Health inspection·January 13, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to: Residents Affected - Some 1. Report the facility's 24 Coronavirus Disease 2019 ([COVID-19] highly contagious viral infection) positive residents to the California Department of Public Health (CDPH) confirmed cases as indicated in the All facilities Letter 23-08 ([AFL] a letter from the Center for Health Care Quality (CHCQ), Licensing and Certification (L&C) Program to health facilities that are licensed or certified by L&C with information that include changes in requirements in healthcare, enforcement, new technologies, scope of practice, or general information that affects the health facility) dated 1/18/2023, which indicated to report outbreaks (the occurrence of cases of a disease or condition above the expected or baseline level, usually over a given period of time, in a geographic area or facility, or in a specific population) and unusual infectious disease occurrences to the local public health officer and the California Department of Public Health (CDPH) . 2. Implement its policy and procedure (P&P) titled, COVID-19 Facility Mitigation Management Plan, which indicated all Health Care Personnel (HCP) will be provided facemask or N95 masks for use while working in the facility. These failures resulted in the delay of the investigation by the CDPH and had the potential to increase the spread of COVID-19 infections to all the residents, staff, and visitors. Findings: During a review of the Medical Provider Report of Laboratory Results, dated 12/15/2024, the report indicated the facility had reported to the Acute Communicable Disease Control (ACDC) agency that Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10, tested positive for COVID-19 on 12/13/2024 and were symptomatic. During a record review of the Complaint/Incident Intake Report (HS 802) form dated 12/31/2024 at 5:30 p.m., the HS 802 indicated an anonymous (not identified by name) person reported the COVID-19 outbreak to the Licensing and Certification District Office with 24 residents infected with COVID-19. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly), primary insomnia (a sleep disorder that makes it difficult to fall asleep, stay asleep, or get quality sleep) and low back pain. Page 1 of 3 056417 056417 01/13/2025 View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident1 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 11/13/2024, indicated Resident 1 had clear speech, the ability to express ideas and wants, and understands. The MDS indicated Resident 1 required set up or clean up assistance with oral hygiene and personal hygiene, and able to eat independently. During a review of Resident 1 ' s COVID-19 test result, dated 12/13/2024, the test result indicated the sample origin was a nasal swab and resulted positive for SARS-COV-2 antigen (a protein found in the SARS-CoV-2 virus that can be detected using a COVID-19 rapid antigen test). During a review of Resident 1 ' s Change of Condition (COC) Evaluation, dated 12/13/2024 at 4:54 p.m., the COC indicated Resident 1 had a Rapid Positive COVID test result and was seen by the physician via Zoom (a brand name for computer software that allows a group of two or more people to see and talk to each other over the internet using their computers, tablets, or smartphones) and there are no new orders at this time. During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of schizophrenia disorder (a chronic mental illness that affects how a person thinks, feels, and behaves), primary insomnia, and alcohol dependence. During a review of Resident 2 ' s MDS, dated [DATE], indicated Resident 2 had clear speech, the ability to express ideas and wants, and understands. The MDS indicated Resident 2 was independent with eating, toileting, and personal hygiene. During a review of Resident 2 ' s COVID-19 test result, dated 12/13/2024, the test result indicated the sample origin was a nasal swab and resulted positive for SARS-COV-2 antigen. During a review of Resident 2 ' s COC Evaluation, dated 12/14/2024 at 2:22 p.m., the COC indicated Resident 2 had a Rapid Positive COVID test result and the physician was made aware and gave a new order of Paxlovid (300/100) Oral Tablet therapy. During a review of Resident 2 ' s care plan, dated 12/13/2024, the care plan indicated Resident 2 tested positive for COVID-19. The care plan goal indicated Resident 2 will maintain and comply with infection prevention strategies. The care plan nursing interventions included to encourage Resident 2 to wash hands often, encourage to stay in room, and give prescribed medication as ordered. During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was admitted on [DATE] with diagnosis of schizophrenia, hypertension (high blood pressure), and alcohol dependence. During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 had clear speech, the ability to express ideas and wants, and understands. The MDS indicated Resident 2 was independent with eating, toileting, and shower/bathe self. During a review of Resident 3 ' s COVID-19 test result, dated 12/13/2024, the test result indicated the sample origin was a nasal swab and resulted positive for SARS-COV-2 antigen. During a review of Resident 3 ' s COC Evaluation, dated 12/13/2024 at 4:10 p.m., the COC indicated Resident 3 was seen by the physician via Zoom after testing positive for COVID-19. Resident 3 has a dry cough and encouraged to increase fluid intake, wash hands often, wear a mask and encouraged to 056417 Page 2 of 3 056417 01/13/2025 View Heights Conv Hosp 12619 S. Avalon Blvd Los Angeles, CA 90061

F 0880 stay in room at this time. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 1/6/2025 at 10:20 a.m., in the activities room, an Activity Assistant (unidentified) was observed monitoring residents with an N95 mask below her nose, top strap of mask hanging loose, and a bottle of water. The Activity Assistant stated she was not wearing her mask properly because she was drinking water and failure to wear mask properly may increase the spread of infection among staff and residents. Residents Affected - Some During a concurrent observation and interview on 1/6/2025 at 11:05 a.m. with the Laundry Assistant 2, in the laundry room, the Laundry Assistant 2 was observed wearing a surgical mask below her nose, laundry assistant 2 stated she should wear an N 95 mask covering her nose during the COVID-19 outbreak to prevent the spread of COVID-19 to residents, staff and visitors. During a telephone interview on 1/6/2025 at 3:55 p.m., with the Infection Preventionist (IP), the IP stated she was unaware of COVID-19 outbreak reporting to the district office (DO). The IP stated she thought she was reporting the COVID 19 outbreak correctly. The IP stated failure to report the COVID outbreak to the DO left the DO unaware of the severity of the COVID-19 outbreak. During a telephone interview on 1/14/2025 at 8 :50 a.m., with the Public Health Nurse (PHN), the PHN confirmed a COVID 19 outbreak was reported on 12/16/2024 and the PHN did an onsite visit to the facility and spoke with the IP nurse and made her aware to report the outbreak to the Licensing and Certification district office. During a review of the AFL (All Facilities Letter) 2309, dated 1/18/23, the AFL indicated a reminder to licensed health facilities' requirements to report outbreaks and unusual infectious disease occurrences to the local health department (LHD) and Licensing and Certification District Office. The AFL indicated to provide the DO investigation and reporting thresholds for reporting for COVID-19. The AFL also indicated a reminder to licensed health facilities of the requirements to report outbreaks and unusual infectious disease occurrences to the LHD pursuant to Title 17 CCR sections 2500, 2501, and 2502, and to their Licensing and Certification District Office pursuant to Title 22 CCR sections 70737, 70739, 72523, 72539, and 72541. During a review of the facility ' s policy and procedure (P&P) titled, COVID-19 Facility Mitigation Management Plan, undated, the P&P indicated it is the policy of this facility to protect the residents, staff and others who may be in the facility from harm during emergency events. The P&P indicated, the facility reports data pertaining to COVID-19 to California Department of Public Health no later than 12 p.m. daily via online survey tool. The P&P indicated the reporting includes reporting on Saturday and Sunday, the number of confirmed positive COVID-19 patients, number of suspected COVID-19 patients, facility staffing levels, Personal Protective Equipment (PPE) availability and other needs of the facility. The P&P also indicated all HCP will be provided facemask or N95 masks for use while working in the facility. The P&P indicated while there are positives cases in the facility, all HCP will be required to wear N95 respirators, gowns, face shields/eye goggles and gloves while working directly with residents. 056417 Page 3 of 3