Health inspection·April 6, 2026

42 CFR §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. (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: (1) A system for reporting 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 §483.70(e) and following accepted national standards. 22 CCR § 72321. Nursing Service -Patients with Infectious Diseases. (b) The facility shall adopt, observe, and implement written infection control policies and procedures. 22 CCR §72523- Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be implemented to ensure that patient related goals and facility objectives are achieved. (b) All policies and procedures required of these regulations shall be carried out as written. 22 CCR § 72537 Reporting Communicable Diseases All cases of reportable communicable diseases shall be reported to the local health officer. 22 CCR § 72539 Reporting of Outbreaks Any outbreak or undue prevalence of infectious or parasitic disease or infestation shall be reported to the local health officer. 22 CCR §72541- Unusual Occurrences Occurrences such as epidemic outbreaks 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 should furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. On 2/11/2026, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate multiple complaint allegations. One of the allegations indicated an unexpected death of Resident 1. The facility failed to: 1). Report the Influenza A (a viral infection that attacks the respiratory system, including the nose, throat, and lungs) outbreak (a sudden increase in the occurrence of a disease that exceeds what is typically expected) to the CDPH within 24 hours, as indicated in the facility's policy and procedure (P&P) titled "Unusual Occurrence Reporting". This failure delayed the investigation by the CDPH. Resident 1 was a 61-year-old female, admitted to the facility on 9/22/2025, with diagnoses including heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), stage four chronic kidney disease (severe kidney impairment), and chronic obstructive pulmonary disease (a chronic lung disease causing difficulty in breathing). A review of Resident 1's History and Physical (H&P), dated 9/25/2025, indicated Resident 1 had the capacity to make medical decisions. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/5/2026, indicated Resident 1 was cognitively intact and did not reject evaluation or care. Resident 1 was independent with eating. Resident 1 required set-up or clean-up assistance with oral hygiene, toileting hygiene, personal hygiene and upper body dressing. Resident 1 required supervision or touching assistance (Helper provides verbal cues and/ or touching/ steadying and/or contact guard assistance as resident completes activity) with shower/ bathing self and lower body dressing. Resident 1 required partial/ moderate assistance (Helper does less than half the effort) in putting on/ taking off footwear. A review of Resident 1's Influenza Antigen Test (a test to detect influenza) Result Form, dated 2/2/2026 12:00 p.m., indicated a positive test result (indicates active infection). 2). Resident 8 was a 70-year-old female, admitted to the facility on 7/28/2025 with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertensive heart disease (a heart disorder which causes the heart to not pump the blood efficiently), and pleural effusion (abnormal build-up of fluid in the space between the lungs and chest wall). A review of Resident 8's H&P, dated 7/31/2025, indicated Resident 8 was capable to understand and make decisions. A review of Resident 8's MDS, dated 2/4/2026, indicated Resident 8 had moderate cognitive impairment. Resident 8 was independent with eating, oral hygiene, toileting hygiene, personal hygiene, upper and lower body dressing, and in putting on/ taking off footwear. Resident 1 required set-up or clean-up assistance with shower/ bathing self. A review of Resident 8's Influenza Antigen Test Result Form, dated 2/2/2026 at 12:00 p.m., indicated Resident 8's influenza test was positive. During a concurrent interview and record review on 2/24/2026 at 9:40 a.m., with the Infection Preventionist (IP), Resident 1 and Resident 8's Influenza Antigen Test Result Form, dated 2/2/2026, the Los Angeles County (LAC) DPH's "Influenza and other Respiratory Virus Diseases Outbreak Toolkit (a document that provide streamlined guidance and strategies that can be broadly applied for the prevention and control of influenza... and other common respiratory viruses in Los Angeles County Skilled Nursing Facilities)," dated 12/2025, and the facility's undated P&P titled "Unusual Occurrence Reporting," were reviewed. The IP stated the LAC DPH Outbreak Toolkit indicated two or more laboratory confirmed influenza cases identified within 72 hours of each other was considered an outbreak and must be reported to the CDPH Licensing & Certification local office. The IP stated Resident 1 and Resident 8's Influenza A positive test results on 2/2/2026 at 12:00 p.m., were two confirmed cases that were not reported to CDPH. The IP stated Influenza A was a communicable respiratory disease and should have been reported to the CDPH within 24 hours, on 2/3/2026 at 12:00 p.m., as indicated in the P&P titled "Unusual Occurrence Reporting." A review of "LAC DPH Influenza and other Respiratory Virus Diseases Outbreak Toolkit," dated 12/2025, indicated two or greater laboratory confirmed influenza cases identified within 72 hours of each other are considered an outbreak. The toolkit indicated that any sudden increases in acute respiratory illness cases, such as influenza, over the normal background rate or outbreaks of any respiratory virus are reportable and must be reported to the CDPH Licensing & Certification local office as soon as the facility suspects an outbreak in their facility. A review of the facility's undated P&P titled "Unusual Occurrence Reporting," indicated the facility will report unusual occurrences or other reportable events which affect the health, safety, or welfare of the residents, employees or visitors. The facility will report epidemic outbreak of any disease, prevalence of communicable disease, via telephone, to appropriate agencies, within 24 hours of such incident or as required by federal and state regulations. A review of the facility's undated Job Description titled "Infection Preventionist," indicated the IP must report all reportable diseases to the state health department. The facility failed to: 1). Report the Influenza A outbreak to the CDPH within 24 hours, as indicated in the facility's P&P titled "Unusual Occurrence Reporting". This failure delayed the investigation by the CDPH. This violation had a direct or immediate relationship to the health, safety, or security of the residents.