Health inspection·May 28, 2025

The following reflects the findings of the California Department of Public Health during the investigation of: CA00951444. Event ID: 9VET11 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 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 Facility 1 to investigate a complaint regarding uncontrolled spread of infection in the facility. The cross-contamination resulted in non-infected residents becoming infected, including: - Residents 1, 2, and 3 became infected with Klebsiella Pneumoniae Carbapenemase (KPC, a group of emerging highly drug-resistant Gram-negative bacilli bacteria causing infections associated with significant morbidity and mortality). - Resident 6 became infected with Carbapenem-resistant Acinetobacter baumannii (CRAB, a group of emerging highly drug-resistant Gram-negative bacilli bacteria causing infections associated with significant morbidity and mortality) with New Delhi metallo-ß-lactamase (NDM, an enzyme that makes bacteria resistant to a broad range of antibiotics including the carbapenem family). - Residents 4 and 5 became infected with Carbapenem-Resistant Pseudomonas aeruginosa (CRPA, a bacterium that can cause pneumonia, bloodstream infections, urinary tract infections, and surgical site infections, and they are particularly dangerous for patients with chronic lung diseases). Facility 1 failed to follow infection control practices to prevent the spread of infection when the following were identified: 1. Facility 1 did not demonstrate infection prevention practices were implemented as evidenced by the line list (a table that contains key information about each case in an outbreak) that showed uninfected residents becoming infected. 2. Facility 1 did not notify California Department of Public Health (CDPH) about the infection outbreak. 3. Facility 1 failed to separate direct care staff (assists with tasks such as bathing, dressing, personal hygiene, and medication management) for non-infected residents and Resident 1 and Resident 2 who were infected with Klebsiella Pneumoniae Carbapenemase (KPC, a group of emerging highly drug-resistant Gram-negative bacilli bacteria causing infections associated with significant morbidity and mortality). 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) in Facility 1. 1. During an interview on 3/13/25 at 12:56 p.m. with Facility 2's Infection Preventionist (IP), IP stated she was the only IP for Facility 1 and Facility 2 even though both facilities have separate licenses, and the regulations say otherwise. During an interview on 3/13/25 at 1:16 p.m. with Administrator (ADM), ADM stated there was only one shared IP for both Facility 1 and Facility 2. ADM stated he was not aware of the regulation that each facility should have an IP. ADM also stated that he thought one IP was enough because Facility 1 and Facility 2 are owned by one organization. During an interview on 3/14/25 at 3:31 p.m. with Facility 2's IP, IP was requested to provide an updated line list for Facility 1 and Facility 2 with laboratory test dates (date laboratory results were reported), the residents tested positive for CRO infections. During a follow up interview and record review on 3/14/25 at 3:45 p.m. with Facility 2's IP, IP provided an updated line list with laboratory test dates for Facility 2 but did not provide the line list for Facility 1. IP was requested to provide Facility 1's line list record with laboratory test dates. During a phone interview on 3/20/25 at 8:04 a.m. with Facility 2's IP, IP was requested to provide another updated line list for Facility 1 and Facility 2 with the laboratory test dates included. During a review of an undated document, titled, "CRO List" sent via email by Medical Record Director (MRD) on 3/20/25 at 10:09 a.m., the "CRO List" only included Facility 2's line list and did not include Facility 1's updated line list. During a communication sent via email on 3/21/25 at 8:47 a.m. to MRD, MRD again was requested to provide an updated line list for Facility 1. During a review of the undated document, titled, "Facility 1 Multi-Drug Resistant Organisms (MDROs, are bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria) Line List", the line list sent via email on 3/21/25 at 10:17 a.m. by MRD, the Facility 1 line list was still not updated and did not include the laboratory test dates. During a record review of the undated document, titled, "Facility 1 MDRO Line List", the line list indicated Residents 1, 2, and 3 were infected with KPC, Resident 4 and Resident 5 were infected with CRPA infection, and Resident 6 was infected with NMD infection. There was no laboratory results provided for Residents 3, 5, and 6 to confirm the date infection was identified. 2. During an interview on 3/13/25 at 3:15 p.m. with Facility 2's IP, IP stated Facility 1 had a recent CRO outbreak last February 2025 and CDPH was only notified on 3/12/25 that there were new cases of infection identified. IP stated she forgot to inform CDPH about the two new cases because she was already overwhelmed with the CRO outbreak. IP further stated she did not think that the two new cases of infection noted in February were reportable. IP stated she should have reported it to the CDPH because more than one case of communicable infection was considered an outbreak. During a review of Facility 1's Policy & Procedure (P&P) titled, "Outbreak of Communicable Diseases", dated 2001, the P&P indicated, "An outbreak is defined as one of the following...a. One case of an infection that is highly communicable or has serious health implications...." During a review of Facility 1's undated P&P titled, "Reporting Communicable Diseases", the P&P indicated, "The infection preventionist is responsible for notifying the local, district, or state health department of confirmed cases of state specific reportable diseases...." 3. During an interview on 3/13/25 at 12:36 p.m. with Facility 2's IP, IP stated Facility 1's CRO outbreak started around January 2025 when direct care staff from Facility 2 were assigned to Facility 1 on the same day. IP stated that she identified the previous scheduling coordinator assigned staff to work in Facility 2 then work in Facility 1. IP stated she informed the previous scheduling coordinator that sharing staff between Facility 1 and Facility 2 was not allowed because Facility 2 had an outbreak and Facility 1 did not have an outbreak. IP stated despite her instructions; the previous scheduler continued to assign direct care staff to work double shifts in Facility 1 after working in Facility 2 during January 2025. IP stated sharing staff between Facility 1 and Facility 2 contributed to Facility 1's CRO infection outbreak. During an interview on 3/14/25 at 3:09 p.m. with the Director of Nursing (DON), DON stated floating staff between Facility 1 and Facility 2 is not highly recommended. DON stated staff would start in Facility 2 and then move to clean buildings, including Facility 1. DON stated it was acceptable for staff to work from "dirty" buildings to "clean" buildings if wearing personal protective equipment (PPE, 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.) During a review of Facility 1's document titled, "Nursing and CNA Staffing Sign-in Sheet - Facility 1", dated 3/13/25, the document indicated Certified Nurse Assistant (CNA) 3 worked in Facility 1 from 7:00 a.m. to 3:30 p.m. and was assigned to Resident 1 and Resident 2 who were infected with KPC. During a concurrent observation and interview on 3/13/25 at 2:46 p.m. with CNA 3 in Facility 1, CNA 3 was observed in Resident 1 and Resident 2's room that had signage indicating contact precautions (an infection control measures used to prevent the spread of diseases that are transmitted through direct or indirect contact with an infected person or environment) posted on the door. CNA 3 stated Facility 1 and scheduled her in the afternoon to work in Facility 2 after her morning shift in Facility 1. During a review of Facility 2's document titled, "Nursing and CNA Staffing Sign-in Sheet", dated 3/13/25, the documented indicated CNA 3 worked in Facility 2 for evening shift (3:00 p.m. to 11:30 p.m.) after working the morning shift (7:00 a.m. to 3:30 p.m.) in Facility 1. During a phone interview on 3/14/25 at 10:36 a.m. with Scheduling Coordinator (SC), SC stated CNA 3 should have stayed in Facility 1 when CNA 3 worked a double shift. SC stated there was too much going on and she did not have time to check the staffing schedules for Facility 1 and Facility 2 on 3/13/25. During a follow up interview on 3/14/25 at 11:57 a.m. with Facility 2's IP, IP stated she informed SC multiple times CNAs should not be shared between Facility 1 and Facility 2. IP stated CNA 3 worked on 3/13/25 in Facility 1 in the morning and continued the evening shift in Facility 2's unit that did not have an outbreak. IP stated CNA 3 who provided direct care to Resident 1 and Resident 2 who were on contact precautions for KPC was also assigned to residents who did not have the infection and were not on contact precautions in Facility 2. IP stated the Local Public Health Department (LPHD) recommended that if staff were to work a double shift, staff should have stayed in one building or should have been allowed to have a gap of 8 hours in between shifts. IP stated the 8-hour gap between shifts would have been an opportunity for staff to go home, take a shower, and change clothing. IP stated sharing staff between Facility 1 and Facility 2 could have exposed the residents to transmission of different infections such as CRAB, CRPA, NDM, KPC, etc. During an interview on 3/14/25 at 3:08 p.m. with DON, DON stated the facility's staff should have provided care to residents who did not have an infection first before being assigned to infected residents. DON stated sharing staff between buildings had the risk of transmission of bacteria to other residents who did not have an infection. DON stated residents who were exposed to an infection could have had resistance to antibiotics that could have potentially led to sepsis or death. During a review of the facility's P&P titled, "Multi-Drug-Resistant Organisms (MDROs)", dated 2001, the P&P indicated, "MDROs are bacteria and other microorganisms that have developed resistance to one or more classes of antimicrobial drugs...Resident Admission and Room Placement...3. When transmission continues despite adherence to standard and contact precautions and cohorting residents, assign dedicated nursing and ancillary service staff to the care of MDRO residents only." 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 as a last-line treatments for serious infections) infection in Facility 1. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.