Resident 75 at Elan Skilled Nursing and Rehab developed a rash in August that doctors ordered tested with a skin scraping or biopsy on August 19. The facility never completed either test.
Instead, staff treated the resident with a series of medications over seven weeks while the condition worsened and spread. The resident received fexofenadine for allergies and hydrocortisone cream for the rash on August 19. By September 10, a nurse practitioner documented increased facial swelling, arm scratches, scalp flaking and intermittent itching.
Staff prescribed prednisone steroids and antifungal shampoo. The rash continued spreading.
A September 25 progress note described a worsening scalp rash with multiple raised bumps and continuous scratching. Doctors ordered tacrolimus ointment and Selsun Blue shampoo. By October 6, the nurse practitioner found scratches on the resident's arms and numerous red lesions across the scalp with evidence of scratching.
Only then did staff consult a wound physician on October 7. The specialist immediately identified the problem during a bedside microscopic examination: mites consistent with scabies.
The facility ordered Elimite cream treatment that same day and implemented contact precautions requiring staff to wear gowns and gloves. Resident 75 received the scabies treatment at 10:54 PM on October 7.
But the damage was done. The infection had spread to 35 other residents.
All residents on the third floor received Elimite treatment, along with two residents on the second floor and one on the fifth floor. Another resident, identified as Resident 52, also tested positive for scabies on microscopic examination.
During interviews with federal inspectors on November 19, the facility's Infection Preventionist confirmed that no skin scraping or biopsy was ever completed despite the August 19 doctor's order. The Director of Nursing acknowledged that obtaining the ordered tests "possibly could have prevented spread and earlier mitigation of scabies in the facility."
By November 18, when inspectors observed Resident 75, the rash had cleared from the resident's arms, chest and scalp, and no scratching was visible.
The outbreak represents a cascade of missed opportunities. Scabies is highly contagious and spreads through close contact, making nursing homes particularly vulnerable to outbreaks. Early identification and treatment are critical to preventing transmission.
The facility had clear medical orders for diagnostic testing that could have identified the mites in August. Instead, staff spent weeks treating symptoms while the underlying infestation spread throughout the building.
Federal inspectors cited the facility for failing to follow physician orders and provide adequate nursing services. The violation affected multiple residents and created potential for actual harm.
Scabies causes intense itching and can lead to secondary bacterial infections from scratching. In elderly residents with compromised immune systems, the condition can cause significant discomfort and complications.
The facility's response once scabies was identified appeared appropriate, with immediate treatment and isolation precautions. But the two-month delay in proper diagnosis allowed what should have been a contained case to become a facility-wide outbreak affecting nearly three dozen residents.
The case highlights the importance of following medical orders promptly, particularly for diagnostic tests that can prevent the spread of infectious conditions in congregate care settings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Elan Skilled Nursing and Rehab, A Jewish Senior Li from 2025-11-21 including all violations, facility responses, and corrective action plans.
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