Complaint Investigation Report

Allegation: “Staff did not address an outbreak of scabies in the facility.”

It was reported that Resident #1 (R1) had scabies, and the facility did not address the matter. It was alleged that R1 had neighboring residents – Resident #2 (R2) and Resident #3 (R3) – who also had scabies and persistent rashes that resulted in R1 contracting scabies.

Record review revealed that R2 was admitted to the facility with persistent rashes that was actively treated by the facility and hospice. On 03/06/2025, R2 was prescribed Ivermectin for itching and on 06/16/2025 they were prescribed Permethrin and treated for scabies. Administrator Holly Gold stated that infection protocols were followed and R2’s condition subsided. Records confirmed R2 did not have any skin issues in July 2025. R3 was admitted to the facility with wound care addressed by hospice and prescribed Hydrocortisone with no documentation of rashes.

R1 was diagnosed with skin cancer and reported by Staff #1 (S1) and Staff #2 (S2) to have very fragile skin due to R1’s age and condition. S2 stated R1 had recurrent skin issues that were addressed and treated accordingly and due to autoimmune and inflammation episodes, had on and off again rashes. The Reporting Party (RP) initially reported scabies in November 2024 to which the facility staff denied the observation. However, the facility and hospice proceeded to treat R1’s rashes with scabies medication. They observed the medications and Aquaphor were not effective and switched to Triamcinolone ointment. The Triamcinolone was observed to work well and R1’s rashes improved. The RP was persistent with the alleged scabies outbreak to which they had R1 undergo a scrape test through UCLA Health on 03/04/2025 and the test returned negative. The RP reported that in April to May 2025, R1’s rash came back. Record review and interview with Hospice staff confirmed that during this time, R1 transferred hospice agencies and was no longer prescribed Triamcinolone. Once R1 was received the ointment again, the rashes improved.