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32 | The investigation revealed the following:
Allegation: Staff are not properly preventing recurring outbreak(s)
It is being alleged that in the last year there have been several scabies outbreaks. On 8/24/26, LPA Felisa Shirley conducted a review of current infection control practices and protocols which included isolation, appropriate hand hygiene, use of Personal Protective Equipment (PPE) when indicated, environmental cleaning and disinfection. During file review on 8/24/26, LPA Felisa Shirley observed an incident report indicating that one resident tested positive for scabies on 8/13/26. LPA Shirley also reviewed Test Details indicating R1’s skin biopsy noted scabies. Per interview on 8/24/26 with S1, Executive Director and a review of facility records, there had been only one reported case of scabies since 2025. LPA Shirley interviewed S5 on 8/24/26. Per interview, S5 stated maintenance wipes down surfaces, handrails, and disinfects the resident’s rooms first thing in the morning on a daily basis.
LPA interviewed staff 1 – staff 5 (S1 – S5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed resident 2 – resident 5 (R2 – R5). Of those who interviewed 4 out of 4 denied the allegation. R1 did not speak during the interview.
Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff are not properly preventing recurring outbreak(s),” therefore, the allegation is unsubstantiated.
Allegation: Staff are not provided with adequate PPE supplies
It is being alleged that staff does not have adequate Personal Protective Equipment (PPE). During the facility tour on 8/24/26, LPA Shirley observed the physical therapy room and noted numerous face shields, masks, gloves, shoe covers, gowns and hand sanitizer were readily available and accessible to staff for use in the event of an outbreak or an isolated case of infection. During interview with S4 on 8/24/26, staff indicated they were provided with and utilized appropriate PPE while providing treatment to R1 throughout the resident’s isolation period.
LPA interviewed staff 1 – staff 5 (S1 – S5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed resident 2 – resident 5(R2 – R5). Of those who interviewed 3 out of 4 denied the allegation. R1 did not speak during the interview. One resident confirmed the allegation
Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff are not provided with adequate PPE supplies,” therefore, the allegation is unsubstantiated.
Con'd on 9099-C
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