F0880

E

Failure to Implement Scabies Surveillance and Timely Outbreak Reporting

Glendale, California Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its Infection Prevention and Control Program (IPCP) and follow county scabies guidelines for four residents with suspected scabies. The Infection Preventionist (IP) did not initiate or maintain a line list for residents or staff with suspected scabies, despite multiple residents and some staff developing generalized rashes and being placed on contact precautions. The IP acknowledged that some staff reported rashes and concern for scabies but stated he did not create a list and was unsure how many staff were affected. Infection surveillance logs from 10/2025 to 1/2026 did not include residents with suspicious rashes treated with Permethrin, including a resident who was suspected of having scabies and treated with Permethrin cream in 10/2025. The IP stated he did not consider rashes treated with Permethrin as infections requiring monitoring and only tracked infections requiring antibiotics.

One resident, admitted with neuropathy and diabetes mellitus, complained of mild itchiness and localized rash in 10/2025. The IP documented that the rash was of unknown etiology with potential for transmission, and the resident and roommates were placed on contact isolation and treated with Permethrin cream, Hydroxyzine, and Hydrocortisone. However, no skin scrape test was performed at that time to rule out scabies, and this episode was not entered into the infection surveillance log. The same resident later developed a generalized rash again in 2/2026, was placed on contact precautions, and was prophylactically treated with Permethrin before a skin scrape was performed. The IP and a licensed nurse confirmed that the skin scrape for this resident was done after Permethrin treatment, and the IP stated that residents should have been tested with a skin scrape prior to treatment.

In early 2/2026, three additional residents with significant comorbidities (including COPD, CHF, Parkinson’s disease, CVA, hemiplegia, DM, adult failure to thrive, and kidney stones) were identified with generalized body rashes. Dermatology consultations were obtained, and all four residents were placed on contact precautions, had environmental cleaning measures implemented, and were prophylactically treated with Permethrin cream; two residents also received oral Ivermectin and Hibiclens. Physician orders for skin scraping were written for these residents, but the scrapes were performed only after Permethrin treatment and after the arrival of collection kits. The IP’s notes show that skin scrape specimens for multiple residents were completed and then left at the front desk until picked up by the lab two days later. Despite having at least four residents on contact precautions for suspicious rashes and staff reporting rashes, the IP did not maintain an updated infection surveillance log for 2/2026 and did not prepare a line list of symptomatic residents and staff.

The facility also failed to recognize and timely report a suspected scabies outbreak to the local public health department. The county guidance available in the facility defined an outbreak as two or more clinically suspected or confirmed cases of scabies in residents, healthcare workers, volunteers, or visitors within a six-week period and directed facilities to report healthcare-associated scabies outbreaks. The IP stated he did not report a potential outbreak when the four residents were placed on contact precautions and tested for scabies because skin scrape results were still pending, and he chose to wait until a positive result was obtained. A fax to the county department of public health reporting a possible scabies outbreak was not sent until eight days after the residents were placed on contact precautions. The IP later acknowledged that, based on the county guideline, he should have reported a potential outbreak earlier and that he should have recommended scabies testing before Permethrin treatment from an infection prevention standpoint.