Health inspection·April 10, 2025

California Code of Regulations, Title 22, section 72321 – Nursing Service – Patients with Infectious Diseases (b) The facility shall adopt, observe and implement written infection control policies and procedures. These policies and procedure shall be reviewed at least annually and revised as necessary. California Code of Regulations, Title 22, section 72523(c)(3) - Patient Care Policies and Procedures (c) Each facility shall establish and implement policies and procedures, including but not limited to: (3) Infection control policies and procedures. Code of Federal Regulation, Title 42, 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. On February 20, 2025, at 9:05 a.m., an announced visit to the facility was conducted to investigate infection control issue. It was determined that the facility failed to implement Enhanced Barrier Precautions (EBP – a strategy recommending the use of gown and gloves during provision of high-contact patient care activities) during provision of care to the patients (Patients 4, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, and 21) with wounds, with indwelling devices, and/or with infection or colonization with an MDRO (multidrug resistant organism resistant to many antibiotics), in accordance with the Centers for Disease and Prevention Control (CDC) guidelines. This failure had the potential to result in the spread of MDROs to the immunocompromised patients and could cause serious harm and aggravate the already vulnerable and compromised health conditions of the patients. On February 20, 2025, at 9:50 a.m., during an observation, the following were observed: - Patient 5 has tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck). Respiratory Therapist (RT) 1 was observed providing respiratory care at bedside to Patient 5 while wearing a surgical mask and gloves. RT 1 was observed not wearing gown. There was no EBP sign outside Patient 5’s room; - One female staff was observed inside Patient 6’s room rendering care not wearing a mask and a gown. There was no posted EBP sign outside Patient 6’s room. Patient 6 was observed with tracheostomy; - Patients 1, 2, 3, and 13's rooms were observed to have a sign outside the door indicating "Contact Precautions (infection control measures used to prevent the spread of infectious diseases that are transmitted through direct contact with the patient or their contaminated environment requiring use of PPE such as mask, gown, gloves)," and instructions to wear specific PPE; - There was no sign for EBP by the door of Patients 4, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, and 21's rooms; and - Patients 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, and 21, were observed to have indwelling devices such as tracheostomies and gastrostomy (GT - tube that is inserted into the stomach through the abdominal wall to provide nutrition, hydration, or medicine). Patients 11 and 15 had an indwelling catheter (a thin, flexible tube inserted into the urinary bladder to collect and drain urine). On February 20, 2025, at 10:03 a.m., during an interview with the Infection Preventionist (IP), she stated the following patients were placed on contact precautions due to the presence of MDRO infection: - Patient 1; CRPA (carbapenem-resistant pseudomonas aeruginosa - a type of bacterial infection that is resistant to many antibiotics) in the sputum; - Patient 2; CRPA in the urine; - Patient 3; CRPA in the wound; and - Patient 13; MRSA (methicillin-resistant staphylococcus aureus - a type of bacteria resistant to several antibiotics) in the wound. The IP further stated there were no patients placed on EBP. On February 20, 2025, at 11:01 a.m., Certified Nursing Assistant (CNA)1 was interviewed. CNA 1 stated she did not know what EBP was and had never heard of it before. On February 20, 2025, at 11:18 a.m., CNA 2 was interviewed. CNA 2 stated she had no awareness of what EBP was. On February 20,2025, at 12:53 p.m., a follow up interview was conducted with the IP. The IP stated there were no patients in the facility who were placed on EBP. On February 20, 2025, at 3:21 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated he was not aware what EBP was and had never cared for any patients who were placed on EBP in the unit. LVN 1 further stated he never received any in-services regarding EBP, but always wore gloves and masks for any kind of patient care since all the patients were "trached (had tracheostomies)." LVN 1 could not articulate what type of PPEs were to be used when a patient was placed on EBP. On February 20, 2025, at 4:10 p.m., the following were observed: - LVN 2 entered Patients 17 and 18's room and provided care to the patients. LVN 2 was observed wearing only gloves. LVN 2 was observed not wearing gown or mask prior to entering and while providing care to Patients 17 and 18; and - CNA 3 entered Patients 17 and 18's room wearing a mask but did not put on any gown or gloves prior to entering and was observed to have changed the linens of the patients. On February 20, 2025, at 4:34 p.m., CNA 2 entered Patients 17 and 18's room and was observed wearing gloves but did not put on a gown or mask while assisting CNA 3 with patient care and turning the patients. On February 20, 2025, at 4:35 p.m., CNA 3 was interviewed. CNA 3 stated the facility only used EBP during COVID-19 outbreaks. On February 20, 2025, at 4:57 p.m., LVN 2 was interviewed. LVN 2 stated she was not sure what EBP referred to and had never heard of EBP. On February 20, 2025, at 5:13 p.m., the IP was interviewed. The IP stated the staff should use gloves or gowns when providing care to the patients. The IP further stated gowns were optional when doing perineal care or turning a patient when staff needed to create a barrier between staff and the patient. The IP stated they did not put EBP signs on the patient’s door because all patients should be using EBP. On February 20, 2025, at 5:44 p.m., the Director of Nursing (DON) was interviewed. The DON stated EBP was a new practice, and not a lot of staff knew about it yet, and EBP was not being practiced at the facility. The DON stated the staff should wear the appropriate PPEs, such as gown, gloves, when providing care to patients placed on EBP. The DON stated, "the hospital doesn't understand it," and the facility staff would not know what EBP was because she had not trained them on it. The DON stated if EBP or other infection precautions were not to be followed, there would be a potential risk for spread of infections such as MDROs among the patients. The DON further stated the facility did not have a policy on EBP. On February 20, 2025, a review of patients’ records indicated the following: a. Patient 4's "Patient Information," indicated Patient 4 was admitted to the facility on February 6, 2025, with diagnoses which included sepsis (body's extreme response to an infection, a life-threatening medical emergency). Patient 4's "History and Physical," dated February 6, 2025, indicated PEG placement (percutaneous endoscopic gastrostomy- a type of feeding tube), tracheostomy, and right frontal ventricular drain (a catheter inserted into the brain through the skull to monitor and drain cerebrospinal fluid) placement. Patient 4's record did not include a physician's order and care plan for Patient 4 to be placed on EBP. b. Patient 5's "Patient Information," indicated Patient 5 was admitted to the facility on January 23, 2023, with diagnoses which included chronic (persisting for a long time) respiratory failure. Patient 5's "Patient Medication Profile," dated January 31, 2025, indicated administration of medications via feeding tube/GT. Patient 5's "Patient Care Summary," included physician's orders for tracheostomy therapy and nutritional formula feeding via GT, as well as care and maintenance orders for the feeding tube. Patient 5's record did not include a physician's order and care plan for Patient 5 to be placed on EBP. c. Patient 6's "Patient Information," indicated Patient 6 was admitted to the facility on January 26, 2024, with diagnoses which included respiratory failure and anoxic (oxygen deficient) brain injury. Patient 6's "Patient Medication Profile," dated January 31, 2025, indicated administration of medications via feeding tube. Patient 6's "Patient Care Summary," dated January 31, 2025, included physician's orders for tracheostomy care and treatment. The orders also included care and maintenance orders for the feeding tube. Patient 6's record did not include a physician's order and care plan for Patient 6 to be placed on EBP. d. Patient 7's "Patient Information," indicated Patient 7 was admitted to the facility on May 29, 2024, with diagnoses which included chronic respiratory failure s/p (status post) trach (tracheostomy) and PEG. Patient 7's "Patient Medication Profile," dated January 31, 2025, indicated administration of medications via feeding tube. Patient 7's "Patient Care Summary," dated January 31, 2025, included a physician's orders for tracheostomy care and treatment and nutritional formula feeding via J-tube (a type of GT surgically inserted into the small intestine to deliver food and medicine), as well as care and maintenance orders for the feeding tube. Patient 7's record did not include a physician's order and care plan for Patient 7 to be placed on EBP. e. Patient 8's "Patient Information," indicated Patient 8 was admitted to the facility on March 14, 2014, with diagnoses which included respiratory failure. Patient 8's "Patient Medication Profile," dated January 31, 2025, indicated administration of medications via feeding tube. Patient 8's "Patient Care Summary," dated January 31, 2025, included a physician's orders for tracheostomy care and treatment and nutritional formula feeding via GT, as well as care and maintenance orders for the feeding tube. Patient 8's record did not include a physician's order and care plan for Patient 8 to be placed on EBP. f. Patient 9's "Patient Information," indicated Patient 9 was admitted to the facility on July 9, 2019, with diagnoses which included cardiopulmonary arrest (heart attack). Patient 9's "Patient Medication Profile," dated January 31, 2025, indicated administration of medications via feeding tube. Patient 9's "Patient Care Summary," dated January 31, 2025, included physician's orders for tracheostomy care and treatment and nutritional formula feeding via GT, as well as care and maintenance orders for the feeding tube. Patient 9's record did not include a physician's order and care plan for Patient 9 to be placed on EBP. g. Patient 10's "Patient Information," indicated Patient 10 was admitted to the facility on September 20, 2016, with diagnoses which included respiratory failure. Patient 10's "Patient Medication Profile," dated January 31, 2025, indicated administration of medications via feeding tube. Patient 10's "Patient Care Summary," dated January 31, 2025, included physician's orders for tracheostomy care and treatment and nutritional formula feeding via GT, as well as care and maintenance orders for the feeding tube. Patient 10's record did not include a physician's order and care plan for Patient 10 to be placed on EBP. h. Patient 11's "Patient Information," indicated Patient 11 was admitted to the facility on October 16, 2024, with diagnoses which included acute (begins and worsens quickly) respiratory failure and acute encephalopathy (group of conditions that cause brain dysfunction). Patient 11's "Patient Medication Profile," dated January 31, 2025, indicated administration of medications via feeding tube. Patient 11's "Patient Care Summary," dated January 31, 2025, included physician's orders for tracheostomy care, urinary catheter care and treatment, and nutritional formula feeding via GT. Patient 11's record did not include a physician's order and care plan for Patient 11 to be placed on EBP. i. Patient 12's "Patient Information," indicated Patient 12 was admitted to the facility on July 3, 2022, with diagnoses which included acute respiratory failure, cardiac arrest, and anoxic brain injury. Patient 12's "Patient Medication Profile," dated January 31, 2025, indicated administration of medications via feeding tube. Patient 12's "Patient Care Summary," dated January 31, 2025, included physician's orders for tracheostomy care and treatment, nutritional formula feeding via GT, as well as care and maintenance orders for the feeding tube. Patient 12's record did not include a physician's order and care plan for Patient 12 to be placed on EBP. j. Patient 14's "Patient Information," indicated Patient 14 was admitted to the facility on January 28, 2024, with diagnoses which included respiratory failure and chronic heart failure. Patient 14's "Patient Medication Profile," dated January 31, 2025, indicated administration of medications via feeding tube. Patient 14's "Patient Care Summary," dated January 31, 2025, included physician's orders for tracheostomy care and treatment and maintenance orders for the feeding tube. Patient 14's record did not include a physician's order and care plan for Patient 14 to be placed on EBP. k. Patient 15's "Patient Information," indicated Patient 15 was admitted to the facility on November 21, 2024, with diagnoses which included chronic respiratory failure, and anoxic quadriplegia (paralysis of all four limbs). A Patient 15's "Patient Medication Profile," dated January 31, 2025, indicated administration of medications via feeding tube. A Patient 15's "Patient Care Summary," dated January 31, 2025, included physician's orders for tracheostomy care and treatment, nutritional formula feeding via GT, care and maintenance orders for the feeding tube, and urinary catheter change. Patient 15's record did not include a physician's order and care plan for Patient 15 to be placed on EBP. l. Patient 16's "Patient Information," indicated Patient 16 was admitted to the facility on October 25, 2024, with diagnoses which included kidney failure. Patient 16's "Patient Medication Profile," dated January 31, 2025, indicated administration of medications via feeding tube. Patient 16's "Patient Care Summary," dated January 31, 2025, included physician's orders for tracheostomy care and treatment, nutritional formula feeding via GT, and care and maintenance orders for the feeding tube. Patient 16's record did not include a physician's order and care plan for Patient 16 to be placed on EBP. m. Patient 16's "Patient Information," indicated Patient 17 was admitted to the facility on July 31, 2024, with diagnoses which included acute respiratory failure and acute encephalopathy. Patient 17's "Patient Medication Profile," dated January 31, 2025, indicated administration of medications via feeding tube/GT. Patient 17's "Patient Care Summary," included physician's orders for tracheostomy care and treatment, nutritional formula feeding via GT, and care and maintenance orders for the feeding tube. Patient 17's record did not include a physician's order and care plan for Patient 17 to be placed on EBP. n. Patient 18's "Patient Information," indicated Patient 18 was admitted to the facility on September 20, 2024. Patient 18's "History and Physical," dated May 29, 2024, indicated the physician's impression (clinical assessment) of anoxic brain injury, decubiti (pressure injury-bed sore), GT, and tracheostomy. Patient 18's "Patient Medication Profile," dated January 31, 2025, indicated administration of medications via feeding tube. Patient 18's "Patient Care Summary," dated January 31, 2025, included physician's orders for tracheostomy care and treatment, nutritional formula feeding via feeding tube, and care and maintenance orders for the feeding tu