complaint·March 13, 2025

San Diego Epidemiology provided guidance to include the following: request symptomatic residents remain in their rooms until symptom-free for at least 48 hours; if possible, provide in-room meal service and restrict ill residents from participating in group activities; temporarily discontinue or limit group activities; and disinfect common areas and high-touch surfaces with an EPA-registered cleaning product effective against Norovirus. The facility had Sani-Cloth Germicidal Disposable Wipes, which can be used to disinfect Norovirus, but only used for hard surfaces. Resident interviews confirmed not having knowledge of the outbreak. Some residents that were infected stated they continued to eat meals in the dining room and stayed away from their friends by choice, not to infect others. Infected residents revealed they were not provided guidance by staff to self-isolate. Therefore, they continued to interact with other residents. Resident interviews also confirmed staff entered the resident’s room during the infected time period without PPE. In addition, residents stated signs were not posted on their doors to reflect contagious outbreak. A resident not infected revealed they were not made aware by staff the facility had an outbreak. Per the Executive Director, emails were sent to the resident and responsible parties. However, some residents do not have access to emails. A review of the facility records indicated the email was sent to the residents/responsible parties on 02/17/25, which was after the infected period. The email stated “We will continue to provide you with updates as they become available. Please know that we are strictly adhering to all directions from the local and state health department.” The facility did not follow the recommendation of the health department to limit activities and dining. Outside source interviews revealed there were no follow up emails sent to families. Outside source interviews confirmed they were not notified about the outbreak until days later after the outbreak. Outside interviews also stated there were no signs posted in the facility warning people of the outbreak. One resident went to the hospital and upon return the following the day, their room was not disinfected. The room was observed with liquid feces on the floor, carpet, and bedding. Staff explained they have disinfectant wipes that could have cleaned the feces off the floor. However, available products to staff did not include a bleach-based solution to disinfect the room, at the time of the resident’s return. Staff explained they were not aware the resident was returning to the facility from the hospital. LPA explained all rooms should be disinfected on a regular basis when there is an infectious outbreak. Staff stated an order must be placed to clean the carpets, as that is not handled by caregivers or housekeeping. The facility shall be prepared to ensure infection control guidelines are followed, regardless of the time of day or resident’s absence from the community. Continued on an LIC 9099C. The resident’s room was disinfected by the resident’s family member using a bleach-based solution. The facility should have mitigated the infection by ensuring the infected resident rooms were disinfected and activities and dining should have been limited. The infected residents were walking around the facility and interacting with the other residents. The Executive Director (ED) explained isolation of residents can be difficult on residents when they are not able to interact/socialize with one another. LPA explained it was more important to stop the spread of the virus, which is harmful to residents. The facility has a Lead Infection Preventionist assigned to the facility. However, they were not aware of the details of the outbreak and/or involved with the mitigation. According to the ED there are two (2) assigned Leads to the facility, which was not documented. In addition, the Lead documented on their Infection Control Plan should have been involved to assist with mitigation. Based on interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Health Service Director, Stephanie Scudder whose signature below confirms receipt of these rights.