Health inspection·September 24, 2025

F880 §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. (iv) 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 § 72541 Unusual Occurrences. Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. From 8/11/2025 to 8/212025, an unannounced visit was conducted at the facility for a recertification survey and to investigate one Facility Reported Incident regarding infection control. Based on observation, interview, and record review, the facility failed to ensure infection control measures were implemented during the facility's COVID-19 (name of disease caused from SARS-CoV-2 [severe acute respiratory syndrome coronavirus 2, a type of coronavirus]) outbreak (when a disease spreads to more people than usual, and caused by an infectious agent, such bacteria, viruses, or parasites) when: 1. There was no Transmission-Based Precaution (a second tier of basic infection control used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission) related to COVID-19 posted at the double doors, and no isolation cart (a cart used in hospitals and other healthcare facilities to store all the personal protective equipment [PPE, are items like gloves, masks, gowns, and eye protection worn by healthcare workers to create a barrier and prevent the spread of infections] and supplies needed to care for a patient in isolation) found prior to the entry into Station AA (COVID-19 designated area and Dementia [a group of symptoms affecting thinking and social abilities interfering with daily functioning] locked unit) with 30 residents who tested positive for COVID-19 infections (residents with the virus and had an infection) and with 10 residents who tested negative for COVID-19 infections (residents who were not infected and had a negative test result). 2. There was inconsistent use of personal protective equipment among staff assigned to Station AA, and the room doors of residents with COVID-19 infections were left open; 3. Two activity aides provided group activities in the hallway to three residents, who were without face masks in place, seated close to each other in Station AA; and, 4. The facility failed to report timely the COVID-19 outbreak to the California Department of Public Health (CDPH, a state government agency). These infection control failures required immediate correction to prevent further transmission of the outbreak's virus among people at the facility. On 8/11/2025 at 7:09 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified and declared, in the presence of the facility's Administrator (ADM) related to the above failures. On 8/15/2025 at 4:34 p.m., the IJ was removed after the ADM submitted an acceptable IJ Removal Plan (IJRP, a plan with interventions to immediately correct the deficient practices), and after the survey team verified and confirmed the corrective actions while onsite. The failures resulted in an increased number of COVID-19 infections among 36 residents (Residents 23, 97, 11, 22, 8, 34, 115, 70, 136, 80, 45, 37, 100, 86, 88, 39, 89, 7, 77, 131, 60, 67, 73, 33, 78, 35, 122, 18, 92, 148, 101, 125, 42, 44, 121, and 75) and staff. Resident 22 was transferred to an acute care (medical care provided to patients with sudden, severe, or time-sensitive health conditions that require immediate attention and treatment) hospital on 8/5/2025 due to medical complications related to COVID-19 infection. The failures had the potential for the remaining facility residents and staff that tested negative, and visitors to acquire the virus for a COVID-19 infection. Findings: 1. During an observation on 8/11/2025 at 9:15 a.m., in front of the facility's double doors to Station AA, there was no Transmission-Based Precaution related to COVID-19 infection posted. There was no isolation cart on sight prior to the entry into Station AA. During an interview with the infection preventionist (IP) on 8/11/2025 at 1:28 p.m., the IP confirmed there was no signage posted in the Station AA's double doors which indicated the use of PPE prior to entry. The IP further confirmed visitors were just wearing face masks when they entered Station AA and should only don (put on) the rest of the PPE (gown, face shield and gloves) prior to resident's room entry. The IP confirmed visitors were exposed to residents with COVID-19 infection that frequently walked at the hallway. During a phone interview with the county's communicable disease investigator (CCDI) on 8/11/2025 at 12:26 p.m., the CCDI confirmed due to the increasing number of positive COVID-19 residents, she recommended transferring them to Station AA to contain all positive COVID-19 residents. During a review of the Centers for Disease Control and Prevention (CDC) COVID-19 guidelines provided by Santa Clara's Public Health office to the facility titled, "Infection Control Guidance: SARS-CoV-2 [the virus that causes a respiratory disease called coronavirus disease 19 ]," dated 6/24/2024, indicated, "Post visual alerts (e.g. signs, posters) at the entrance and in strategic places (e.g. waiting areas, elevators...).These alerts should include instructions about current IPC [infection prevention and control] recommendations (e.g. when to use source control and perform hand hygiene). Dating these alerts can help ensure people know that they reflect current recommendations." 2. During a concurrent observation and interview with activity aide H (AA H) on 8/11/2025 at 9:20 a.m., inside Station AA's hallway in front of Rooms BB and CC, the AA H was wearing an N95 mask (a respiratory protective device that filters out at least 95% of airborne particles when worn and fitted correctly), face shield and gown at the hallway. The AA H stated they were instructed to wear the full PPE when they entered Station AA. There were three residents seated outside Rooms BB and CC and were observed not wearing any mask. Further observation revealed there were residents walking in the hallway not wearing any masks. During a concurrent observation and interview with activity aide I (AA I) on 8/11/2025 at 9:22 a.m., in Station AA's hallway, the AA I was observed wearing an N95, face shield and gown at the hallway and stated they were instructed to wear the full PPE because they have to assist residents who were positive of COVID-19 infection at the hallway. During a concurrent observation and interview with restorative nursing aide J (RNA J) on 8/11/2025 at 9:23 a.m., in Station AA's hallway, the RNA J was observed wearing a mask, face shield and putting on the gown while walking at the hallway. The RNA J stated she needed to follow residents at the hallway, especially the "wanderers [residents, often with dementia, who moves around in a confused, aimless, or repetitive manner, sometimes without awareness of their location or surroundings, and can become lost or disoriented]." During additional observation on 8/11/2025 at 9:24 a.m., at Station AA's hallway, two facility staff were observed just wearing N95 masks, not wearing gowns, and face shields, walking from the nurse station to the hallway, passed by wandering residents in Station AA. Some residents were not wearing face masks. During an interview with the IP on 8/11/2025 at 9:26 a.m., the IP confirmed that it was last week when she instructed staff in Station AA to wear gowns and face shields at the hallway because of the "wanderers" who tested positive of COVID-19 infections in Station AA. The IP stated staff inside Station AA should protect themselves by wearing PPE at the hallway. During an interview with the activity supervisor (AS) on 8/11/2025 at 10:02 a.m., AS confirmed AA H and AA I were assigned in Station AA. The AS stated, they were not instructed to wear a gown, and face shield at the Station AA hallway. During an observation in front of Station AA's double door entry on 8/12/2025 at 3:10 p.m., two visitors went inside Station AA with only face masks. During an observation inside Station AA on 8/12/2025 at 3:16 p.m., in front of Resident 73 and 33's room, the door was left open, with transmission-based precaution posted and Resident 73 was observed in bed with productive cough (a cough that brings up mucus or phlegm [sputum] from the airways and lungs). Resident 33 was asleep in bed. During an observation inside Station AA on 8/12/2025 at 3:19 a.m., in front of Resident 60 and 67's room, the door was left open, with transmission-based precaution posted and both residents were not in their room. During an observation inside Station AA on 8/12/2025 at 3:23 p.m., in front of Resident 148 and 18's room, the door was left open, with transmission-based precaution posted and both Residents 148 and 18 were asleep. During an observation inside Station AA's hallway on 8/12/2025 at 3:25 p.m., there were residents observed seated outside their rooms and there were residents who wandered at the hallway without face masks. During an observation inside Station AA on 8/12/2025 at 3:27 p.m., in front of Resident 34 and 131's room, the door was left open, with transmission-based precaution posted and Resident 34 was asleep in bed. Resident 131 was not in the room. During an observation inside Station AA on 8/12/2025 at 3:29 p.m., in front of Resident 37, 136, and 45's room, the door was left open, with transmission-based precaution posted, Resident 37 was not in the room, Resident 136 was seated at the edge of the bed watching a show via a tablet, and Resident 45 was asleep in bed. During an observation inside Station AA on 8/12/2025 at 3:30 p.m., in front of Resident 100's room, the door was left open, with transmission-based precautions posted, and Resident 100 was observed in bed. During an observation inside Station AA on 8/12/2025 at 3:32 p.m., in front of Resident 22, and 11's room, the door was left open, with transmission-base precaution posted, both Residents 22 and 11 were asleep in bed. During an observation inside Station AA on 8/12/2025 at 3:33 p.m., in front of Resident 70, 89, and 7's room, the door was left open, with transmission-based precaution posted, and Residents 70 and 89 were not in the room. Resident 7 was observed asleep in bed. During an observation inside Station AA on 8/12/2025 at 3:37 p.m., in front of Resident 35 and 39's room, the door was left open, with transmission-based precaution posted, Resident 35 walked out of the room without face mask, while Resident 39 was asleep in bed. During an interview with registered nurse M (RN M) on 8/12/2025 at 3:43 p.m., RN M confirmed there were three rooms with residents still negative of COVID-19 infection. RN M confirmed negative residents mingled with positive residents. During a concurrent observation inside Station AA and interview with certified nursing assistant L (CNA L) on 8/12/2025 at 3:45 p.m., in front of Resident 78 and 122's room, the door was left open, with transmission-based precaution posted, CNA L was wearing N95, face shield and gown while standing in front of Resident 78 and 122's room, while Resident 78 was seated outside the room. Resident 122 was observed asleep in bed. CNA L confirmed both Residents 78 and 122 were at risk of falling and she was their sitter (a caregiver who provides companionship and supervision to patients who need constant observation or assistance, often due to medical conditions or behavioral issues that could pose a risk). CNA L further confirmed both residents were positive for COVID-19 infection. CNA L stated staff should encourage residents to wear face masks whenever they are out of their rooms. During an observation inside Station AA on 8/12/2025 at 3:48 p.m., in front of Resident 92 and 86's room, the door was left open, with transmission-based precaution posted, and both Residents 92 and 86 were in bed. During an observation inside Station AA 8/12/2025 at 3:50 p.m., in front of Resident 101 and 125's room, the door was left open, with transmission-based precaution posted, and both Residents 101 and 125 were in bed. During an observation inside Station AA on 8/12/2025 at 3:52 p.m., in front of Resident 115, 77 and 8's room, the door was left open, with transmission-based precaution posted. Resident 115 and Resident 8 were in bed. Resident 77 walked out of the room to greet the nurse surveyor without a face mask. During an observation inside Station AA on 8/12/2025 at 3:55 p.m., in front of Resident 88's room, with transmission-based precaution posted and the door was closed. During an interview with RN M on 8/12/2025 at 4:00 p.m., RN M confirmed residents with COVID-19 infections should be encouraged to wear face masks when they were out of their rooms. RN M further confirmed their residents' (with COVID-19 infection) doors should remain closed. During a concurrent interview with the infection preventionist (IP) and record review of the 8/11/2025 infection control line listing (a spreadsheet-like table that provides a quick summary of essential information about each case during a disease outbreak) on 8/19/2025 at 2:3