Health inspection·May 28, 2025

The following reflects the findings of the California Department of Public Health during the investigation of: CA00951381. Event ID: 3X6511 State Citation A was written §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. Title 22, § 72321. Nursing Service-Patients with Infectious Diseases. (b) The facility shall adopt, observe and implement written infection control policies and procedures. These policies and procedures shall be reviewed at least annually and revised as necessary. On 3/13/25 at 12:30 p.m., California Department of Public Health made an unannounced visit to the facility to investigate a complaint regarding uncontrolled spread of infection in the facility. The cross-contamination of infection resulted in non-infected residents becoming infected, including: - Residents 10, 49, 50, 52, 53, 54, and 56 were infected with Carbapenem-Resistant Pseudomonas aeruginosa (CRPA, bacteria that can cause pneumonia, bloodstream infections, urinary tract infections, and surgical site infections, and they are particularly dangerous for patients with chronic lung diseases). - Residents 1, 6, 7, 8, 9, 39, 40, 41, 42, 43, 44, 45, 46, 47, and 48 were infected with MDRO - Residents 4, 5, 11, 12, 13, 14, 15, 16, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, and 38 were infected with Carbapenem-resistant Acinetobacter baumannii (CRAB, a bacteria that can cause human infections of the blood, urinary tract, lungs, wounds, and other body sites. CRAB is a multidrug-resistant, making infections very difficult to treat) and/or with New Delhi metallo-ß-lactamase (NDM, an enzyme that makes bacteria resistant to a broad range of antibiotics including the carbapenem family). Facility 2 failed to follow infection control practices to prevent the spread of infection when the following were identified: 1. Facility 2 did not follow the recommendations to stop the spread of infection as outlined by the local public health department (LPHD). The recommendations were as follows: a. "...Close Facility 2 to new admissions and halt movement of residents from other buildings to the facility...." b. "...Submission of adherence monitoring logs for hand hygiene, PPE (personal protective equipment, any piece of clothing or equipment that's worn by the employees to minimize exposure to biological, chemical, or any physical hazards on work site) use, and environmental cleaning at weekly intervals and contact precaution (infection control measures used to prevent the spread of infectious diseases that are transmitted through direct contact with an infected person or their contaminated environment) and hand hygiene observations of staff to 50 per shift...." c. "...Implement infection control committee meetings if not currently in place, including lead staff from all disciplines. Provide meeting cadence and participant list to LPHD...." d. "...Provide documentation of outbreak notification and education provided to residents and families...." e. "...Notify licensing California Department of Public Health about infection outbreak...." 2. Certified Nursing Assistant (CNA) 1 and CNA 2 entered Resident 1 and Resident 2's room without performing hand hygiene. 3. Facility 2 failed to separate direct care staff (assists with tasks such as bathing, dressing, personal hygiene, and medication management) for residents who were infected with MDRO (multi-drug-resistant organism, are bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria) from non-infected residents. These failures resulted in an increase of Carbapanemase-Resistant Organism (CRO, bacteria that are resistant to a class of antibiotics called carbapenems which are typically used a last-line treatments for serious infections) infections in Facility 2. These failures resulted in an increase of Carbapanemase-Resistant Organism (CRO, bacteria that are resistant to a class of antibiotics called carbapenems which are typically used a last-line treatments for serious infections) infections in Facility 2. During a review of Resident 1's "Admission Record" (AR), printed on 3/14/25, the "AR" indicated Resident 1 was admitted to Facility 2 in February 2025 with diagnoses that included quadriplegia (a severe medical condition that causes partial or total loss of sensation and movement of all four limbs) and acute respiratory failure (ARF, results from inadequate gas exchange by the respiratory system). During a review of Facility 2's "CRO Line List", dated March 2025, the "CRO Line List" showed Resident 1 tested positive for an MDRO on 2/18/25. During a review of Resident 4's "AR", printed on 3/14/25, the "AR" indicated Resident 4 was admitted to Facility 2 in April 2016 with a diagnosis of traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head). During a review of Facility 2's "CRO Line List", dated March 2025, the "CRO Line List" showed Resident 4 tested positive for CRAB and NDM infections on "unknown" test date. During a review of Resident 5's "AR", printed on 3/14/25, the "AR" indicated Resident 5 was admitted to Facility 2 in May 2018 with a diagnosis of nontraumatic intracerebral hemorrhage (a type of stroke or bleeding within the brain tissue). During a review of Facility 2's "CRO Line List", dated March 2025, the "CRO Line List" showed Resident 5 tested positive for CRAB and NDM infections on "unknown" test date. During a review of Resident 6's "AR", printed on 3/14/25, the "AR" indicated Resident 6 was admitted to Facility 2 in February 2025 with diagnoses of ARF and dependence in ventilator (a machine that helps an individual breathe) status. The "AR" showed Resident 6 was admitted to Facility 2 from Facility 1 in February 2025. During a review of Facility 2's "CRO Line List", dated March 2025, the "CRO Line List" showed Resident 6 tested positive for an MDRO on 2/2/25. During a review of Resident 7's "AR", printed on 3/14/25, the "AR" indicated Resident 7 was admitted to Facility 2 in November 2024 with a diagnosis of amyotrophic lateral sclerosis (ALS, a nervous system disease that affects nerve cells in the brain and spinal cord that can cause loss of muscle control). During a review of Facility 2's "CRO Line List", dated March 2025, the "CRO Line List" showed Resident 7 tested positive for an MDRO on 2/15/25. During a review of Resident 8's "AR", printed on 3/14/25, the "AR" indicated Resident 8 was admitted to Facility 2 in February 2025 with diagnoses of quadriplegia and chronic obstructive pulmonary disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis). The "AR" showed Resident 8 was admitted to Facility 2 from Facility 1 in February 2025. During a review of Facility 2's "CRO Line List", dated March 2025, the "CRO Line List" showed Resident 8 tested positive for an MDRO on 2/2/25. During a review of Resident 9's "AR", printed on 3/14/25, the "AR" indicated Resident 9 was admitted to Facility 2 in January 2025 with diagnoses of cerebral infarction (stroke), hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body), affecting right dominant side, and tracheostomy status. During a review of Facility 2's "CRO Line List", dated March 2025, the "CRO Line List" showed Resident 9 tested positive for an MDRO on 2/15/25. During a review of Resident 10's "AR", printed on 3/14/25, the "AR" indicated Resident 10 was admitted to Facility 2 in February 2025 with diagnoses of nontraumatic intracerebral hemorrhage (an emergency condition in which a ruptured blood vessel causes bleeding inside) and dependence on ventilator status. The "AR" showed Resident 10 was admitted to Facility 2 from Facility 1 in February 2025. During a review of Facility 2's "CRO Line List", dated March 2025, the "CRO Line List" showed Resident 10 tested positive for CRPA on 2/23/25. During a review of Resident 11's "AR", printed on 3/14/25, the "AR" indicated Resident 11 was admitted to Facility 2 in January 2025 with diagnoses of anoxic brain damage (a condition where the brain is deprived of oxygen for a prolonged period, leading to damage or death of brain cells), ARF, and cardiac arrest (when the heart stops beating suddenly). During a review of Facility 2's "CRO Line List", dated March 2025, the "CRO Line List" showed Resident 11 tested positive for CRAB on 2/15/25. During a review of Resident 12's "AR", printed on 3/14/25, the "AR" indicated Resident 12 was admitted to Facility 2 in February 2025 with diagnoses of critical illness myopathy (is a form of generalized weakness involving the muscles of the extremities, trunk, and respiration that frequently occurs in conjunction with severe illness), COPD, and tracheostomy status. The "AR" showed Resident 12 was admitted to Facility 2 from Facility 1 in February 2025. During a review of Facility 2's "CRO Line List", dated March 2025, the "CRO Line List" showed Resident 12 tested positive for CRAB on 2/15/25. During a review of Resident 13's "AR", printed on 3/14/25, the "AR" indicated Resident 13 was admitted to Facility 2 in January 2025 with diagnoses of quadriplegia, ARF, and ventilator dependence status. During a review of Facility 2's "CRO Line List", dated March 2025, the "CRO Line List" showed Resident 13 tested positive for CRAB and NDM infections in February 2025. During a review of Resident 14's "AR", printed on 3/14/25, the "AR" indicated Resident 14 was admitted to Facility 2 in January 2024 with diagnoses of cardiac arrest, secondary malignant neoplasm (cancer) of left lung, tracheostomy status and dependence in ventilator status. During a review of Facility 2's "CRO Line List", dated March 2025, the "CRO Line List" showed Resident 14 tested positive for CRAB in August 2024. During a review of Resident 15's "AR", printed on 3/14/25, the "AR" indicated Resident 15 was admitted to Facility 2 in September 2024 with diagnoses of cervical spine fusion (a surgical procedure that connect two or more bones in the spine), tracheostomy status and dependence in ventilator status. During a review of Facility 2's "CRO Line List", dated March 2025, the "CRO Line List" showed Resident 15 tested positive for CRAB on 2/15/25. During a review of Resident 16's "AR", printed on 3/14/25, the "AR" indicated Resident 16 was admitted to Facility 2 in September 2024 with diagnoses of chronic respiratory failure, tracheostomy status, and unspecified pressure ulcer (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) of sacral region. During a review of Facility 2's "CRO Line List", dated March 2025, the "CRO Line List" showed Resident 16 tested positive for NDM on 10/23/24. During a review of Resident 24's "AR", printed on 3/14/25, the "AR" indicated Resident 24 was admitted to Facility 2 in January 2024 with diagnoses of acute and chronic respiratory failure, encephalopathy (a brain disease that alters functions or structure), COPD, tracheotomy status and severe sepsis (an infection in the blood). During a review of Facility 2's "CRO Line List", dated March 2025, the "CRO Line List" showed Resident 24 tested positive for CRAB on 12/29/24. During a review of Resident 25's "AR", printed on 3/14/25, the "AR" indicated Resident 25 was admitted to Facility 2 in September 2024 with diagnoses of nontraumatic intracerebral hemorrhage, chronic respiratory failure, quadriplegia, and resistance to multiple antibiotics. During a review of Facility 2's "CRO Line List", dated March 2025, the "CRO Line List" showed Resident 25 tested positive for CRAB on "unknown" test date. During a review of Resident 26's "AR", printed on 3/14/25, the "AR" indicated Resident 26 was admitted to Facility 2 in November 2023 with diagnoses of sepsis, cerebral infarction, and tracheostomy status. During a review of Facility 2's "CRO Line List", dated March 2025, the "CRO Line List" showed Resident 26 tested positive for CRAB in December 2023. During a review of Resident 27's "AR", printed on 3/14/25, the "AR" indicated Resident 27 was admitted to Facility 2 in October 2023 with diagnoses of paraplegia (the inability to voluntarily move the lower parts of the body), severe sepsis, and ventilator associated pneumonia. During a review of Facility 2's "CRO Line List", dated March 2025, the "CRO Line List" showed Resident 27 tested positive for CRAB in November 2023. During a review of Resident 28's "AR", printed on 3/14/25, the "AR" indicated Resident 28 was admitted to Facility 2 in March 2023 with diagnoses of ARF, sepsis, pressure ulcer of right and left hip stage 4, attention to tracheostomy, and dependence on ventilator. During a review of Facility 2's "CRO Line List", dated March 2025, the "CRO Line List" showed Resident 28 tested positive for CRAB on "unknown" test date. During a review of Resident 29's "AR", printed on 3/14/25, the "AR" indicated Resident 29 was admitted to Facility 2 in March 2024 with pneumonia, ARF, nontraumatic intracerebral hemorrhage, and tracheostomy status. During a review of Facility 2's "CRO Line List", dated March 2025, the "CRO Line List" showed Resident 29 tested positive for CRAB in October 2024. During a review of Resident 30's "AR", printed on 3/14/25, the "AR" indicated Resident 30 was admitted to Facility 2 in September 2024 with diagnoses of cerebral infarction, ARF, tracheostomy status, and resistance to multiple antimicrobial drugs. During a review of Facility 2's "CRO Line List", dated March 2025, the "CRO Line List" showed Resident 30 tested positive for CRAB on 11/23/24. During a review of Resident 31's "AR", printed on 3/14/25, the "AR" indicated Resident 31 was admitted to Facility 2 in April 2023 with diagnoses of ARF, COPD with exacerbation, and dep