The Springs Post-Acute: Scabies Protocol Failures - CA
The findings came from a complaint inspection conducted December 1, 2025.
The facility's Infection Preventionist Nurse told inspectors that residents diagnosed with "dermatitis unspecified" received scabies medication, including Ivermectin cream and Permethrin, because staff didn't know the origin of their rashes. She confirmed directly that no skin scraping was performed before the medication was administered. "She could have suggested skin scraping but she did not," the inspection report states.
Skin scraping is the standard method for confirming a scabies diagnosis. Without it, there is no way to know whether a resident's rash is actually caused by Sarcoptes scabiei, the mite that burrows into skin, or by something else entirely, such as eczema or another form of dermatitis.
The Director of Nursing offered a different framing of the same practice. She told inspectors that Permethrin and Ivermectin are given "prophylactically" to residents diagnosed with unspecified dermatitis, and described the scabies medication as "necessary to treat dermatitis." The Director of Nursing also told inspectors that suspected scabies cases are not reportable, only confirmed ones.
That claim sat in direct tension with what the facility's own dermatologist said.
The dermatologist, interviewed the following morning, told inspectors that unspecified dermatitis could represent possible scabies or eczema. She confirmed that unspecified dermatitis is treated prophylactically when scabies are suspected. But she also stated it is standard for the facility to isolate, report, and test residents when scabies is suspected.
Test. The word the Infection Preventionist Nurse and the Director of Nursing had each moved past.
The facility's own written policy, last revised in August 2022, describes its purpose as treating residents "infected with and sensitized to Sarcoptes scabiei" and preventing the spread of scabies to other residents and staff. The policy does not describe a protocol built around medicating residents whose diagnosis remains unknown.
What the inspection captured was a gap between what the facility's policy described, what its dermatologist said was standard, and what its infection control nurse and nursing director actually did. Residents were placed on contact isolation precautions. They were monitored for skin changes. They completed full courses of medication. None of that happened after a confirmed diagnosis. It happened after a rash appeared and staff decided, without testing, that scabies was a reasonable enough possibility to treat.
The Infection Preventionist Nurse told inspectors that scabies are reported to the health department right away when diagnosed. The Director of Nursing told inspectors that only confirmed cases are reportable. Whether any cases were reported, and on what basis, the inspection report does not say.
What it does say is that the nurse who oversees infection prevention at the facility acknowledged, plainly, that she had the ability to request a skin scraping and did not. The residents completed their medication courses. The rashes, of unknown origin, were treated with drugs designed for a parasite that was never confirmed to be there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Springs Post-acute from 2025-12-01 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
THE SPRINGS POST-ACUTE in NORWALK, CA was cited for violations during a health inspection on December 1, 2025.
The findings came from a complaint inspection conducted December 1, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.