatitis, apply to entire body from neck down, rub in and leave on for 24 hours. - 12/11/23- Permethrin 5%- apply to head to toe topically one time only for scabies infestation. Leave on for 8-14 hours, use strict contact precautions with protective garments. - 12/11/23- Contact Isolation: use strict contact precautions with protective garments, every shift for scabies infestation. Record review of Resident #25's December 2023 MAR revealed, Resident #25 received Permethrin 5% on: - 12/12/23 at 08:43 AM - 12/20/23 at 12:52 AM Observation and interview on 12/13/2023 at 2:00 PM of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #25 was in the middle bed in a full body, long sleeve jump suit. When the Treatment Nurse removed his body suit, Resident #25 was observed with had light pink, small, raised bumps to both upper arms and on the abdomen. The Treatment Nurse stated Resident #25 was treated with Hydrocortisone cream beginning 11/30/2023 for a rash to both arms and legs. Resident #37 Record review of Resident #37's Face Sheet dated 12/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: epilepsy, asthma, arthritis, type 2 diabetes and scabies with an onset date of 12/16/23. Record review of Resident #37's MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 05 out of 15, rejection of care, substantial/maximal assistance with most ADLs and application of ointments/medications to skin other than feet. Record review of Resident #37's undated Care Plan revealed, no documented focus areas addressing, skin, rashes or scabies. Record review of Resident #37's Census revealed he shared a room with Resident #107 from 08/28/23 to 09/23/23. Record review of Resident #37's Progress Notes from 12/22/22 to 12/23/23 revealed: - 09/22/23 at 02:33 PM the resident had a new rash to both arms, chest and legs. There was no documentation of the resident being placed on contact isolation. - 09/22/23 at 02:49 PM: Change of condition identified in a change in skin condition, the resident has a personal history of infectious and parasitic diseases. Skin Status Evaluation: itching rash and an order was given for Permethrin 5% to chest both legs and both arms which should be washed of in 8-12 hrs, hydrocortisone 1% cream for 7 days and calamine lotion for 2 weeks. There was no documentation of the resident being placed on contact isolation. - 10/02/23 at 10:34 PM: PERMETHRIN CREAM 5% APPLIED ON RESIDENT ENTIRE BODY THIS SHIFT AND TO BE WASHED OFF IN 8-12HRS. - 10/16/23 Resident on day 5/7 of antibiotics for cellulitis. Rash remains. - 10/18/23 Resident still on antibiotics for cellulitis. Rash still present and some itching noted. - 10/20/23 Resident still noted with rash all over his body and treatments continue - 10/27/23 Resident continues with steroid cream to the body for generalized rash, red raised bumps noted. - 10/40/23 Generalized rash red in color and bumpy. - 11/03/23 Rash present to body, generalized mild redness with complaints of mild itching. - 11/06/23 Rash still visible. - 11/08/23 Resident with generalized rash to body, some itching noted-redirected to avoid infection/pain. - 11/21/23 Resident seen by NP, new orders to apply steroid cream to rash all over his body twice daily for 30 days. - 11/24/23 Rash remains reddened pronounced and generalized. - 11/28/23 Rash remains reddened pronounced and generalized - 12/06/23 Rash remains reddened. Apply steroid cream to torso, back, upper extremities and thighs. - 12/13/23 Resident was on antibiotics for skin cellulitis and generalized rash remains to the entire body. Redness and self-inflicted scratches to the back, legs, arms, neck and abdomen noted. - 12/14/23 Rash with little improvement. - 12/15/23 generalized rash remains to the entire body. Redness and self-inflicted scratches to the back, legs, arms, neck and abdomen noted and worse. - 12/18/23 Day 1 of Permethrin 5% treatment to body An observation and interview on 12/12/23 at 09:55 AM revealed, Resident #37 lying in bed well dressed and well-groomed with rashes/scabs to his arms. When asked about the rash./sores the resident said everything was ok and would not respond further. Record review of Resident #37's NP Note dated 11/28/23 revealed, evaluation of dermatitis. Patient has rash to upper torso. Record review of Resident #37's NP Note dated 12/09/23 revealed, dermatitis unresolved. Record review of Resident #37's NP Note dated 12/12/23 revealed, dermatitis unresolved. Likely scabies infection will treat with Permethrin, repeat dose if not resolved and contact isolation precautions. Record review of Resident #37's Order Summary sprinted 12/23/23 revealed: - 06/23/23 Permethrin 5% for dermatitis, apply for 2 days. - 09/22/23 Permethrin 5%- apply to arms, legs, chest typically one time only written for 2 days. - 10/02/23 Permethrin 5% for scabies - Contact precautions- use contact precautions with protective garments. There are no previous orders for contact precautions - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments - 12/21/23 Permethrin 5% for scabies. Use contact precautions with protective garments Record review of Resident #37's September 2023 MAR printed 12/23/23 revealed: - 09/22/23 Permethrin 5% applied at 04:45 PM. - 09/22/23 to 09/29/23 hydrocortisone 1% to arms, legs, and chest for pruritis at 09:00 AM and 05:00 PM Record review of Resident #37's October 2023 MAR printed 12/23/23 revealed: - 10/02/23 Permethrin 5% applied at 09:29 PM. - 10/26/23 to 10/31/23 Hydrocortisone 2.5 % to legs, armpits, trunk nightly for dermatitis Record review of Resident #37's November 2023 MAR printed 12/23/23 revealed: - 11/01/23 to 11/06/23 Hydrocortisone 2.5 % to legs, armpits, trunk nightly for dermatitis Resident #84 Record review of Resident #84's Face Sheet dated 12/19/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of: Parkinson, dementia, depression, communication deficit and scabies with onset of 12/16/23. Record review of Resident #84's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 09 out of 15, extensive assistance with most ADLs and application of ointments/medications to the skin other than the feet. Record review of Resident #84's undated Care Plan revealed, no focus areas address rashes, itching or scabies. Record review of Resident #84's Census revealed, he shared a room with Resident #107 from 08/28/23 to 09/23/23 Record review of Resident #84's Progress Notes from 12/22/22 to 12/23/23 revealed, - 09/15/23 Resident noted with rash to entire body. - 10/03/23 Rash red and bumpy in appearance to legs and right thigh. - 10/20/23 Resident still noted with rash all over his body, treatment continues - 10/23/23 Resident given oral steroids for rash to lower legs, and areas of dry skin - 11/03/23 rash to both legs present bumpy and red. - 11/06/23 Dermatology appointment cancelled and will be rescheduled. - 11/16/23 Rash remains reddened, raised and generalized. - 11/30/23 Resident given oral antifungal for rash. - 12/14/23 Resident rash to both legs with little improvement. -12/15/23 Generalized rash/itching remain the same Record review of Resident #84's Order Summary report printed 12/23/23 revealed: - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments - 12/16/23 Contact precautions with protective garments every shift - 12/2/23 Permethrin 5% for scabies. Use contact precautions with protective garments An observation on 12/12/23 at 09:55 AM revealed, Resident # 84 lying in bed with a limited range of motion and wedge pillows propping him up. The resident was observed to have a rash on both his arms and had limited communication capability and all he could say his butt burned. In an interview on 12/12//23 at 10:00 AM, the treatment nurse said Resident #84 was previously treated for wounds on his buttocks but the medication was discontinued because the issue had resolved. She said she would visit the resident to reassess him, and notify the wound care doctor about the resident's complaints. The Treatment Nurse did not address the Resident #84's itching. Resident #20 Record review of Resident #20's Face Sheet dated 12/16/23 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses: dementia, mood disorder, Anxiety disorder and depression. Record review of Resident #20's 5-day MDS dated [DATE] revealed, severely intact cognition as indicated by a BIMS score of 00 out of 15, partial assistance with most ADLs and no application of ointments/medication to the skin. Record review of Resident #20's undated Care Plan revealed, focus- elopement risk/wanderer onset 04/17/23; intervention- intervene as appropriate, distract resident from wandering by offering pleasant diversion, food, conversations, television or books. The care plan does not address any skin issues. Record review of Resident #20's MD Note dated 12/13/23 revealed, resident was started on a steroid cream for itching for 7 days. Skin: new rash to the back of the hand with some redness around it. Record review of Resident #20's Order Summary dated 12/23/23 revealed: - 11/03/23 Prednisone ( a steroid) 20 mg- 1 tablet one time a day for rash for 3 days. - 11/03/23 Hydrocortisone 1 %- apply topically two times a day for rash/dry skin - 11/03/23 Diphenhydramine (Benadryl) 25 mg- give 1 tablet by mouth for rash. - 11/03/23 Prednisone 10 mg- 1 tablet by mouth 1 time a day for rash for 5 days starting 11/08/23. - 11/27/23 Prednisone 20 mg- give 2 tablets by mouth daily for pruritus. - 11/27/23 Diphenhydramine (Benadryl) 25 mg- give 1 tablet by mouth for rash. - 11/28/23 Hydrocortisone 1 % for pruritus- apply topically two times a day to torso, both upper and lower extremities. - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments - 12/16/23 Contact Precautions- use contact precautions with protective garments. - 12/21/23 Permethrin 5% for scabies. Use contact precautions with protective garments scheduled for 12/24/23 An observation and interview on 12/12/23 at 09:45 AM revealed, Resident #20 well dressed, well-groomed in a wheelchair in front of his room. The resident was wearing a long sleeve shirt but a rash could be seen at the end of the sleeve of his right arm

**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 designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for 13 out of 15 residents (Resident #1, Resident #16,Resident #20, Resident #25, Resident #37, Resident #39, Resident #51, Resident #61, Resident #81, Resident #84, Resident #95, Resident #100, Resident #107, Resident #109) and 4 of 5 Staff ( CNA AA, CNA BB, CNA CC, CNA D and CNA S) reviewed for infection control. - The facility failed to implement environment controls and surveillance to prevent a scabies outbreak. Resulting in 13 residents (Resident #1, Resident #16,Resident #20, Resident #25, Resident #37, Resident #39, Resident #51, Resident #61, Resident #81, Resident #84, Resident #100, Resident #107, Resident #109) and 4 Staff ( CNA AA, CNA BB, CNA CC and CNA S). - Administration was aware that residents and staff had contracted the same unspecified rash over multiple months (September through December) and did not implement infection control procedure. - The facility failed to retain an IP with qualified training, complete tracking and trending of infections from August to October of 2023. -CNA D failed to change gloves, perform hand hygiene after peri care and prior to touching clean items for Resident #95 (identified outside of the IJ). -CNA D failed to perform hand hygiene prior to leaving the resident's room after providing peri care to Resident #95 (identified outside of the IJ). An IJ was identified on 12/15/23. The IJ template was provided to the facility on [DATE] at 03:00 PM. While the IJ was removed on 12/19/23, at 02:39 PM. The facility remained out of compliance at a scope of pattern and a severity level of actual harm that was not immediate due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures placed residents at risk for contracting a severe contagious skin infection, resulting in severe itching, discomfort, pain, decreased quality of life, and hospitalization. Findings included: Record review of the facility Infection Control Tracking and Trending for August, September and October of 2023 revealed, the tracking and trending was completed retrospectively for those months on 11/08/23. Resident #107 Record review of Resident #107's Face Sheet dated 12/18/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of depression, difficulty swallowing, down syndrome, fluid overload, hypertension. The resident had a diagnosis of Atopic dermatitis and congenital ichthyosis (a group of rare skin conditions that cause dry, scaly skin that individuals are usually born with) as of 11/03/23, he did not have a diagnosis of Scabies. Record review of Resident #107's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, substantial/maximal assistance for most ADLs, an indwelling catheter, frequently incontinent of bowel and application of ointments/medications other than to feet. Record review of Resident #107's undated care plan revealed, focus areas of - ID, DD with PASRR services, potential nutritional problems, potential for pressure ulcer development, impaired cognitive function, a communication problem and tube feeding. There was no focus area to address Resident #107's treatment/diagnosis of scabies. Record review of Resident #107's Order Summary dated 12/18/23 revealed, Resident #107 had orders for Permethrin (an insecticide used to treat scabies) on multiple occasions but was only on contact isolation once: - 06/23/23 Permethrin 5% for dermatitis for 2 days: apply to head to toe topically one time only for 2 days. Leave on for 8-14 hours. - 07/26/23 Permethrin 5% for pruritus: apply from head to toe excluding genitalia for 8-12 hours and rinse off next morning. - 08/18/23 Permethrin 5%: apply from head to toe excluding genitalia for 8-12 hours and rinse off next morning per dermatologist. - 11/03/23 Permethrin 5% for prophylactic dermatitis for 2 days: apply at bedtime and leave overnight. Rinse of in AM. - 12//11/23 Permethrin 5% apply topically one time for scabies infestation. Leave in for 8-14 hours, use strict contact precautions with protective garments. - 12/11/23 Contact Isolation- use strict contact precautions with protective garments. Record review of Resident #107's Dermatologist Note dated 07/26/23 revealed: Resident #107 was being seen as a referral from the Medical Director for a rash located on the body throughout. The rash was itchy and red and moderate in severity and it had been present for months. scaling and well demarcated (defined boundaries), eczematous (skin conditions with redness and itching) patches; differential diagnosis includes irritation dermatitis vs. scabies; plan- Plan: treat with triamcinolone 0.1% topical steroid cream, hydroxyzine 25 mg tablets as needed for itch and permethrin 5% apply topically once per week. Follow up in 6 weeks for skin check. Record review of Resident #107's Dermatologist Note dated 11/03/23 revealed: Impression: Eczema associated diagnosis: Scabies; status: worsening, Itch Numerical Rating scale:10; % body surface covered in rash: 70. Plan: treat with triamcinolone 0.1% topical steroid cream, hydroxyzine 25 mg tablets as needed for itch and permethrin 5% apply topically once per week. Record review of Resident #107's Physician Note dated 12/13/23 signed by the Medical Director revealed, Resident #107 was seen due to rash noted over the extremities and right upper shoulder that appeared crusted in nature. Diagnosis/Plan: unspecified dermatitis secondary to scabies infection, was started on permethrin cream, repeat treatment after 7 days, clean linens/clothes, deep clean room and contact isolation precautions in place. Record review of Resident #107's MARs from 06/2023 to 12/2023 revealed: - Jun 2023: Permethrin 5% apply to skin at bedtime for dermatitis for 2 days- it was only applied once on 6/24/23. - July 2023: Permethrin 5 % apply to skin for persistent dermatoses- applied on 07/21/23. Permethrin 5% apply topically for pruritus- applied 7/26/23. - August 2023: Permethrin 5 %- applied 08/18/23 - November 2023: Permethrin 5 % prophylactically for dermatitis for 2 day- was only applied on 11/04/23 - December 2023: Permethrin 5% for scabies infestation use strict contact isolation- applied on 12/11/23 at 10:30 PM. Record review of Resident #107's Progress Notes from 06/24/23 to 12/23/23 revealed the resident's rash: - 06/24/23- generalized rash noted to entire body - 07/17/23- resident noted with recurrent rash to upper extremities - 07/23/23 day 7/7 of prednisone for generalized rash to torso. Area clean with red bumps noted from front/back torso. Resident scratching right front chest. - 08/24/23- generalized rash remains. - 09/12/23- Rash noted all over resident skin. - 11/02/23 at 01:30 AM: generalized rash remains pronounced, - 11/04/23 at 03:17 AM: generalized rash remains pronounced, dry, raised in some areas. - 11/04/23 at 10:15 AM : rash was still present to entire body and has new orders for permethrin 5% cream for 2 days and ammonium lactate 12% cream on shower day which will be on Monday 11/6/2023 - 12/14/23 at 02:30 AM- scaly, shedding, redness/self-inflicted scratches noted to skin. Resident on contact isolation There was only one mention of the resident having scabies on 12/12/23 at 04:01 AM- remain in contact isolation for scabies, permethrin cream applied to the entire body; and Resident #107 was first placed on contact isolation on 12/11/23. Record review of Resident #107's Hospital Wound Care Note dated 12/15/23 at 03:22 PM revealed, consult requested for cracking and flaking of skin with some deeper skin layer involvement. Dry thick crusted skin that extends from the right side of his head, neck, down the right shoulder, armpit, arm, right side of chest and left side of chest and armpit. Possible diagnosis of crusted scabies Record review of Hospital Infectious Disease Progress Note dated 12/17/23 at 07:46 AM revealed, Skin: chest, upper abdominal/upper extremity rash with skin lesions. Impression: Crusted Scabies Recommendations: Oral Ivermectin (an antiparasitic) and Topical Permethrin for crusted scabies. Record review of Hospital Infectious Disease Progress Note dated 12/18/23 at 05:32 AM revealed, Skin: chest, upper abdominal/upper extremity rash with skin lesions. Impression: Crusted Scabies Recommendations: Oral Ivermectin (an antiparasitic) for 4 days and Topical Permethrin for 3 days for crusted scabies. Record review of Resident #107's Medical Diagnoses printed 12/23/23 at 11:39 AM revealed, no diagnosis of scabies. An observation and interview on 12/13/2023 at 2:00 PM of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #107 was in the bed by the window, he was awake, receiving tube feeding, had a urinary foley catheter and was non interviewable. Resident #107 had fair colored skin with thick, dry, crusty, scaly large areas to the upper body. On both shoulders and upper arms were thick crusty, powdery white areas with red cracks. There were raised red bumps and rash to both forearms and to both upper thighs. The thighs had red scratch marks. The webbing between the thumb and pointer finger on both hands had powdery white irregular bumps. Resident #107 was scratching his groin and upper thighs. The treatment nurse stated he had dermatitis that worsened since he returned from the hospital in October 2023. The treatment nurse stated the rash on Resident #39 and Resident #107 appeared to be the same. She did not mention that Resident #107 had a presumptive diagnosis of scabies or that the resident was being treated for scabies. An observation and interview on 12/15/2023 at 4:00 PM revealed, Resident #107 in the ICU at the hospital with a diagnosis of respiratory failure and sepsis. Resident #107's room door was open and the resident was intubated The assigned hospital nurse stated when he was admitted on [DATE] d/t low blood pressures and elevated WBC. The hospital nurse stated they were not notified of the resident having scabies. The hospital nurse picked up her phone that was ringing and said it was the wound care nurse on the line who just told her she completed her evaluation done on 12/15/2023 and thought he might have scabies. The hospital nurses closed the resident's door and set up for contact isolation. Isolation signage was put up on the glass door. In an interview on 12/15/23 at 09:25 AM, MA A said she was present on 11/03/23 when Resident #107 saw the dermatologist. She said due to the rash being chronic and the severity of itching as well as the facility informing them other residents had similar rashes the Dermatologist wanted to treat Resident #107 for scabies. She said the MD ordered Permethrin 5% for Resident #107 to be repeated in 7 days. In an interview on 12/20/23 at 07:55 AM, the Hospital Treatment Nurse said when Resident #107 arrived to the hospital she observed thick plaques and rashes all over the parts of the body she could see (at least 1/3rd ) and she was surprised. She said the hyperkeratotic presentation and the residents history made her believe he had crusted scabies. Resident #39 Record review of Resident #39's Face Sheet dated 12/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: chronic pain syndrome, contractures, lack of coordination, anemia and a scabies (onset 12/11/23). Record review of Resident #39's Annual MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 11 out of 15, dependence for most ADLs and application of ointments/medications other than to feet. Record review of Resident #39's undated Care Plan revealed, focus-impaired visual function, refusal of care (showers/shampoos and general grooming), total assistance with all ADLs except feeding. Focus- actual impaired to skin integrity r/t thick skin and callous buildup to feet, he refuses to shower routinely which precipitates dry skin formation; intervention- identify/document potential causative factors and eliminate/resolver where possible; keep skin clean and dry. Record review of Resident #39's NP Note dated 11/30/23 signed by the NP revealed, skin: chronic seborrheic dermatitis- refuses showers. Record review of Resident #39's NP Note dated 12/08/23 signed by the NP revealed, Diagnosis/Plan: seborrheic dermatitis- refuses showers. There was no documented description of the resident's rash. Record review of Resident #39's MD note dated 12/13/23 and signed by the Medical Director revealed, Resident #39 had a red rash over the extremities of both upper and lower extremities. The resident was on isolation and was started on permethrin for scabies but he continued to refuse showers and application of creams. Diagnosis/plan: unspecified dermatitis secondary to scabies infection, on contact isolation, on permethrin cream repeated after 7 days and room to be deep cleaned and linens washed. Record review of Resident #39's Clinical Census dated 12/23/23 revealed, Resident #39 shared a room with Resident #107 from 10/24/23 until Resident #107 was discharged to the hospital on [DATE]. Record review of Resident #39's Medical Diagnoses dated 12/23/23 at 12:57 PM, the diagnosis of scabies was added on 12/16/23 and the onset of the disease was 12/11/23. Record review of Resident #39's Progress notes from 12/22/22 to 12/23/23 revealed, Resident #39's had rashes dating back to 06/2023. - 6/13/23 at 04:46 PM- Resident's lower extremities are swollen with wound, Also has rash all over the body but was refusing treatment and medication. - 06/26/2023 at 10:40- The entire body skin observed with rash. There was no other mention of Resident #39 suffering from a rash until 12/14/23 (3 days after being diagnosed with scabies: - 12/14/23- remain in contact isolation/precautions, generalized skin rash remains to the body. Record review of Resident #39's Order Summary dated 12/23/23 revealed, - 12/11/23 Permethrin 5% apply head to toe at bedtime for scabies infestation. Use strict contact precautions with protective garments. - 12/11/23 Permethrin 5% apply head to toe at bedtime for scabies infestation. Use strict contact precautions with protective garments. Start date 12/19/23. Record review of Resident #39's December 2023 MAR revealed, -Permethrin 5% topically at bedtime for scabies infestation- applied on 12/11/23 at 9:30 PM and 12/19/23 at 12:16 AM. Observation and interview on 12/13/2023 at 2:00 PM, of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #39 was awake, dressed in a hospital gown and brief and was in the bed by the door. Resident #39's arms, legs and hands were contracted. Resident #39 stated it was ok to look at his skin and that areas on his skin were very itchy. Resident #39 had small, red bumps on the scalp, forehead, cheeks, on both elbows, arms and both lower legs had large red bumps. The treatment nurse stated the redness to the elbows and red areas on his back were not new. The treatment nurse stated the new red bumps appeared sometime last week (12/4/2023 to 12/08/2023). The treatment nurse stated these new red bumps occurred at the same time Resident #107's red bumps appeared. Observation and interview on 12/23/2023 at 12:00 PM, Resident#39 was in contact isolation. He had a plate of food on his chest. He had red bumps on his scalp, face and arms and was unchanged from 12/13/23. He said he did receive the treatment cream, then showers the next day. Resident #39 stated he was told the cream was for scabies. He stated that it started with Resident #107 and maybe from not having the bed linens changed and washed. He stated that the bed linens were changed out daily and his personal belongings were removed. He stated he did not feel as itchy. He stated he was able to sleep through the night but during mornings he would feel itchy when he thinks about it. He stated he will be getting out of isolation soon and was happy about that because he wanted to get his money so he can buy soda. Resident #25 Record review of Resident #25's Face Sheet dated 12/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of ID, schizophrenia, anemia, anxiety, hallucinations, depression and scabies (onset date 12/11/23). Record review of Resident #25's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, substantial to maximal assistance with most ADLs, and always incontinent of both bladder and bowel. There was no documentation of any applications of ointments/medication to the skin. Record review of Resident #25's undated Care Plan revealed, no related focus areas. There was no mention of any skin issues including rashes and scabies. Record review of Resident #25's Clinical Census revealed, Resident #25 shared a room with Resident #107 since 10/24/23. Record review of Resident #25's NP Note dated 11/27/23 revealed, no documented skin issues. Record review of Resident #25's NP Note dated 11/30/23 revealed- head to toe assessment done due to reports of patient had rash to both sides of his upper and lower extremities. He has elevated red bumps, dry scaly skin scattered to chest, abdominal area, back, both legs and arm but no rashes were observed on the web spaces of his hands, genitals or scalps. Monitor closes due to skin rash issues in the unit. Record review of Resident #25's NP Note dated 12/08/23 revealed, the resident was on hydrocortisone (steroid cream) for skin rash and the rash was unresolved. Record review of Resident #25's NP Note visit date 12/09/23 but signed on 12/18/23 revealed, Resident #25 was noted itching/scratching and had a persistent skin rash likely scabies. Resident #25 was treated with Sulfur 5% nightly for 3 days, with a plan to treat with Permethrin if the rash didn't resolve. Contact Isolation precautions and an oral medication to treat itching. Record review of Resident #25's Medical Diagnoses dated 12/23/23 at 12:57 PM, the diagnosis of scabies was added on 12/16/23 and the onset of the disease was 12/11/23. Record review of Resident #25's Order Summary dated 12/23/23 revealed: - 12/09/23- Sulfur 5% lotion for dermatitis, apply to entire body from neck down, rub in and leave on for 24 hours. - 12/11/23- Permethrin 5%- apply to head to toe topically one time only for scabies infestation. Leave on for 8-14 hours, use strict contact precautions with protective garments. - 12/11/23- Contact Isolation: use strict contact precautions with protective garments, every shift for scabies infestation. Record review of Resident #25's December 2023 MAR revealed, Resident #25 received Permethrin 5% on: - 12/12/23 at 08:43 AM, and - 12/20/23 at 12:52 AM. Observation and interview on 12/13/2023 at 2:00 PM of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #25 was in the middle bed in a full body, long sleeve jump suite. When the Treatment Nurse removed his body suite, Resident #25 was observed with had light pink, small, raised bumps to both upper arms and on the abdomen. The Treatment Nurse stated he was treated with Hydrocortisone cream beginning 11/30/2023 for a rash to both arms and legs. Resident #37 Record review of Resident #37's Face Sheet dated 12/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: epilepsy, asthma, arthritis, type 2 diabetes and scabies with an onset date of 12/16/23. Record review of Resident #37's MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 05 out of 15, rejection of care, substantial/maximal assistance with most ADLs and application of ointments/medications to skin other than feet. Record review of Resident #37's undated Care Plan revealed, no documented focus areas addressing, skin, rashes or scabies. Record review of Resident #37's Census revealed he shared a room with Resident #107 from 08/28/23 to 09/23/23. Record review of Resident #37's Progress Notes from 12/22/22 to 12/23/23 revealed: - 09/22/23 at 02:33 PM the resident had a new rash to both arms, chest and legs. There was no documentation of the resident being placed on contact isolation. - 09/22/23 at 02:49 PM: Change of condition identified in a change in skin condition, the resident has a personal history of infectious and parasitic diseases. Skin Status Evaluation: itching rash and an order was given for Permethrin 5% to chest both legs and both arms which should be washed of in 8-12 hrs, hydrocortisone 1% cream for 7 days and calamine lotion for 2 weeks. There was no documentation of the resident being placed on contact isolation. - 10/02/23 at 10:34 PM: Permethrin cream 5% applied on resident entire body this shift and to be washed off in 8-12hrs. - 10/16/23 Resident on day 5/7 of antibiotics for cellulitis. Rash remains. - 10/18/23 Resident still on antibiotics for cellulitis. Rash still present and some itching noted. - 10/20/23 Resident still noted with rash all over his body and treatments continue - 10/27/23 Resident continues with steroid cream to the body for generalized rash, red raised bumps noted. - 10/40/23 Generalized rash red in color and bumpy. - 11/03/23 Rash present to body, generalized mild redness with complaints of mild itching. - 11/06/23 Rash still visible. - 11/08/23 Resident with generalized rash to body, some itching noted-redirected to avoid infection/pain. - 11/21/23 Resident seen by NP, new orders to apply steroid cream to rash all over his body twice daily for 30 days. - 11/24/23 Rash remains reddened pronounced and generalized. - 11/28/23 Rash remains reddened pronounced and generalized - 12/06/23 Rash remains reddened. Apply steroid cream to torso, back, upper extremities and thighs. - 12/13/23 Resident was on antibiotics for skin cellulitis and generalized rash remains to the entire body. Redness and self-inflicted scratches to the back, legs, arms, neck and abdomen noted. - 12/14/23 Rash with little improvement. - 12/15/23 generalized rash remains to the entire body. Redness and self-inflicted scratches to the back, legs, arms, neck and abdomen noted and worse. - 12/18/23 Day 1 of Permethrin 5% treatment to body An observation and interview on 12/12/23 at 09:55 AM revealed, Resident #37 lying in bed well dressed and well-groomed with rashes/scabs to his arms. When asked about the rash/sores the resident said everything was ok and would not respond further. Record review of Resident #37's NP Note dated 11/28/23 revealed, evaluation of dermatitis. Patient has rash to upper torso. Record review of Resident #37's NP Note dated 12/09/23 revealed, dermatitis unresolved. Record review of Resident #37's NP Note dated 12/12/23 revealed, dermatitis unresolved. Likely scabies infection will treat with Permethrin, repeat dose if not resolved and contact isolation precautions. Record review of Resident #37's Order Summary sprinted 12/23/23 revealed: - 06/23/23 Permethrin 5% for dermatitis, apply for 2 days. - 09/22/23 Permethrin 5%- apply to arms, legs, chest typically one time only written for 2 days. - 10/02/23 Permethrin 5% for scabies. - Contact precautions- use contact precautions with protective garments. There are no previous orders for contact precautions. - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments. - 12/21/23 Permethrin 5% for scabies. Use contact precautions with protective garments. Record review of Resident #37's September 2023 MAR printed 12/23/23 revealed: - 09/22/23 Permethrin 5% applied at 04:45 PM. - 09/22/23 to 09/29/23 hydrocortisone 1% to arms, legs, and chest for pruritis at 09:00 AM and 05:00 PM. Record review of Resident #37's October 2023 MAR printed 12/23/23 revealed: - 10/02/23 Permethrin 5% applied at 09:29 PM. - 10/26/23 to 10/31/23 Hydrocortisone 2.5 % to legs, armpits, trunk nightly for dermatitis Record review of Resident #37's November 2023 MAR printed 12/23/23 revealed: - 11/01/23 to 11/06/23 Hydrocortisone 2.5 % to legs, armpits, trunk nightly for dermatitis Resident #84 Record review of Resident #84's Face Sheet dated 12/19/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of: Parkinson, dementia, depression, communication deficit and scabies with onset of 12/16/23. Record review of Resident #84's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 09 out of 15, extensive assistance with most ADLs and application of ointments/medications to the skin other than the feet. Record review of Resident #84's undated Care Plan revealed, no focus areas address rashes, itching or scabies. Record review of Resident #84's Census revealed, he shared a room with Resident #107 from 08/28/23 to 09/23/23 Record review of Resident #84's Progress Notes from 12/22/22 to 12/23/23 revealed, - 09/15/23 Resident noted with rash to entire body. - 10/03/23 Rash red and bumpy in appearance to legs and right thigh. - 10/20/23 Resident still noted with rash all over his body, treatment continues - 10/23/23 Resident given oral steroids for rash to lower legs, and areas of dry skin - 11/03/23 rash to both legs present bumpy and red. - 11/06/23 Dermatology appointment cancelled and will be rescheduled. - 11/16/23 Rash remains reddened, raised and generalized. - 11/30/23 Resident given oral antifungal for rash. - 12/14/23 Resident rash to both legs with little improvement. -12/15/23 Generalized rash/itching remain the same Record review of Resident #84's Order Summary report printed 12/23/23 revealed - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments - 12/16/23 Contact precautions with protective garments every shift - 12/2/23 Permethrin 5% for scabies. Use contact precautions with protective garments An observation on 12/12/23 at 09:55 AM revealed, Resident # 84 lying in bed with a limited range of motion and wedge pillows propping him up. The resident was observed to have a rash on both his arms and had limited communication capability and all he could say his butt burned. In an interview on 12/12//23 at 10:00 AM, the treatment nurse said Resident #84 was previously treated for wounds on his buttocks but the medication was discontinued because the issue had resolved. She said she would visit the resident to reassess him, and notify the wound care doctor about the resident's complaints. The Treatment Nurse did not address the Resident #84's itching. Resident #20 Record review of Resident #20's Face Sheet dated 12/16/23 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses: dementia, mood disorder. Anxiety disorder and depression. Record review of Resident #20's 5 day MDS dated [DATE] revealed, severely intact cognition as indicated by a BIMS score of 00 out of 15, partial assistance with most ADLs and no application of ointments/medication to the skin. Record review of Resident #20's undated Care Plan revealed, focus- elopement risk/wanderer onset 04/17/23; intervention- intervene as appropriate, distract resident from wandering by offering pleasant diversion, food, conversations, television or books. The care plan does not address any skin issues. Record review of Resident #20's MD Note dated 12/13/23 revealed, resident was started on a steroid cream for itching for 7 days. Skin: new rash to the back of the hand with some redness around it. Record review of Resident #20's Order Summary dated 12/23/23 revealed: - 11/03/23 Prednisone ( a steroid) 20 mg- 1 tablet one time a day for rash for 3 days. - 11/03/23 Hydrocortisone 1 %- apply topically two times a day for rash/dry skin - 11/03/23 Diphenhydramine (Benadryl) 25 mg- give 1 tablet by mouth for rash. - 11/03/23 Prednisone 10 mg- 1 tablet by mouth 1 time a day for rash for 5 days starting 11/08/23. - 11/27/23 Prednisone 20 mg- give 2 tablets by mouth daily for pruritus. - 11/27/23 Diphenhydramine (Benadryl) 25 mg- give 1 tablet by mouth for rash. - 11/28/23 Hydrocortisone 1 % for pruritus- apply topically two times a day to torso, both upper and lower extremities. - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments - 12/16/23 Contact Precautions- use contact precautions with protective garments. - 12/21/23 Permethrin 5% for scabies. Use contact precautions with protective garments scheduled for 12/24/23 An observation and interview on 12/12/23 at 09:45 AM revealed, Resident #20 well dressed, well-groomed in a wheelchair in front of his room. The resident was wearing a long sleeve shirt but a rash could be seen at the end of the sleeve of his right arm and a skin tear on the back of his right arm. When asked questions the resident would only respond that he wanted coffee. An observation on 12/15/23 at 03:00 PM revealed, Resident #20 observed in the dining area with a rash on his right hand and arm, a skin tear to the right hand that appeared to be scabbed. An observation on 12/15/23 at 03:23 PM revealed, Resident #20 ambulating in his wheelchair to the front lobby. The resident attempted to open the office door and was instructed by the DON that he could not be in the hallway because he was on isolation. The resident left the office and headed toward the resident rooms, the DON did not escort the resident back to his room or get assistance from other staff. Resident #20 returned 5 minutes later with a mask on his face. In an observation and interview on 12/16/23 at 12:50 PM, Resident #20's room was observed to be empty and the Isolation signage as well as the bin were no longer at the resident's door. The DON said Resident #20 was removed from isolation because the facility was unable to keep him in his room and the resident roamed the building. An observation on 12/16/23 at 03:55 PM revealed, Resident #20 ambulating in the front lobby trying to get access to the office by pulling the door. Resident #100 Record review of Resident #100's Face Sheet dated 12/23/23 revealed, an [AGE] year-old man who admitted to the facility on [DATE] with diagnoses of: dementia, malnutrition, depression, anxiety and scabies with an onset date of 12/18/23. Record review of Resident #100's MDS (Minimum Data Set) dated 11/4/2023 revealed a BIMS (Brief Interview for Mental Status) score of 0 out of 15 indicating Resident # was severely cognitively impaired. Section GG revealed the resident needed substantial/maximal assistance with toileting, showering/bathing, upper and lower body dressing, and personal hygiene. Section M1200 revealed Applications of ointments/medications other than to feet. Record review of Resident #100's Care Plan dated 4/28/2023 revealed in part . The resident has infection of the skin .the resident will be free from complications related to infection through the review date. Record review of Resident #100's Progress Notes from 12/22/22 to 12/23/23 revealed, - 05/09/23 Permethrin Cream treatment for rash all over body - 09/06/23 Resident receiving topical steroid for body itching, less scratching observed. - 10/16/23 Resident observed multiple times scratching arms and che[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a person designated as the infection preventionist had completed specialized training in infection prevention and control for 1 of 1 staff (DON) reviewed for Infection Preventionist qualifications and role. - The facility failed to ensure the DON had completed the required Nursing Facility Infection Preventionist training course IP which resulted in failure to implement an effective Infection Control Program, resulting in Residents #107, #39, #25, #37, #100, #51, #61, #81, #16, #84, #109, #20, and #1 contracting and being treated for scabies. - The facility failed to ensure the Infection Preventionist completed tracking and trending of infections for August through October of 2023. - The facility failed to ensure that there was a qualified Infection Preventionist from November 4th to December 15th 2023. An IJ was identified on 12/15/23. The IJ template was provided to the facility on [DATE] at 03:00 PM. While the IJ was removed on 12/19/23, at 02:39 PM. The facility remained out of compliance at a scope of pattern and a severity level of actual harm that was not immediate due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures placed residents at risk for itching, discomfort, pain, secondary skin infections and hospitalization. Findings included: Record review of the facility Infection Control Tracking and Trending for August, September and October of 2023 revealed, the tracking and trending was completed retrospectively for those months on 11/08/23 by the DON. Resident #107 Record review of Resident #107's Face Sheet dated 12/18/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of depression, difficulty swallowing, down syndrome, fluid overload, hypertension. The resident had a diagnosis of Atopic dermatitis and congenital ichthyosis (a group of rare skin conditions that cause dry, scaly skin that individuals are usually born with) as of 11/03/23, he did not have a diagnosis of Scabies. Record review of Resident #107's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, substantial/maximal assistance for most ADLs, an indwelling catheter, frequently incontinent of bowel and application of ointments/medications other than to feet. Record review of Resident #107's undated care plan revealed, focus areas of - ID, DD with PASRR services, potential nutritional problems, potential for pressure ulcer development, impaired cognitive function, a communication problem and tube feeding. There was no focus area to address Resident #107's treatment/diagnosis of scabies. Record review of Resident #107's Order Summary dated 12/18/23 revealed, Resident #107 had orders for Permethrin (an insecticide used to treat scabies) on multiple occasions but was only on contact isolation once: - 06/23/23 Permethrin 5% for dermatitis for 2 days: apply to head to toe topically one time only for 2 days. Leave on for 8015 hours. - 07/26/23 Permethrin 5% for pruritus: apply from head to toe excluding genitalia for 8-12 hours and rinse off next morning. - 08/18/23 Permethrin 5% : apply from head to toe excluding genitalia for 8-12 hours and rinse off next morning per dermatologist. - 11/03/23 Permethrin 5% for prophylactic dermatitis for 2 days: apply at bedtime and leave overnight. Rinse of in AM. - 12//11/23 Permethrin 5%c0 apply topically one time for scabies infestation. Leave in for 8-14 hours, use strict contact precautions with protective garments. - 12/11/23 Contact Isolation- use strict contact precautions with protective garments. Record review of Resident #107's Dermatologist Note dated 07/26/23 revealed: Resident #107 was being seen as a referral from the Medical Director for a rash located on the body throughout. The ratch was itchy and red and moderate in severity and it had been present for months. scaling and well demarcated, eczematous patches; differential diagnosis includes irritation dermatitis vs. scabies; plan- Plan: treat with triamcinolone 0.1% topical steroid cream, hydroxyzine 25 mg tablets as needed for itch and permethrin 5% apply topically once per week. Follow up in 6 weeks for skin check. Record review of Resident #107's Dermatologist Note dated 11/03/23 revealed: Impression: Eczema associated diagnosis: Scabies; status: worsening, Itch Numerical Rating scale:10; % body surface covered in rash: 70. Plan: treat with triamcinolone 0.1% topical steroid cream, hydroxyzine 25 mg tablets as needed for itch and permethrin 5% apply topically once per week. Record review of Resident #107's Physician Note dated 12/13/23 signed by the Medical Director revealed, Resident #107 was seen due to rash noted over the extremities and right should that appeared crusted in nature. Diagnosis/Plan: unspecified dermatitis secondary to scabies infection, was started on permethrin cream, repeat treatment after 7 days, clean linens/clothes, deep clean room and contact isolation precautions in place. Record review of Resident #107's MARs from 06/2023 to 12/2023 revealed: - Jun 2023: Permethrin 5% apply to skin at bedtime for dermatitis for 2 days- it was only applied once on 6/24/23. - July 2023: Permethrin 5 % apply to skin for persistent dermatoses- applied on 07/21/23. Permethrin 5% apply topically for pruritus- applied 7/26/23. - August 2023: Permethrin 5 %- applied 08/18/23 - November 2023: Permethrin 5 % prophylactically for dermatitis for 2 day- was only applied on 11/04/23 - December 2023: Permethrin 5% for scabies infestation use strict contact isolation- applied on 12/11/23 at 10:30 PM. Record review of Resident #107's Progress Notes from 12/22/22 to 12/23/23 revealed the resident's rash : - 06/24/23- generalized rash noted to entire body - 07/17/23- resident noted with recurrent rash to upper extremities - 07/23/23 day 7/7 of prednisone for generalized rash to torso. Area clean with red bumps noted from front/back torso. Resident scratching right front chest. - 08/24/23- generalized rash remains. - 09/12/23- Rash noted all over resident skin. - 11/02/23 at 01:30 AM: generalized rash remains pronounced, - 11/04/23 at 03:17 AM: generalized rash remains pronounced, dry, raised in some areas. - 11/04/23 at 10:15 AM : rash was still present to entire body and has new orders for permethrin 5% cream for 2 days and ammonium lactate 12% cream on shower day which will be on Monday 11/6/2023 - 12/14/23 at 02:30 AM- scaly, shedding, redness/self-inflicted scratches noted to skin. Resident on contact isolation There was only one mention of the resident having scabies on 12/12/23 at 04:01 AM- remain in contact isolation for scabies, permethrin cream applied to the entire body; and Resident #107 was first placed on contact isolation on 12/11/23. Record review of Resident #107's Hospital Wound Care Note dated 12/15/23 at 03:22 PM revealed, consult requested for cracking and flaking of skin with some deeper skin layer involvement. Dry thick crusted skin that extends from the right side of his head, neck, down the right shoulder, armpit, arm, right side of chest and left side of chest and armpit. Possible diagnosis of crusted scabies Record review of Hospital Infectious Disease Progress Note dated 12/17/23 at 07:46 AM revealed, Skin: chest, upper abdominal/upper extremity rash with skin lesions. Impression: Crusted Scabies Recommendations: Oral Ivermectin (an antiparasitic) and Topical Permethrin for crusted scabies. Record review of Hospital Infectious Disease Progress Note dated 12/18/23 at 05:32 AM revealed, Skin: chest, upper abdominal/upper extremity rash with skin lesions. Impression: Crusted Scabies Recommendations: Oral Ivermectin (an antiparasitic) for 4 days and Topical Permethrin for 3 days for crusted scabies. Record review of Resident #107's Medical Diagnoses printed 12/23/23 at 11:39 AM revealed, no diagnosis of scabies. An Observation and interview on 12/13/2023 at 2:00 PM of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #107 was in the bed by the window, he was awake, receiving tube feeding, had a urinary foley catheter and was non interviewable. Resident #107 had fair colored skin with thick, dry, crusty, scaly large areas to the upper body. On both shoulders and upper arms were thick crusty, powdery white areas with red cracks. There were raised red bumps and rash to both forearms and to both upper thighs. The thighs had red scratch marks. The webbing between the thumb and pointer finger on both hands had powdery white irregular bumps. Resident #107 was scratching his groin and upper thighs. The treatment nurse stated he had dermatitis that worsened since he returned from the hospital in October 2023. The treatment nurse stated the rash on Resident #39 and Resident #107 appeared to be the same. She did not mention that Resident #107 had a presumptive diagnosis of scabies or that the resident was being treated for scabies. An Observation and interview on 12/15/2023 at 4:00 PM revealed, Resident #107 in the ICU at the hospital with a diagnosis of respiratory failure and sepsis. Resident #107's room door was open and the resident was intubated The assigned hospital nurse stated when he was admitted on [DATE] d/t low blood pressures and elevated WBC. The hospital nurse stated they were not notified of the resident having scabies. The hospital nurse picked up her phone that was ringing and said it was the wound care nurse on the line who just told her she completed her evaluation done on 12/15/2023 and thought he might have scabies. The hospital nurses closed the resident's door and set up for contact isolation. Isolation signage was put up on the glass door. In an interview on 12/15/23 at 09:25 AM, MA A said she was present on 11/03/23 when Resident #107 saw the dermatologist. She said due to the rash being chronic and the severity of itching as well as the facility informing them other residents had similar rashes the Dermatologist wanted to treat Resident #107 for scabies. She said the MD ordered Permethrin 5% for Resident #107 to be repeated in 7 days. In an interview on 12/20/23 at 07:55 AM, the Hospital Treatment Nurse said when resident #107 arrived to the hospital she observed thick plaques and rashes all over the parts of the body she could see (at least 1/3rd ) and she was surprised. She said the hyperkeratotic presentation and the residents history made her believe he had crusted scabies. Resident #39 Record review of Resident #39's Face Sheet dated 12/23/23 revealed, a 50-year-olf male who admitted to the facility on [DATE] with diagnoses of: chronic pain syndrome, contractures, lack of coordination, anemia and a scabies (onset 12/11/23). Record review of Resident #39's Annual MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 11 out of 15, dependence for most ADLs and application of ointments/medications other than to feet. Record review of Resident #39's undated Care Plan revealed, focus-impaired visual function, refusal of care (showers/shampoos and general grooming), total assistance with all ADLs except feeding. Focus- actual impaired to skin integrity r/t thick skin and callous buildup to feet, he refuses to shower routinely which precipitates dry skin formation; intervention- identify/document potential causative factors and eliminate/resolver where possible; keep skin clean and dry. Record review of Resident #39's NP Note dated 11/30/23 signed by the NP revealed, skin: chronic seborrheic dermatitis- refuses showers. Record review of Resident #39's NP Note dated 12/08/23 signed by the NP revealed, Diagnosis/Plan: seborrheic dermatitis- refuses showers. There was no documented description of the resident's rash. Record review of Resident #39's MD note dated 12/13/23 and signed by the Medical Director revealed, Resident #39 had a red rash over the extremities of both upper and lower extremities. The resident was on isolation and was started on permethrin for scabies but he continued to refuse showers and application of creams. Diagnosis/plan: unspecified dermatitis secondary to scabies infection, on contact isolation, on permethrin cream repeated after 7 days and room to be deep cleaned and linens washed. Record review of Resident #39's Clinical Census dated 12/23/23 revealed, Resident #39 shared a room with Resident #107 from 10/24/23 until Resident #107 was discharged to the hospital on [DATE]. Record review of Resident #39's Medical Diagnoses dated 12/23/23 at 12:57 PM, the diagnosis of scabies was added on 12/16/23 and the onset of the disease was 12/11/23. Record review of Resident #39's Progress notes from 12/22/22 to 12/23/23 revealed, Resident #39's had rashes dating back to 06/2023. - 6/13/23 at 04:46 PM- Resident's lower extremities are swollen with wound, Also has rash all over the body but was refusing treatment and medication. - 06/26/2023 at 10:40- The entire body skin observed with rash. There was no other mention of Resident #39 suffering from a rash until 12/14/23 (3 days after being diagnosed with scabies: - 12/14/23- remain in contact isolation/precautions, generalized skin rash remains to the body. Record review of Resident #39's Order Summary dated 12/23/23 revealed, - 12/11/23 Permethrin 5% apply head to toe at bedtime for scabies infestation. Use strict contact precautions with protective garments. - 12/11/23 Permethrin 5% apply head to toe at bedtime for scabies infestation. Use strict contact precautions with protective garments. Start date 12/19/23. Record review of Resident #39's December 2023 MAR revealed, -Permethrin 5% topically at bedtime for scabies infestation- applied on 12/11/23 at 9:30 PM and 12/19/23 at 12:16 AM. Observation and interview on 12/13/2023 at 2:00 PM of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #39 was awake, dressed in a hospital gown and brief and was in the bed by the door. Resident #39's arms, legs and hands were contracted. Resident #39 stated it was ok to look at his skin and that areas on his skin were very itchy. Resident #39 had small, red bumps on the scalp, forehead, cheeks, on both elbows, arms and both lower legs had large red bumps. The treatment nurse stated the redness to the elbows and red areas on his back were not new. The treatment nurse stated the new red bumps appeared sometime last week (12/4/2023 to 12/08/2023). The treatment nurse stated these new red bumps occurred at the same time Resident #107's red bumps appeared. Observation and interview on 12/23/2023 at 12:00 PM, Resident#39 was in contact isolation. He had a plate of food on his chest. He had red bumps on his scalp, face and arms and was unchanged from 12/13/23. He said he did receive the treatment cream, then showers the next day. Resident #39 stated he was told the cream was for scabies. He stated that it started with Resident #107 and maybe from not having the bed linens changed and washed. He stated that the bed linens were changed out daily and his personal belongings were removed. He stated he did not feel as itchy. He stated he was able to sleep through the night but during mornings he would feel itchy when he thinks about it. He stated he will be getting out of isolation soon and was happy about that because he wanted to get his money so he can buy soda. Resident #25 Record review of Resident #25's Face Sheet dated 12/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of ID, schizophrenia, anemia, anxiety, hallucinations, depression and scabies (onset date 12/11/23). Record review of Resident #25's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, substantial to maximal assistance with most ADLs, and always incontinent of both bladder and bowel. There was no documentation of any applications of ointments/medication to the skin. Record review of Resident #25's undated Care Plan revealed, no related focus areas. There was no mention of any skin issues including rashes and scabies. Record review of Resident #25's Clinical Census revealed, Resident #25 shared a room with Resident #107 since 10/24/23. Record review of Resident #25's NP Note dated 11/27/23 revealed, no documented skin issues. Record review of Resident #25's NP Note dated 11/30/23 revealed- head to toe assessment done due to reports of patient had rash to both sides of his upper and lower extremities. He has elevated red bumps, dry scaly skin scattered to chest, abdominal area, back, both legs and arm but no rashes were observed on the web spaces of his hands, genitals or scalps. Monitor closes due to skin rash issues in the unit. Record review of Resident #25's NP Note dated 12/08/23 revealed, the resident was on hydrocortisone (steroid cream) for skin rash and the rash was unresolved. Record review of Resident #25's NP Note visit date 12/09/23 but signed on 12/18/23 revealed, Resident #25 was noted itching/scratching and had a persistent skin rash likely scabies. Resident #25 was treated with Sulfur 5% nightly for 3 days, with a plan to treat with Permethrin if the rash didn't resolve. Contact Isolation precautions and an oral medication to treat itching. Record review of Resident #25's Medical Diagnoses dated 12/23/23 at 12:57 PM, the diagnosis of scabies was added on 12/16/23 and the onset of the disease was 12/11/23. Record review of Resident #25's Order Summary dated 12/23/23 revealed: - 12/09/23- Sulfur 5% lotion for dermatitis, apply to entire body from neck down, rub in and leave on for 24 hours. - 12/11/23- Permethrin 5%- apply to head to toe topically one time only for scabies infestation. Leave on for 8-14 hours, use strict contact precautions with protective garments. - 12/11/23- Contact Isolation: use strict contact precautions with protective garments, every shift for scabies infestation. Record review of Resident #25's December 2023 MAR revealed, Resident #25 received Permethrin 5% on: - 12/12/23 at 08:43 AM - 12/20/23 at 12:52 AM Observation and interview on 12/13/2023 at 2:00 PM of the shared room of Resident #39, Resident #25 and Resident #107 with the Treatment Nurse revealed, the room door closed, with signage for contact isolation and a PPE cart at the door. Resident #25 was in the middle bed in a full body, long sleeve jump suite. When the Treatment Nurse removed his body suite, Resident #25 was observed with had light pink, small, raised bumps to both upper arms and on the abdomen. The Treatment Nurse stated he was treated with Hydrocortisone cream beginning 11/30/2023 for a rash to both arms and legs. Resident #37 Record review of Resident #37's Face Sheet dated 12/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: epilepsy, asthma, arthritis, type 2 diabetes and scabies with an onset date of 12/16/23. Record review of Resident #37's MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 05 out of 15, rejection of care, substantial/maximal assistance with most ADLs and application of ointments/medications to skin other than feet. Record review of Resident #37's undated Care Plan revealed, no documented focus areas addressing, skin, rashes or scabies. Record review of Resident #37's Census revealed he shared a room with Resident #107 from 08/28/23 to 09/23/23. Record review of Resident #37's Progress Notes from 12/22/22 to 12/23/23 revealed: - 09/22/23 at 02:33 PM the resident had a new rash to both arms, chest and legs. There was no documentation of the resident being placed on contact isolation. - 09/22/23 at 02:49 PM: Change of condition identified in a change in skin condition, the resident has a personal history of infectious and parasitic diseases. Skin Status Evaluation: itching rash and an order was given for Permethrin 5% to chest both legs and both arms which should be washed of in 8-12 hrs, hydrocortisone 1% cream for 7 days and calamine lotion for 2 weeks. There was no documentation of the resident being placed on contact isolation. - 10/02/23 at 10:34 PM: PERMETHRIN CREAM 5% APPLIED ON RESIDENT ENTIRE BODY THIS SHIFT AND TO BE WASHED OFF IN 8-12HRS. - 10/16/23 Resident on day 5/7 of antibiotics for cellulitis. Rash remains. - 10/18/23 Resident still on antibiotics for cellulitis. Rash still present and some itching noted. - 10/20/23 Resident still noted with rash all over his body and treatments continue - 10/27/23 Resident continues with steroid cream to the body for generalized rash, red raised bumps noted. - 10/40/23 Generalized rash red in color and bumpy. - 11/03/23 Rash present to body, generalized mild redness with complaints of mild itching. - 11/06/23 Rash still visible. - 11/08/23 Resident with generalized rash to body, some itching noted-redirected to avoid infection/pain. - 11/21/23 Resident seen by NP, new orders to apply steroid cream to rash all over his body twice daily for 30 days. - 11/24/23 Rash remains reddened pronounced and generalized. - 11/28/23 Rash remains reddened pronounced and generalized - 12/06/23 Rash remains reddened. Apply steroid cream to torso, back, upper extremities and thighs. - 12/13/23 Resident was on antibiotics for skin cellulitis and generalized rash remains to the entire body. Redness and self-inflicted scratches to the back, legs, arms, neck and abdomen noted. - 12/14/23 Rash with little improvement. - 12/15/23 generalized rash remains to the entire body. Redness and self-inflicted scratches to the back, legs, arms, neck and abdomen noted and worse. - 12/18/23 Day 1 of Permethrin 5% treatment to body An observation and interview on 12/12/23 at 09:55 AM revealed, Resident #37 lying in bed well dressed and well-groomed with rashes/scabs to his arms. When asked about the rash./sores the resident said everything was ok and would not respond further. Record review of Resident #37's NP Note dated 11/28/23 revealed, evaluation of dermatitis. Patient has rash to upper torso. Record review of Resident #37's NP Note dated 12/09/23 revealed, dermatitis unresolved. Record review of Resident #37's NP Note dated 12/12/23 revealed, dermatitis unresolved. Likely scabies infection will treat with Permethrin, repeat dose if not resolved and contact isolation precautions. Record review of Resident #37's Order Summary sprinted 12/23/23 revealed: - 06/23/23 Permethrin 5% for dermatitis, apply for 2 days. - 09/22/23 Permethrin 5%- apply to arms, legs, chest typically one time only written for 2 days. - 10/02/23 Permethrin 5% for scabies - Contact precautions- use contact precautions with protective garments. There are no previous orders for contact precautions - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments - 12/21/23 Permethrin 5% for scabies. Use contact precautions with protective garments Record review of Resident #37's September 2023 MAR printed 12/23/23 revealed: - 09/22/23 Permethrin 5% applied at 04:45 PM. - 09/22/23 to 09/29/23 hydrocortisone 1% to arms, legs, and chest for pruritis at 09:00 AM and 05:00 PM Record review of Resident #37's October 2023 MAR printed 12/23/23 revealed: - 10/02/23 Permethrin 5% applied at 09:29 PM. - 10/26/23 to 10/31/23 Hydrocortisone 2.5 % to legs, armpits, trunk nightly for dermatitis Record review of Resident #37's November 2023 MAR printed 12/23/23 revealed: - 11/01/23 to 11/06/23 Hydrocortisone 2.5 % to legs, armpits, trunk nightly for dermatitis Resident #84 Record review of Resident #84's Face Sheet dated 12/19/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of: Parkinson, dementia, depression, communication deficit and scabies with onset of 12/16/23. Record review of Resident #84's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 09 out of 15, extensive assistance with most ADLs and application of ointments/medications to the skin other than the feet. Record review of Resident #84's undated Care Plan revealed, no focus areas address rashes, itching or scabies. Record review of Resident #84's Census revealed, he shared a room with Resident #107 from 08/28/23 to 09/23/23 Record review of Resident #84's Progress Notes from 12/22/22 to 12/23/23 revealed, - 09/15/23 Resident noted with rash to entire body. - 10/03/23 Rash red and bumpy in appearance to legs and right thigh. - 10/20/23 Resident still noted with rash all over his body, treatment continues - 10/23/23 Resident given oral steroids for rash to lower legs, and areas of dry skin - 11/03/23 rash to both legs present bumpy and red. - 11/06/23 Dermatology appointment cancelled and will be rescheduled. - 11/16/23 Rash remains reddened, raised and generalized. - 11/30/23 Resident given oral antifungal for rash. - 12/14/23 Resident rash to both legs with little improvement. -12/15/23 Generalized rash/itching remain the same Record review of Resident #84's Order Summary report printed 12/23/23 revealed - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments - 12/16/23 Contact precautions with protective garments every shift - 12/2/23 Permethrin 5% for scabies. Use contact precautions with protective garments An observation on 12/12/23 at 09:55 AM revealed, Resident # 84 lying in bed with a limited range of motion and wedge pillows propping him up. The resident was observed to have a rash on both his arms and had limited communication capability and all he could say his butt burned. In an interview on 12/12//23 at 10:00 AM, the treatment nurse said Resident #84 was previously treated for wounds on his buttocks but the medication was discontinued because the issue had resolved. She said she would visit the resident to reassess him, and notify the wound care doctor about the resident's complaints. The Treatment Nurse did not address the Resident #84's itching. Resident #20 Record review of Resident #20's Face Sheet dated 12/16/23 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses: dementia, mood disorder. Anxiety disorder and depression. Record review of Resident #20's 5 day MDS dated [DATE] revealed, severely intact cognition as indicated by a BIMS score of 00 out of 15, partial assistance with most ADLs and no application of ointments/medication to the skin. Record review of Resident #20's undated Care Plan revealed, focus- elopement risk/wanderer onset 04/17/23; intervention- intervene as appropriate, distract resident from wandering by offering pleasant diversion, food, conversations, television or books. The care plan does not address any skin issues. Record review of Resident #20's MD Note dated 12/13/23 revealed, resident was started on a steroid cream for itching for 7 days. Skin: new rash to the back of the hand with some redness around it. Record review of Resident #20's Order Summary dated 12/23/23 revealed: - 11/03/23 Prednisone ( a steroid) 20 mg- 1 tablet one time a day for rash for 3 days. - 11/03/23 Hydrocortisone 1 %- apply topically two times a day for rash/dry skin - 11/03/23 Diphenhydramine (Benadryl) 25 mg- give 1 tablet by mouth for rash. - 11/03/23 Prednisone 10 mg- 1 tablet by mouth 1 time a day for rash for 5 days starting 11/08/23. - 11/27/23 Prednisone 20 mg- give 2 tablets by mouth daily for pruritus. - 11/27/23 Diphenhydramine (Benadryl) 25 mg- give 1 tablet by mouth for rash. - 11/28/23 Hydrocortisone 1 % for pruritus- apply topically two times a day to torso, both upper and lower extremities. - 12/16/23 Permethrin 5% for scabies. Use contact precautions with protective garments - 12/16/23 Contact Precautions- use contact precautions with protective garments. - 12/21/23 Permethrin 5% for scabies. Use contact precautions with protective garments scheduled for 12/24/23 An observation and interview on 12/12/23 at 09:45 AM revealed, Resident #20 well dressed, well-groomed in a wheelchair in front of his room. The resident was wearing a long sleeve shirt but a rash could be seen at the end of the sleeve of his right arm and a skin tear on the back of his right arm. When asked questions the resident would only respond that he wanted coffee. An observation on 12/15/23 at 03:00 PM revealed, Resident #20 observed in the dining area with a rash on his right hand and arm, a skin tear to the right hand that appeared to be scabbed. An observation on 12/15/23 at 03:23 PM revealed, Resident #20 ambulating in his wheelchair to the front lobby. The resident attempted to open the office door and was instructed by the DON that he could not be in the hallway because he was on isolation. The resident left the office and headed toward the resident rooms, the DON did not escort the resident back to his room or get assistance from other staff. Resident #20 returned 5 minutes later with a mask on his face. In an observation and interview on 12/16/23 at 12:50 PM, Resident #20's room was observed to be empty and the Isolation signage as well as the bin were no longer at the resident's door. The DON said Resident #20 was removed from isolation because the facility was unable to keep him in his room and the resident roamed the building. An observation on 12/16/23 at 03:55 PM revealed, Resident #20 ambulating in the front lobby trying to get access to the office by pulling the door. Resident #100 Record review of Resident #100's Face Sheet dated 12/23/23 revealed, an [AGE] year-old man who admitted to the facility on [DATE] with diagnoses of: dementia, malnutrition, depression, anxiety and scabies with an onset date of 12/18/23. Record review of Resident #100's MDS (Minimum Data Set) dated 11/4/2023 revealed a BIMS (Brief Interview for Mental Status) score of 0 out of 15 indicating Resident # was severely cognitively impaired. Section GG revealed the resident needed substantial/maximal assistance with toileting, showering/bathing, upper and lower body dressing, and personal hygiene. Section M1200 revealed Applications of ointments/medications other than to feet. Record review of Resident #100's Care Plan dated 4/28/2023 revealed in part . The resident has infection of the skin .the resident will be free from complications related to infection through the review date. Record review of Resident #100's Progress Notes from 12/22/22 to 12/23/23 revealed, - 05/09/23 Permethrin Cream treatment for rash all over body - 09/06/23 Resident receiving topical steroid for body itching, less scratching observed. - 10/16/23 Resident observed multiple times scratching arms and chest - 11/18/23 resident on oral medication for itching and continues to scratch - 12/14/23 mild redness raised area generalized to body. - 12/15/23 red rashes remains on different parts of the body and the resident was now on a topical steroid cream twice daily. - 12/17/23 resident placed on contact isolation precautions. Continues to scratch at sites Record review of resident #100's Orders Summary dared 12/23/23 revealed - 5/8/2023 revealed Permethrin External Cream 5% Apply head to Toes for itching for 2 days. - 12/17/2023 revealed Permethrin Cream 5% apply to affected areas topically at bedtime for scabies. - 12/17/23 Contact isolation-wear protective garments. Resident had no orders for contact isolation in May 2023. Record review of Resident #100's May 2023 MAR revealed, Permethrin was applied on 05/08/23 at 10:00 PM and 5/11/23. Record review of Review of Resident #100's NP note with [TRUNCATED]