Health inspection·February 26, 2024

42 CFR §483.80 The facility must establish and maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. (a) The facility must establish an infection prevent and control program that must include, at a minimum, the following elements: (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 §483.70 (e) and following accepted national standards. (a) (2) Written standards, policies, and procedures for the program which must include, but are not limited to: (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. 22 CCR § 72521 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. 22 CCR § 72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (3) Infection control policies and procedures. 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, 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 confirming 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 organized fire service, to the State Fire Marshall. On 1/19/2024, the California Department of Public Health (CDPH) received a complaint indicating the facility had 1 resident case of the Coronavirus ([Covid-19] a highly contagious infection caused by a virus that can easily spread from person to person) which met the Covid-19 outbreak (a sudden rise in the incidence of a disease) criteria. On 1/25/2024, the CDPH conducted an unannounced visit at the facility to investigate the Covid-19 outbreak. The facility failed to: 1. Implement its policy and procedure (P&P) titled, “Infection Prevention and Control Program” which indicated to notify appropriate Government agencies of reportable contagious or infectious diseases. 2. Report the facility’s Covid-19 outbreak to the Licensing and Certification District Office (DO) per All Facilities Letter ([AFL] a letter from the Center for Health Care Quality, Licensing and Certification Program to health facilities that contained changes in requirements in healthcare, enforcement or general information that affected the health facility) 23-09 dated 1/18/2023. As a result, there was a high risk for an increase in Covid-19 cases in the facility, and placed residents, staff, and the community at risk for contracting the Covid-19 virus. A review of Resident 1’s Admission Record indicated Resident 1 was a 69-year-old female, admitted to the facility on 6/22/2022, and readmitted on 3/23/2023, with diagnoses including muscle weakness and diabetes mellitus (high blood sugar). A review of Resident 1’s History and Physical (H&P) dated 8/24/23 indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care planning tool) dated 10/10/2023 indicated Resident1 was dependent on staff for Activities of Daily Living (ADL’s) such as toileting, showering and dressing. A review of Resident 1’s Change of Condition (COC) Evaluation dated 1/18/2024 indicated Resident 1 had symptoms of cough and runny nose. The COC indicated Resident 1 tested positive for Covid-19 when a rapid test (testing method that provided a result in 20 minutes or less) was conducted. A review of Resident 1’s Covid-19 PCR ([polymerase chain reaction] laboratory test) result dated 1/19/2024 indicated Covid-19 was detected for Resident 3. During an interview on 1/25/2024 at 1:10 p.m., the Infection Prevention Nurse (IP) stated the facility’s Covid-19 outbreak started on 1/19/2024 and she was not aware it needed to be reported to the CDPH and so, she did not report the outbreak. During an interview on 1/25/2024 at 2:00 p.m., the Director of Nursing (DON) stated, a Covid-19 outbreak needed to be reported to the CDPH. The DON stated reporting the cases of Covid-19 to the CDPH would help the facility to follow guidelines to control and stop the spread the disease. During an interview on 1/25/2024 at 2:45 p.m., the Administrator (ADM) stated the facility’s Covid-19 outbreak should have been reported to the Licensing DO. The ADM stated it was important to report to the DO, so the facility could follow up with the guidelines and keep the residents safe. A review of the facility’s P&P titled, “Infection Prevention and Control Program” dated 10/2022, indicated the facility will establish and maintain an Infection Control Program to provide a safe environment to prevent the development and transmission of disease and infection in accordance with Federal and State requirements. The P&P indicated the facility will notify appropriate Government agencies of reportable contagious or infectious diseases. A review of AFL 23-09 titled, “Coronavirus Disease 2019 (Covid-19) Outbreak Investigation and Reporting Thresholds” dated 1/18/2023 indicated licensed health facilities were required to report outbreaks and unusual infectious disease occurrences to their local health department and to their Licensing and Certification District Office. The facility failed to: 1. Implement its P&P titled, “Infection Prevention and Control Program” which indicated to notify appropriate government agencies of reportable contagious or infectious diseases. 2. Report the facility’s COVID-19 outbreak to the Licensing and Certification DO per AFL 23-09 dated 1/18/2023. As a result, there was a high risk for an increase in COVID-19 cases in the facility, and placed residents, staff, and the community at risk for contracting the COVID-19 virus. This violation had a direct or immediate relationship to the health, safety, or security of residents.