GLENDORA, CA - Federal health inspectors found serious infection control violations at Mesa Glen Care Center after a nursing assistant diagnosed with scabies potentially exposed dozens of residents to the highly contagious skin condition before proper protocols were implemented.
Delayed Response to Contagious Skin Condition
The incident began when Certified Nursing Assistant (CNA) 12 developed a spreading rash that started around her wrist and expanded to her forearms, elbows, shoulders, chest, and back. Despite the CNA's concerns about a possible scabies outbreak and her observations of several residents with rashes, the facility took no immediate action.
The nursing assistant worked her regular shifts from February 16-20 and February 23-27, 2025, providing direct patient care to 58 residents during the period when her symptoms were developing. She was diagnosed with scabies on February 28, 2025, but had been experiencing symptoms for approximately a week before seeking medical attention.
According to inspection records, CNA 12 had expressed concerns to the Director of Staff Development about a potential scabies outbreak and suggested conducting skin checks for residents in specific rooms where she had observed rashes. However, the facility did not act on these concerns until after the formal diagnosis.
Breakdown in Communication and Protocol Implementation
The facility's response to the scabies diagnosis revealed significant gaps in infection control procedures. The Director of Staff Development acknowledged that she failed to immediately notify the Infection Preventionist when CNA 12 reported her diagnosis around noon on February 28. Instead, this crucial notification was delayed until later that evening.
This delay violated the facility's own infection control protocols, which specifically identify scabies as a pathogen associated with serious outbreaks requiring immediate response. The facility's surveillance policy explicitly states that when a communicable disease outbreak is suspected, information must be communicated to the Infection Preventionist immediately.
The Infection Preventionist admitted to inspectors that once notified, she failed to initiate proper measures to mitigate the potential risk of a scabies outbreak. These measures should have included creating a line listing of exposed individuals, conducting contact tracing, implementing monitoring procedures, and establishing appropriate isolation measures.
Medical Significance of Scabies in Healthcare Settings
Scabies is caused by microscopic mites (Sarcoptes scabiei) that burrow into the skin, creating intense itching and rash. The condition is highly contagious through direct skin-to-skin contact, making nursing homes particularly vulnerable environments due to frequent physical contact between staff and residents during daily care activities.
In healthcare settings, scabies can spread rapidly among both staff and residents if proper infection control measures are not implemented immediately upon diagnosis. The mites can survive on bedding, clothing, and furniture for 48-72 hours, creating additional transmission risks beyond direct contact.
Early identification and intervention are critical for preventing outbreaks. Standard protocols require immediate isolation of affected individuals, comprehensive contact tracing to identify potential exposures, and monitoring of all exposed persons for symptoms. Treatment typically involves topical medications like Permethrin cream, but affected individuals remain contagious until treatment is completed.
Personal Protective Equipment Failures
Beyond the scabies incident, inspectors documented additional infection control violations involving improper use of personal protective equipment (PPE). Staff members were observed providing direct care to high-risk residents without wearing required protective gear.
Licensed Vocational Nurse 3 was observed changing a resident's oxygen nasal cannula and checking blood glucose levels without donning appropriate PPE, despite the resident being on Enhanced Barrier Precautions due to a dialysis port. Enhanced Barrier Precautions require staff to wear gowns and gloves during high-contact care activities with residents who have indwelling medical devices or are at higher risk for multidrug-resistant organisms.
The nurse acknowledged the error, stating that proper PPE including gloves, gown, and mask should have been worn to protect both resident and staff safety from infection and bodily fluids.
Missing Safety Equipment and Signage
Inspectors also found that Resident 68, who had physician orders for Enhanced Barrier Precautions related to a gastrostomy tube, lacked proper safety measures. No PPE supplies were available outside the resident's room, and no signage was posted to alert staff about the required precautions.
The facility's policy clearly states that signs must be posted outside residents' rooms indicating required precautions and PPE, with appropriate protective equipment readily available. The Infection Preventionist acknowledged that any nurse could initiate Enhanced Barrier Precautions by setting up a PPE cart and posting appropriate signage, but this had not been done despite active physician orders.
Kitchen Safety Violations
The inspection also revealed food safety issues that could contribute to infection risks. Kitchen staff failed to properly date food items and maintain appropriate sanitization levels in dishwashing equipment.
Apple sauces, mandarin oranges, fruit cocktails, and milk containers were found without received dates. Opened items including muffin mixes, powdered sugar, peanut butter, and dairy products lacked proper dating to track freshness and safety.
Most concerning, the dishwasher's chlorine sanitization system was found to have zero parts per million of chlorine when tested, far below the required 50-100 ppm range. Staff acknowledged they had not been checking chlorine levels, potentially compromising the sanitization of dishes and utensils used throughout the facility.
Regulatory Response and Implications
These violations occurred during a federal inspection conducted by the Centers for Medicare & Medicaid Services in March 2025. The facility serves 91 residents and is located at 638 E Colorado Avenue in Glendora.
The infection control failures were classified as having "minimal harm or potential for actual harm" but affected a significant portion of the facility's population. The violations demonstrate systemic weaknesses in the facility's infection prevention and control program implementation.
Federal regulations require nursing homes to maintain comprehensive infection control programs to protect residents, staff, and visitors from healthcare-associated infections and communicable diseases. Facilities must have policies and procedures for surveillance, outbreak response, isolation precautions, and staff health monitoring.
The inspection findings highlight the critical importance of immediate response to infectious disease diagnoses among healthcare workers, particularly in congregate care settings where vulnerable populations face increased risk of serious complications from preventable infections.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mesa Glen Care Center from 2025-03-07 including all violations, facility responses, and corrective action plans.
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