**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide care in a manner to minimize/prevent accidents/injury for one resident (Resident #17-R17) in a survey sample of eighteen residents, which resulted in harm for R17. The findings included:1. For R17, the facility staff failed to transfer the resident with a mechanical lift in a manner to prevent accidents and injury, which resulted in a significant injury, which was harm. The facility self-identified the deficient practice and achieved past non-compliance on 10/9/24. On 8/19/25-8/20/25, attempts were made to visit with and interview R17 but were not successful since R17 was out of the facility due to a medical procedure. On the evening of 8/20/25, a clinical record review was conducted of R17's chart. According to a progress note dated 10/7/24, the entry read, The CNA [certified nursing assistant] reported to this nurse that the resident was bleeding from his R. [right] leg. Upon assessment, the back of the right leg had a cut he had sustained while being transferred to bed using a Hoyer lift. The resident stated that his leg was caught on the wheelchair's footrest. This nurse had to apply pressure to the area to stop bleeding. NP was notified and will see the resident. There was no documentation with regard to the cut, to include an assessment of the area, what it looked like, treatment applied, other than pressure to stop the bleeding. According to a skin observation dated 10/8/24, it noted that R17 had a new skin issue, the site and description read, Laceration to outer right calf area with dressing in place. There were no details of the laceration, measurements, how it appeared, what was being done, etc. According to physician orders and treatment administration records, on 10/8/24-10/9/24, the order was clean laceration to right rear leg with NC [sic] [normal saline], pat dry, apply dry dressing. On 10/9/24, a wound management detail report was completed that read in part, wound type: other-traumatic injury, wound location: right calf lateral calf, Date/time identified: 10/9/24 at 2:48 p.m. The details were as follows: Length 8 cm, width 5.6 cm, healing status: improving, comments: monitor area for s/s [signs and symptoms] of infection, follow current tx [treatment] plan. Keep clean, dry and covered. On 10/9/24, R17 was seen by the wound specialist, who noted, Staff report patient new injury occurring from use with the ‘sit to stand' mechanical lift. Pt [patient] reports his right lower leg caught the edge of ‘hoyer' lift, causing a painful laceration. Pt rates current pain to RLE [right lower extremity] an 8 on 0 to 10 pain scale with relief from medication. Right lateral calf (+) full thickness ulceration that measures 8.0 x 6.0 x 0.8 cm [length, width, depth]. Wound base 100% granular. Edges adherent to wound base, moderate non-odorous serious drainage, periwound without erythema, no induration or cellulitis. Patient does not demonstrate evidence of pain when area is palpated. Plan: Wound care to right lateral calf as follows: cleanse with NS [normal saline] or wound cleanser, pat dry. Pack with 1/4 strength Dakin's moistened gauze. Cover with gauze and kerlix dressing. (tx [treatment] for moist wound healing and/or autolytic debridement), change dressing QD [every day] and as needed for saturation or soilage. According to the wound care provider notes dated 10/16/24, the injury to R17's right lateral calf was noted with . full thickness ulceration that measured 8.0 x 5.6 x 0.6 cm. Wound base 25% slough, 75% granular prior to debridement. According to the facility's wound management detail report, R17 traumatic injury to the right lateral calf continued to receive treatment and was not healed until five months later on 3/12/25. On 8/21/25, during another clinical record review, according to R17's activities of daily living (ADL) records for October 2024, the resident was noted to have been totally dependent on facility staff for transfers from bed to chair and chair to bed. According to R17's care plan with a start date of 5/1/24, it read, resident is limited in ability to transfer self, related to impaired mobility and requires the use of Hoyer lift to complete transfers. Associated interventions included, but were not limited to: Minimize hazards and risks while completing transfer with lift, provide Hoyer lift assistant for transferring w/ [with] assist of 2 . On 8/21/25 at 8:10 a.m., an interview was conducted with R17. When asked about the incident in October 2024, the resident said, What happened was, it was night and he was getting me up, the leg rests were still on the chair. When he started to raise me in the lift the lift came up and the pedal on the right side got jammed in my leg, it [the lift] continued to come up and it caused it to be cut. R17 identified that certified nursing assistant #4 (CNA #4) was the one assisting the resident at the time of the incident and was using the mechanical lift/Hoyer lift without assistance of another staff member. On 8/21/25 at 9:10 a.m., an interview was conducted with the unit manager, licensed practical nurse #2 (LPN #2), where R17 resided. LPN #2 stated she was not a unit manager at the time of R17's incident that occurred in October 2024. When asked about transfers with a Hoyer lift, she said, Two people with the Hoyer at all times, for safety. Two people are required so there are two sets of eyes, one to maneuver the lift and one to maneuver the resident. According to the facility policy titled, Mechanical Lift Policy with a revision date of 1/7/22, which read in part, . 3. Two staff person assist/oversight is required for total body lifts while one person assist is satisfactory for sit-to-stand lifts. On 8/21/25, at approximately 9 a.m., the director of nursing (DON) was notified that the surveyor was reviewing the incident involving R17 from October 2024 and was asked to provide any information she had. On 8/22/25, the DON provided the survey team with a quality assurance performance improvement (QAPI) Action Plan in response to R17's incident. The facility re-enacted the incident, obtained statements, identified other residents who use the Hoyer lift and interviewed them, educated staff and conducted audits to ensure ongoing compliance. Included was a statement from CNA #4 that said, [R17's name redacted] had a cut to his leg when I was transferring him from wheelchair to bed with Hoyer lift by myself. The facility completed their plan and achieved past non-compliance on 10/9/24, upon completion of the skin checks. 2. For R17, the facility staff failed to provide care in a way to prevent accidents. During activities of daily living (ADL) care, R17 rolled out of bed, sustained injury that required evaluation at the hospital, which constituted harm. On 8/19/25-8/20/25, attempts were made to visit with and interview R17 but were not successful since R17 was out of the facility due to a medical procedure. On the evening of 8/20/25, a clinical record review was conducted of R17's chart. According to R17's progress notes dated 7/29/25, which read, Resident rolled off of bed onto floor during ADL care. Observed skin tear to right flank area. Left thigh/knee area with edema. Resident denies pain r/t [related to] fall. Resident states that he did not hit head. MD/RP [medical doctor/responsible party] aware. There was no description of the skin tear other than the location. There was no documented size/length of the tear or any description of the skin injury's appearance, bleeding status or condition of surrounding tissue. Nursing listed notification to the physician about the injury/incident. According to physician orders dated 7/30/25, which read, cleanse skin tear to right flank area with wound cleanser, pat dry, apply xeroform and dressing QD. On 7/31/25, that order was discontinued and a new order was written that read, Apply skin prep to skin tear/right flank QD x 7/days. According to R17's activities of daily living records, he required substantial/maximal assistance to roll left and right. According to R17's care plan, a problem area was initiated on 6/15/24 that noted, Resident at risk for falling r/t [related to] weakness. An intervention was added on 7/30/25 that read, Resident fell out of bed while turning during ADL care. Sent to ER for eval, no major injury. X 2 person for ADL care. Remains on therapy caseload. On 8/21/25 at 8:10 a.m., an interview was conducted with R17. R17 explained the incident on 7/29/25 and reported, I have to use the bed pan and the aide was trying to clean me up. She was having difficulty getting the feces out of my [NAME]. When I turned, she pushed and I was on my side and went off the bed, my legs hit and got tangled up in this thing [pointing to the over bed table]. When asked if he was injured, he said, Yes. It didn't manifest until later that day, there were no visible cuts, but bruised the heck out of my left thigh. It started to swell later in the day and [the nurse practitioner's name redacted] came and looked at it and he said to keep an eye on it. About 4 p.m., he came back and said it had gotten bigger and thought I needed to go to the ER, they sent me to [hospital name redacted]. They [the hospital] didn't even do an x-ray which I thought was odd, they put two big ace bandages on it and when I got back they [the facility staff] decided I needed to go back and I was sent to [different hospital name redacted], they confirmed it was a hematoma and also found other issues that were not related to the fall and kept me for several days. The resident reported he felt like he was too far to the side of the bed when he turned, and the aide pushed him; it caused him to fall off the bed. On 8/21/25 at 8:45 a.m., the DON was asked to provide hospital records from R17's hospital visits. On 8/21/25 at 9 a.m., an interview was conducted with certified nursing assistant #2 (CNA #2). CNA #2 confirmed she had been providing care to R17 on 7/29/25, when he rolled out of bed. CNA #2 reported, I had him and was cleaning him. He was turned facing the window and his legs fell off the bed which threw the rest of him out of the bed. Now if we turn him, we have to have two people. It happened so fast, I couldn't catch him. He had a small skin tear on his back, when he fell somehow this part of his leg [pointing to her left thigh] swelled. The nurse assessed him and later that day he went to the hospital. I felt so bad. On 8/21/25 at 9:10 a.m., an interview was conducted with licensed practical nurse #2 (LPN #2), who was the unit manager. LPN #2 stated, I got report that she was doing ADL care and was cleaning him alone. When she turned him, he was too close to the edge of the mattress and when he turned, he rolled to the right side of the bed. We offered him a lip mattress [mattress with a raised edge] but he declined, said it wasn't the mattress that he wasn't properly positioned during ADL care. He got an abrasion to his left buttock; he went to the hospital two days later. We did an x-ray here and it was no injuries. They kept him at the hospital for abnormal lab values; this was all per his wife. While in the hospital his wife would come to get items out of his room and she would give us bits and pieces of information, we never got any documentation from the hospital. The DON provided the surveyor with a progress note from the nurse practitioner dated 7/29/25 that read in part, I saw and examined the patient per nursing request s/p [status post] a fall from his bed. Nursing reported to me that the patient rolled off his bed and onto the floor as personal care was being performed around 12:00 s/p having had a bowel movement. He reportedly fell onto the floor landing on his left lower extremity; he apparently did not hit his head. I did notice swelling on the lateral distal left thigh/knee area which appeared to be a hematoma. This was of particular concern to me as the patient was on chronic anticoagulation with apixaban for chronic atrial fibrillation. There was a soft but firm to palpation without any focal area of acute tenderness. There was a distinctly demarcated line between the developing hematoma and the unaffected surrounding tissue. I marked the affected area with a pen establishing an area of 19 cm along the distal lateral femur and 14 cm wide transverse to the leg on my initial visit. I discussed the value of XR [x-ray] imaging to rule out any type of fracture. The patient refused having the leg imaged at this time. I spoke with nursing and ordered to keep the leg elevated, and to apply an ice pack. I promised to return in about an hour to re-evaluate the hematoma and developing situation. I re-examined the patient at 15:30. The patient was in no acute distress, but clearly uncomfortable and appeared frustrated. My examination revealed expansion of the hematoma now to 21 cm long x 18 cm wide. Given my concern r/t [related to] his chronic anticoagulation and hematoma development, and subsequent blood loss, I strongly encouraged the patient to consider being sent out via EMS [emergency medical services] to the ED [emergency department] for emergent evaluation +/- x-ray imaging and blood testing. He agreed to going out. On 8/21/25 at 10 a.m., the DON was again asked about the hospital records and stated they were working to obtain them. The surveyor asked the medical director if he had access to the records and he said he did not, that perhaps the resident or his spouse could access the records. On 8/21/25 at 10:30 a.m., the surveyor met with the DON and asked if she had a QAPI plan for the incident involving R17 for the 7/29/25 incident like she had for the incident in October 2024. The DON stated that she did not and stated, the skin tear was superficial. When asked about an x-ray, the DON stated that the resident refused so no x-ray was obtained at the facility. On 8/21/25 at 10:45 a.m., the survey team met with the facility administrator, DON, and corporate staff to review the above findings. They reported they had no further information to provide. The assistant director of nursing confirmed they had reached out to the hospital to obtain copies of the records from where R17 had been sent to the hospital on 7/29/25. When asked if they had reached out to the hospital prior to that day, when the surveyor started asking for the documents, the assistant director of nursing stated, not that I am aware of. All of the administrative staff in attendance confirmed that the expectation would have been for the hospital records to be contained within R17's clinical record. On 8/21/25, during a meeting with the facility administrator, director of nursing, medical director, and corporate staff, the above concerns were discussed. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, staff interview, facility document review, and in the coarse of a complaint investigation, the facility failed to provide appropriate and sufficient services for the treatment and care of an indwelling catheter resulting in harm for one of 35 Resident's in the survey sample, Resident #100. Resident #100's catheter was pulled out causing trauma to the penis and he was admitted to the hospital. The Findings Include: Resident #100 was admitted to the facility on [DATE] with the most readmission on [DATE]. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 11/6/18. Resident #100 was assessed as being cognitively intact with a score of 15 of 15. Section G of the MDS coded Resident #100 as total dependence with one person assist for bed mobility. Diagnoses for Resident #100 included: Quadriplegia, sepsis, pressure ulcer, muscle weakness, urinary tract infection, and flaccid neuropathic bladder. Resident #100's medical chart was reviewed on 12/12/18. A Change in Condition Evaluation dated 8/10/18 by the facility documented that Resident #100 was actively bleeding, had blood in urine and a Summarized Observation and Evaluation that read: Resident foley pulled out during care by CNA [certified nursing assistant], bleeding over 100 cc [cubic centimeters] in urine bag, unable to determine if urine is flowing. Resident #100 was sent out to the hospital. Review of Resident #100's hospital records documented (via a Hospital Discharge summary, dated [DATE]) that Resident #100 was admitted to the hospital on [DATE] with a diagnoses of [ .] urosepsis related to a traumatic Foley removal. On 12/12/18 10:07 AM Resident #100 was interviewed regarding the incident. Resident #100 verbalized that a CNA had came into the room to turn Resident #100 (as he, Resident #100 is quadriplegic and cannot turn himself). During being turned the CNA did not move the catheter bag from one side of the bed to the other and as a result the Foley catheter tubing was pulled out of the penis with the balloon still inflated. The CNA seen what had happened and went and got the nurse. Resident #100 verbalized that he was unable to feel that the Foley was being pulled due to his paraplegia, but seen a lot of blood. Resident #100 was asked if a catheter anchor (a device used to secure the tubing of the catheter to the leg to prevent the tubing from being pulled from the bladder through the penis) was in place at the time of being turned. Resident #100 verbalized that there was no anchor in place and went onto verbalize that the facility had started putting an anchor in place after coming back from hospital. A facility incident report was provided for review. A hand written note by the CNA dated 8/10/18 said while during rounds with [Resident's name] catheter came out of [Resident's name] penis. As soon I notice [SIC] , I reported to charge nurse [signed by CNA] and dated 8/14/18. There was no other information regarding an investigation or other interviews. The CNA and nurse on duty was unable to be interviewed during this investigation. The nurse no longer works at the facility and the CNA was not available. On 12/12/18 10:49 AM the ADON (assistant director of nursing) was interviewed concerning the finding. The ADON verbalized the incident happened when Resident #100 was being turned and the CNA did not move the Foley bag to the other side of the bed before being turned causing tension on the tubing and pulling out from the penis. Resident #100's care plan was reviewed along with physician orders, nurses notes, skin assessments, and treatment administration record from a time period of July 1st 2018 through August 10th 2018 (the day Resident #100 was sent to the hospital). There was no evidence that a catheter anchor was ordered, care planned, or placed for Resident #100. Resident #100's care plan for indwelling catheter was updated on 10/18/18 to include an intervention for an anchor to Resident #100's Foley catheter. Also an order was written on 10/30/18 and read [ .] ensure foley secured to leg [ .] On 12/12/18 02:52 PM Resident #100 physician (other staff, OS #1) was interviewed. OS #1 was asked about information in regards to Foley coming out. OS #1 verbalized he had not read any of the incident report and was unable to answer why the catheter came out. OS #1 verbalized that he doesn't disagree with hospital diagnoses. When asked about a catheter anchor, OS #1 verbalized that an anchor would have helped prevent the tubing being pulled out, but could not say it would be a fail safe. When asked about ordering an anchor for a catheter OS #1 verbalized he doesn't typically order a anchor so if one was ordered, it must have been ordered because a nurse asked for one, verbalizing that an anchor would be more of a nursing intervention and can be done without an order. On 12/13/18 08:01 AM registered nurse (RN #1) MDS coordinator was interviewed concerning the updated care plan to include a Foley anchor. RN #1 verbalized that the care plan was updated to ensure the Foley catheter would be secure in place and prevent the tubing being pulled out. A facility policy and procedure was asked for and received for indwelling catheter placement and care. The policy was titled Catheterization Competency and read in part Tape the catheter or apply a Velcro leg strap. Never leave the room until the catheter is secured. The mechanical irritation caused by catheter movement can cause urethral and meatal tearing, accidental removal, and serious complications. [ .] The catheter in the male is secured to either the upper thigh (with leg strap)or the abdomen (with tape). On 12/13/18 09:55 AM the above finding was brought to the attention of the director of nursing (DON) and administrator and was asked to provide any evidence to support an anchor being in place at the time of the incident or any evidence that would support the CNA moving the Foley bag prior to turning Resident #100 (as not to cause tension on the Foley tubing). The facility staff did not elaborate. No other information was provided prior to exit conference on 12/13/18. This is a complaint deficiency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, the facility staff failed to implement policies and procedures to prevent the spread of scabies on one of three units in the facility and failed to identify residents affected by the outbreak on the infection control tracking log. Six individual residents (Resident (s) #78, 13, 60, 58, 65 and 104) were all treated with oral and/or topical creams for the treatment of scabies. Residents were not placed on contact precautions to prevent the spread of the infestation resulting in an identified pattern of harm; and the facility staff failed to include information regarding the cases of scabies in the infection control tracking system. Findings were: Resident #78 was admitted to the facility on [DATE]. Her diagnoses included but were not limited to: Alzheimer's, dysphagia, hypothyroidism, and atrial fibrillation. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 10/29/2018, assessed Resident #78 with severe cognitive impairment with a summary score of 01. On 12/11/2018 at approximately 1:15 p.m., during the initial tour of the facility Resident #78 was observed on the third floor of the facility. She was observed walking in and out of other resident rooms, friendly, shaking hands, patting individuals on the back, talking to other residents, staff and surveyors. The clinical record was reviewed at approximately 3:00 p.m. The following note dated 11/23/2018 contained the following: Late entry for 11/20 Resident treated with Ivermectin X (times) [number not documented] doses, prophylaxilty [sic] RP [responsible party] is aware of new order. Further review of the clinical record provided the following information from the progress notes: 9/28/2018 22:29 [10:29 p.m.] Resident has a pink-red circular rash all over body. +[plus/positive] pruritis [itching]. Roommate being treated for same symptoms. 9/28/2018 22:31 [10:31 p.m.] Resident with rash allover [sic] body. + pruritis. Roommate being treated for same. Dr. [names] RNP [nurse practitioner] phoned. Received orders for permethrin, Ivermectin tablets (to be repeated in one week.) In am [a.m.] 9/29/18, all clothes and linens need to beset [sic] to the laundry for hot water/hot dryer to kill source of bites. RP notified. 9/29/2018 22:41 [10:41 p.m.]Resident with rash allover body. + pruritis. Resident was treated with permethrin cream tonight and will be showered, and receive Ivermectin tablets tomorrow then will be (repeated in one week.) In am [a.m.] 9/30/18, all clothes and linens need to be sent to the [sic] for hot water/hot dryer to kill source of bites. 10/01/2018 10:38 [a.m.] Resident continues with rash on body no s/s [signs/symptoms] of discomfort no s/s of adverse reaction to the medication. The physician orders for September 2018 were reviewed and contained the following: 9/28/2018 Permethrin Cream 5% Apply to body topically one time only for rash for 1 day. Apply topically neck to feet and beneath nails. Wash off after 8 hours. 9/28/2018 Ivermectin tablet 3 mg Give 4 tablets by mouth one time only for rash for 1 day. The physician orders for November contained the following: 11/20/2018 Ivermectin Tablet give 12 mg by mouth one time a day every seven days related to ENCOUNTER FOR PROPHYLACTIC MEASURES UNSPECIFIED until 11/28/2018. The facility medication reference system contained the following information regarding the prescribed medications: Permethrin Cream 5% .Common Brand Name Elimite. USES: This medication is used to treat scabies, a condition caused by tiny insects called mites that infest and irritate your skin. Permethrin belongs to a class of drugs known as pyrethrins. Permethrin works by paralyzing and killing the mites and their eggs. Ivermectin 3 mg tablet .Common Brand Name Stromectol. USES: This medication is used to treat certain parasitic roundworm infections .Ivermectin belongs to a class of drugs known as antihelmintics. It works by paralyzing and killing parasites. OTHER USES: This section contains uses of this drug that are not listed in the approved professional labeling for the drug but that may be prescribed by your health care professional This drug may also be used for other parasitic infections, including lice and scabies. Resident #78's roommate was identified as Resident #13. Resident #13 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Alzheimer's disease, unspecified dementia, hypertension and major depressive disorder. The most recent MDS was a quarterly assessment with an ARD of 09/07/2018. Resident #13 was assessed as being severely impaired in her cognitive status with a summary score of 04. The progress notes section of the clinical record were reviewed on 12/11/2018 at approximately 3:30 p.m., and contained the following: 09/27/2018 23:50 [11:50 p.m.] Resident c/o [complaining of] severe itching. Bite marks on arms, legs, back, buttocks. Stated she saw small black bugs biting her. Nurse phoned OC [on call] MD for [name of physician]. Permethrin lotion ordered for 9/28/2018. ? [question] need to order Ivermectin for systemic treatment. ? Linens and clothing needs to go to laundry and be washed in hot water. Medicated for Benadryl at HS [hour of sleep]. 9/27/2018 22:47 [10:47 p.m.] Benadryl Tablet 25 mg Give 25 mg by mouth every 06 hours as needed for pruritis 25-50 mg po [by mouth] PRN Administration was: Effective. 09/28/2018 10:17 [a.m.] Resident's bed linen and clothing was sent to laundry no itching or scratching observed by I the writer. 09/28/2018 10:59 [a.m.] Resident has order Ivermectin 3 mg tab give 4 mg tabs then repeat in one week RP notified. 09/28/2018 22:25 [10:25 p.m.] Permethrin cream applied: neck to feer [sic], including fingernails anf [sic] toe nails at 2030 [8:30 p.m.]. Due for a shower in 8 hours at 0430 [4:30 a.m.]. Ivermectin received this eve. Will be given 9/29/18. 09/30/2018 10:19 [a.m.] Ivermectin given per orders. No observations of itching/scratching this am. Faint red patchy areas to arms and torso, scabbing noted. 09/30/2018 22:17 [10:17 p.m.] Res tolerating new med. Ivermectin well and no s/sx of adverse reactions noted .She continues dry, scabby, bumps type rash to face, hands, bilateral UE/LE [upper extremities/lower extremities], torso, back areas. Res noted with scratch marks from her itching self . 10/01/2018 10:35 [a.m.] Resident continues with dry bumps on arms back ABD [abdomen] area resident cued not to scratch areas Resident denies any discomfort. 10/01/2018 22:48 [10:48 p.m.] Resident continues to have an extensive pruritic rash all over her body. Needs to be seen by MD. 10/01/2018 23:05 [11:05 p.m.] SBAR [Situation/Background/Assessment/Request] S: Change in condition .extensive round pruritic rash all over her body. Has had permethrin cream and Ivermectin tablets . A: Itching rash scabies or other infestation . Skin Checks for Resident #13 were reviewed in the clinical record. The bi-weekly skin check dated 9/28/2018 contained the following information: Scabies treatment in place. The physician orders for September 2018 were reviewed and contained the following: 9/28/2018 Permethrin Cream 5% Apply to body topically one time only for rash for 1 day. Apply topically neck to feet, under finger nails and toe nails at bedtime. Wash off after 8 hours. 9/28/2018 Ivermectin tablet 3 mg Give 4 tablets by mouth one time only for itching for 1 day. The physician orders for November contained the following: 11/20/2018 Ivermectin Tablet give 18 mg by mouth one time a day every seven days related to ENCOUNTER FOR PROPHYLACTIC MEASURES UNSPECIFIED until 11/28/2018. On 12/11/2018 at approximately 4:15 p.m., the DON (director of nursing) was asked about the treatment provided to Resident #78 and #13 on the third floor. She was asked to provide any information that was available regarding the original treatment of the two residents in September and the prophylactic treatment in November. At approximately 4;40 p.m., the DON came to the conference room. She stated, We got a call from the health department in November around the 13th .a resident had transferred out to a facility in [place] and had a rash .the resident was being treated for scabies in the new facility she wanted to know if anyone else had broken out and I told her no .then we talked again around November 20 just to follow-up .I told her we had two more people [Resident #58 and Resident #65] who had gotten rashes and were being treated with the Ivermectin .we never did a scraping to confirm that it was scabies .she said that if anyone else broke out she would recommend that we do a BIT [burrow ink test] and she told me how to do it. The DON was asked what a BIT test was and how it was done. She stated, Well you take a marker and put a mark on the bumps and then wipe it off .if it's scabies then the ink goes down under the skin, into their burrows .On that very day that I talked to her [health department nurse] we had another resident [Resident #104] get a rash on her left arm so [name of unit manager] and I did the BIT test and it was positive .we notified [name of medical director] and we treated the whole floor at that point. The DON was asked if she had let the nurse at the health department know about the positive test. She stated, Yes, I believe so. The DON was asked if she had any tracking as to who the residents were who had a rash or any documentation regarding her conversation with the health department. She stated, No, just my notes .we also did skin sweeps and we inserviced the staff on the policy. She presented an inservice record and the facility policy titled: Scabies. The policy contained the following information: It is the policy of the facility to teat resident infected with and sensitized to Sarcopetes scabiel (scabies) and to prevent the spread of scabies to other residents and staff .General Guidelines: Scabies is an itching skin irritation caused by microscopic human itch mite, which burrows into the skin's upper layers and eventually causes itching, tiny irregular red lines just above the skin and an allergic rash .Incubation period can be 2-6 weeks before onset of itching for persons with no previous exposure .Symptoms sometimes include severe itching which worsens at night .Scabies is spread by skin to skin contact with the infected area, or through contact with bedding, clothing, privacy curtains and some furniture. Diagnosis may be established by recovering the mite from its burrow and identifying it microscopically. Failure to identify scraping as positive does not necessarily exclude the diagnosis. It is difficult to obtain a positive scraping because only one or two mites may cause multiple lesions. Often diagnosis is made from signs and symptoms and treatment followed without scrapings, although scrapings are preferred. Affected residents should remain on Contact Precautions until twenty four (24) hours after treatment. Family and friends of residents who have had close contact should be notified and given instruction .A resident sharing a room with someone infected with scabies should be examined carefully for scabies. If signs and symptoms are present, the resident should be treated in accordance with these procedures. If symptoms are not present, daily assessments should be made until the case has resolved .PRE_TREATMENT PROCEDURE: While the resident is being treated remove four (4) sets of clothing from the resident's room. bag the clothing in a bag and send the bag to the laundry for processing. Place all remaining clothing of the infected resident into a bag. Seal the bag and label Do Not Open Until (date 14 days from storage date). STEPS IN THE PROCEDURE: Implement Contact Isolation. Should scrapings be ordered, obtain before treatment (Note: Negative scraping do not exclude the diagnosis. Treatment should be administered if symptoms are present) .Continue Contact Precautions until twenty -four (24) hours after treatment . The policy also contained guidelines for departmental responsibilities and environmental services. Guidelines for cleaning the environment included but were not limited to: Clean lobbies, lounges, etc before resident bathing and treatment times so that treated residents do not use unclean areas, Vacuum furniture made of fabric in the resident's room. Wrap furniture in plastic and store for two (2) weeks) The policy was reviewed and the DON was asked if any of the residents had been put on Contact Isolation/Precautions. She stated, In November when we treated the whole unit, we isolated all the residents to the floor we didn't let them leave the floor we didn't isolate them to their room just to the unit .we tried to keep the same staff going in and out. She was asked if the other residents that were identified and treated in November prior to the positive BIT test, had been isolated. She stated, No. She was asked if either Resident #78 or Resident #13 had been isolated during their treatment in September. She stated, No, we didn't. She was asked if the furniture had been wrapped in plastic after cleaning either in September or November. She stated, No, we didn't do that either. On 12/11/2018 at approximately 5:44 p.m. the medical director was interviewed about scabies and the treatment used. He stated that he hesitated to use the topical creams on residents with dementia. He stated, You have to paint them from head to toe and then shower them off after so many hours .it can be traumatic for them. He stated that he was aware of the resident who had been transferred to a different facility and had spoken with the family. He was asked if since Resident #78 was a wanderer on the unit should the entire unit have been treated at that time. He stated, It's hard to isolate someone like that .what maybe could have been done for the 24 hours after her treatment would be maybe one to one or put gloves on her, like a reverse precaution thing .I don't know if that would have worked but it could have been tried. On 12/12/2018 the clinical records of Resident #58, Resident #60 and Resident #104 were reviewed. The following information was obtained. Resident #60 was admitted to the facility on [DATE] with the following diagnoses but not limited to: Unspecified Dementia, major depressive disorder, cerebral infarction and myocardial infarction. The most recent MDS was a quarterly assessment with an ARD of 10/16/2018. Resident #60 was assessed as being severely impaired with a cognitive summary score of 0. Review of the progress notes contained the following: 11/18/2018 13:18 [1:18 p.m.] Resident observed to have rash/scabs covering entire body. Resident picking and scratching at skin . 11/18/2018 20:07 [8:07 p.m.] Resident skin assessed. He is covered all over with red marks. Orders in computer to treat for scabies. Linen collected, double bagged and placed in bathroom until taken to laundry. Review of the MAR (medication administration record) for November contained the following: Ivermectin Tablet 3 mg Give 1 tablet by mouth one time only related to ENCOUNTER FOR OTHER PROCEDURES FOR PURPOSES OTHER THAN REMEDYING HEALTH STATED for one day repeat does in 1 week. The medication was given on 11/20/2018 and 11/26/2018. Resident #58's record was reviewed. She was admitted on [DATE] with the following diagnoses, but not limited to: Dementia, hypertension, diabetes mellitus and major depressive disorder. Her most recent MDS was a quarterly assessment with an ARD of 10/12/2018. Her cognitive status was assessed as having difficulty with both long and short term memory and severe impairment in daily decision making skills. Her progress notes contained the following information: 11/18/2018 15:06 [3:06 p.m.] SBAR S: change in condition .red bumps/rash to multiple areas on skin .A: .Skin changes: Itching Rash to have scabies on multiple areas to skin . 11/18/2018 21:33 [9:33 p.m.] Resident has been visiting with family today .continues with rash on body, started on Ivermectin . Resident #104 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Unspecified Dementia, diabetes mellitus, fronto-temporal dementia, and anxiety. The most recent MDS was a quarterly assessment with an ARD of 11/9/2018. Resident #104 was assessed as having a cognitive summary score of 01, indicating severe impairment with her cognitive status. The progress notes were reviewed and contained the following: 11/20/2018 10:22 [a.m.] SBAR Change in Condition: Rash A: Skin changes: Rash to have rash on back legs, arms .R: Order obtained for Ivermectin 3 mg 11/20/2018 11:17 [a.m.] Resident linen and clothing double bagged and sent to laundry. There was no documentation in the clinical record regarding the BIT test conducted on Resident #104. Skin sweeps conducted on the third floor from September to November were requested from the DON on 12/12/2018. Review of the skin sweeps identified a sixth resident treated with a rash and treatment, Resident #60. Review of the clinical record revealed the following: 11/09/2018 18:15 [6:15 p.m.] .Resident with bite marks on back and rt [right] lateral buttock + pruritis. Has scratched 4 areas of open skin on rt lateral posterior buttock .orders received for treatment of possible scabies. Orders to start 11/10/2018 at HS . The MAR contained the following information: Permethrin Cream 5% Apply to affected skin areas, topically one time only for skin bites for 1 day. Apply X 1 at HS. Shower and rinse cream off 8 hours later. The medication was signed off as given on 11/12/2018. The Director of Housekeeping and Laundry was interviewed on 12/12/2018 at 10:57 a.m. He stated that in November all of the rooms on third floor were treated because of scabies. He stated the curtains, walls, resident clothing, common areas, etc. were all cleaned with bleach. We started on the far side of the room at the ceiling and worked our way down . He presented a calendar of which rooms were cleaned and the order they were cleaned. He stated, We started on November 19th and had them all done by the 21st .We did the same thing in the same order a week later stating on November 26 .we wiped down the chairs and cleaned the lobby the same way. He stated the residents clothing was bagged, washed, stored for one week. He was asked about any cleaning done in September. He stated, We cleaned one room like that Room [number] .we cleaned all the common areas too, but we just deep cleaned that one room. The unit manager was interviewed on 12/12/2018 at approximately 11:30 a.m. She was asked what precautions had been taken in September and November when the treatment for scabies was being done. She stated, With [name of Resident #78] you really can't isolate her .she is a wanderer .we tried to redirect her .then in November we isolated the whole unit and tried to keep everyone up here. On 12/12/2018 at approximately 1:45 p.m. the DON and the corporate nurse consultant were asked if there was any additional documentation. Concerns were voiced regarding the number of residents treated on the third floor for scabies and the facility not following the policy to isolate the residents initially involved (Resident #78 and 13). The Corporate nurse consultant stated, The cases weren't identified until November and we treated and isolated the unit. The corporate nurse consultant was informed that review of the clinical records and facility documentation revealed that at least six cases were treated before the unit was isolated. This did not include the resident that was transferred out to another facility. She stated, I wasn't aware we had that many. On 12/12/2018 at approximately 2:00 p.m., the nurse at the local health department was contacted regarding her involvement and conversation with the DON in November. She stated she was the epidemiologist nurse for the area. She stated she remembered speaking with the DON regarding the resident that was transferred but she would need to review her notes and call this surveyor back. The infection control tracking manual was reviewed on 12/13/2018 at approximately 8:00 a.m. There was no tracking or documentation in the manual regarding the treatment of possible scabies in the facility or the case that was confirmed by the BIT testing in November. The DON was interviewed and asked about the documentation. She stated, Yes, it should have been documented and tracked in there .I didn't do it. A form in the infection log titled .CDC Criteria for Signs/Symptoms of .Scabies was shown to the DON. The form contained the following: Scabies Both Criteria 1 and 2 Must be Satisfied 1). A maculopaular and/or itching rash; 2). At least one (1) of the following scabies subcriteria (circle all that apply) a. Physician diagnosis; b. Laboratory Confirmation (scraping or biopsy); c. Epidemiological linkage to a case of scabies with laboratory confirmation. The DON was asked if the facility was suppose to be using the form. She stated, I don't think so .let me check. She returned and stated, Yes, we should have used that. A meeting was held with the DON, the administrator and the corporate nurse consultant on 12/13/2018 at approximately 10:00 a.m. The above information was discussed and the facility staff was notified that possible harm had been identified. The facility staff was asked to present any additionally documentation that may be available. The DON came to the conference room at approximately 12:30 and stated, We don't have anything additional to give you. No further information was obtained prior to the exit conference on 12/13/2018. After exit from the facility a call was received from the nurse at the health department. She stated, I am sorry I am just getting back to you . I needed to review my notes .I am the epidemiologist for the area and I've never had a state surveyor call me before .this is what I remember and have in my notes .I spoke with the DON on 11/14/2018 regarding the resident who transferred out .I asked her if there had been any cases of scabies there or residents with rashes .She told me they had not had a problem at the facility. I asked her to keep in touch with me and to let me know if there were any residents with rashes and if there were any positive cases, since it take someone who has never been infected before up to six weeks to get a rash and exhibit symptoms. The nurse was asked if they had been notified of a positive BIT test at the facility with resulting treatment of the unit. She stated, No, no one let me know they had a positive case .we like to be involved when something like that occurs, especially on a dementia unit .we may or may not have recommended the whole unit be treated .I wish she had contacted me .I actually have it on my calendar to contact her six weeks from when we first talked to see if she had any more problems. No further information was obtained.