Health inspection·February 16, 2022

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 §483.70(e) 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 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 § 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. On 1/10/2021, the California Department of Public Health made an unannounced visit to the facility to conduct a complaint investigation about infection control. The facility failed to provide a safe, sanitary environment to help prevent the spread of infections for Coronavirus Disease 2019 (COVID-19 - a highly contagious respiratory illness in humans capable of producing severe symptoms and even death) in accordance with the facility's Mitigation Plan policy (MP- a plan to reduce loss of life and impact of COVID-19 in the facility) for 53 of 53 residents who resided in the facility by failing to ensure a confirmed COVID-19 positive staff (Activities Director [AD]) did not provide direct care to green zone residents (residents who have recovered or are clear of COVID-19) nor maintain separation from other staff. As a result, there was an increased risk of spreading COVID-19 infections to all residents in the facility. A review of the facility's census dated 1/12/2022 indicated facility had 53 in house. During a concurrent observation and interview on 1/12/2022 at 10:10 a.m., the Activity Director (AD) was observed in the facility's green zone area. During a follow up interview with the AD, AD confirmed that she was in the facility green zone and indicated that she was there diluting a sanitizing solution. During a concurrent observation and interview on 1/12/2022 at 10:15 a.m., the AD was observed in her office with the Dietary Supervisor (DS). AD confirmed the observation of being in her office with DS and further stated that her duties include ensuring residents are provided with activities such as playing board games. During a concurrent observation and interview on 1/12/2022 at 10:50 a.m., AD was observed inside her office with DS. AD confirmed the observation of being in her office with DS. AD further stated that she was made aware of her COVID-19 positive status on 1/10/2022 at around 2:00 p.m. AD stated that she was allowed to continue to work by the ADM because she was asymptomatic (without symptoms). When asked if AD maintained separation from residents that were negative of COVID-19, AD stated that on 1/11/2022 she was in direct contact with residents who resided in the facility's green zone when she provided activities (board game) to them. During a concurrent interview and record review on 1/12/2022 at 11:40 a.m., the facility staff COVID-19 positive results with collection date of 1/4/2022 was reviewed. DON stated that there was a total of three COVID-19 confirmed positive staff. DON stated that AD was tested on 1/4/2022 and that the facility received the positive results on 1/10/2022. The DON stated that AD continued to work throughout the facility. During an interview on 1/12/2022 at 11:33 a.m., Administrator stated that when he was made aware that the AD was COVID-19 positive on 1/10/2022, he informed her that she can remain at work provided she stay in her office by herself and not go to the other units to prevent exposing other staff and residents to COVID-19. When the ADM was asked if he attempted to contact any other activity staff to cover for the AD after finding out she was COVID-19 positive, ADM stated he did not. A review of facility's policy and procedure titled "COVID-19 Mitigation Plan-Infection Prevention and Control" with revised date of 8/1/2021, indicated that health care providers who test positive for COVID-19 and are asymptomatic can continue to work as long as they are only caring for residents with confirmed COVID-19 and maintain separation from other health care providers as much as possible. The facility failed to provide a safe, sanitary environment to help prevent the spread of infections for Coronavirus Disease 2019 (COVID-19 - a highly contagious respiratory illness in humans capable of producing severe symptoms and even death) in accordance with the facility's Mitigation Plan policy (MP- a plan to reduce loss of life and impact of COVID-19 in the facility) for 53 of 53 residents who resided in the facility by failing to ensure a confirmed COVID-19 positive staff (Activities Director [AD]) did not provide direct care to green zone residents (residents who have recovered or are clear of COVID-19) nor maintain separation from other staff. As a result, there was an increased risk of spreading COVID-19 infections to all residents in the facility. The above violations had a direct or immediate relationship to the health, safety, or security of the residents in the facility.