Health inspection·January 8, 2026

REGULATORY VIOLATIONS: F880 Title 42 Code of Federal Regulations §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 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; (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. … (4) A system for recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility. … (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. Title 22 California Code of Regulations §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 11/13/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint about a presumptive healthcare-associated (when a resident had a continuous stay at the skilled nursing facility during the 14 days before onset of symptoms) Legionnaires’ disease (is a severe form of a lung infection called pneumonia caused by Legionella bacteria (naturally found in freshwater, but becomes a health risk when they grow in man-made water systems and the contaminated water is aerosolized - tiny particles suspended in the air, leading to inhalation and causing lung illness) case at the facility. The facility failed to follow its policy and procedure titled, “Infection Prevention and Control Program,” reviewed on 12/28/2023 and 11/6/2025, affecting Resident 1 by failing to: 1. Ensure that a third-party’s (an external company or individual specializing in air and water safety to the facility) recommendations indicated in the Annual Analytical Validation Viable Legionella Bacteria Report (a document that confirms the effectiveness of a facility’s Water Management Program [ongoing plan to control and minimize hazards in building water systems primarily to prevent growth of harmful bacteria such as Legionella bacteria, ensure water safety by identifying risks, assess water systems and implement control measures] in controlling Legionella growth), dated 2/26/2024, 12/9/2024, 1/24/2025, 2/19/2025, and 3/17/2025, were reviewed and followed. These reports indicated that Legionella bacteria were found in the facility’s water system since 2/26/2024; however, the facility failed to act on the findings and failed to implement the recommendations outlined in the report. 2. Ensure the facility’s Water Management Program Water Safety Plan (a comprehensive risk assessment and risk management approach that encompasses all steps in a drinking-water supply chain to identify hazardous conditions and outline steps to minimize the health impact of waterborne pathogens [some bodies of water have microorganisms called pathogens that can cause residents to get sick]) was reviewed and followed when Legionella bacteria were detected at the facility since 2/26/2024. 3. Ensure the Infection Preventionist Nurse (IP Nurse) carried out her (IP Nurse) duties and responsibilities by coordinating and overseeing the facility’s Infection Prevention and Control Program (IPCP – refers to evidence-based practices and procedures that, when applied consistently in health care settings, can prevent or reduce the risk of transmission of microorganisms to residents and health workers) in relation to the Legionella bacteria detected at the facility since 2/26/2024. 4. Ensure the facility identified the areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria (caused by pathogenic microbes [microorganisms that can cause disease in humans] spread via contaminated water). 5. Ensure a communication process was in place for the previous Administrator (Administrator 2) to inform the current Administrator (Administrator 1) of the Legionella bacteria detected at the facility since 2/26/2024 when Administrator 1 took over and started working at the facility on 4/11/2025. As a result, Resident 1 had a Change in Condition (a major decline in a resident’s health status) on 10/25/2025, at 7:37 a.m., including altered mental status (a change in mental function), fever (abnormally high body temperature), shortness of breath, and was found unresponsive (does not respond to activity, touch, sound, or other stimulation). The paramedics (individuals trained to provide emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) arrived at the facility on 10/25/2025, at 7:45 a.m. and transferred Resident 1 to the General Acute Care Hospital (GACH) where Resident 1 underwent a Legionella pneumoniae sputum procedure (a diagnostic test in which a sample of sputum [thick, sticky substance from the lungs] is collected and analyzed in a laboratory for the presence of Legionella bacteria) on 10/25/2025, at 10:46 a.m., which “detected” Legionella bacteria. Resident 1 subsequently died at the GACH on 10/31/2025 at 5:27 a.m. A review of Resident 1’s Admission Record indicated the facility originally admitted Resident 1, a 86-year-old male, on 2/12/2025, and readmitted in the facility on 10/2/2025 with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease that causes air to become trapped in the lungs, making it hard to breathe) and type two (2) diabetes mellitus (DM – a condition where the body does not use insulin [a hormone that regulates blood sugar by helping sugar from food move from the bloodstream into the body's cells for energy] properly to get energy from the food eaten). A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 10/8/2025, indicated that Resident 1 was severely impaired (having significant limitations) in thought processes and required dependent assistance (resident requires total physical or mechanical help) from staff to complete activities of daily living (ADLs – activities such as bathing, dressing, and toileting a person performs daily). A review of Resident 1’s Change in Condition (CIC – major decline in a resident’s health status that will not resolve without interventions) Form, dated 10/25/2025, indicated that Resident 1 was noted with altered mental status, fever, shortness of breath, and was unresponsive. The CIC further indicated that the paramedics arrived on 10/25/2025, at 7:45 a.m. and transferred Resident 1 to the GACH. A review of Resident 1’s Physician’s Order, dated 10/25/2025, timed at 7:59 a.m., indicated to transfer Resident 1 to GACH for further evaluation. A review of Resident 1’s Care Plan Report (a structured and individualized approach that helps clinicians provide effective care for the resident), dated 10/25/2025, indicated that Resident 1 was transferred to GACH for further evaluation due to abnormal vital signs (basic measurements of the body’s essential functions), altered mental status, labored breathing (breathing feels difficult, requiring extra effort), desaturation (a drop in blood oxygen levels below normal) and lethargy (a condition marked by drowsiness and an unusual lack of energy and mental alertness). A review of Resident 1’s GACH record, dated 10/25/2025, indicated the GACH Emergency Department (a medical unit for severe, life-threatening conditions and serious injuries needed immediate care) admitted Resident 1 on 10/25/2025, at 8:05 a.m., presenting with altered mental status and being found unresponsive. The GACH record indicated that on 10/25/2025, at 10:46 a.m., Resident 1 underwent a Legionella pneumoniae sputum procedure, which indicated that Legionella bacteria were “detected.” During an interview on 11/13/2025, at 11:04 a.m., with Maintenance Supervisor (MS) 1, in the facility’s water room, MS 1 stated that the facility’s most recent report titled, “Annual Analytical Validation Viable Legionella Bacteria,” which indicated that Legionella bacteria were present in the facility’s water, was dated 3/2025. MS 1 stated he (MS 1) did not have a copy of the report in his (MS 1) office, but that a copy was kept by the IP Nurse. MS 1 stated that maintenance staff (depending on who was on duty each day) had been performing daily water flushing (the process of running water through the pipes in the water system) in Room 1, Room 2, Room 3, Room 4, Nurse Station 1, Nurse Station 2, Bathtub 1, and Bathtub 2 since 1/2024, based on instructions from the previous Maintenance Supervisor 2 (MS 2). MS 1stated he (MS 1) did not change or rotate any rooms included in the water flushing routine. MS 1 stated there was no documented evidence that the facility implemented additional interventions (other than water flushing) to prevent Legionella bacteria growth, such as replacing the angle stop valves (small valves installed at the “corner” where a water line meets a fixture like under the sink, behind the toilet, or near the water heater), faucets, water supply hoses (used to connect faucets to the water pipes under the sink), or filters (devices that remove impurities by lowering contamination of water using a fine physical barrier). MS 1 further stated he (MS 1) did not have a copy of the facility’s water flow diagram (a visual tool that shows all the water sources and system flow) and was therefore unable to determine where Legionella bacteria or other opportunistic pathogens (an organism that normally does not harm its host but can cause disease especially when the host’s resistance is low) could potentially grow. During an interview on 11/13/2025, at 11:31 a.m., the IP Nurse stated that on 11/12/2025, Public Health Nurse (PHN) 1 e-mailed her (IP Nurse) indicating that the Los Angeles County Department of Public Health’s Acute Communicable Disease Control Program (LACDPH-ACDC) had identified a “presumptive healthcare-associated” Legionella disease case in the facility (Resident 1). During a concurrent interview and record review on 11/13/2025, at 2:02 p.m., with the IP Nurse, the recommended actions from the “Annual Analytical Validation Viable Legionella Bacteria” Reports dated 2/26/2024, 12/9/2024, 1/24/2025, 2/19/2025, and 3/17/2025, and the facility’s “Domestic Water Flushing Log” since 1/2024, were reviewed. The IP Nurse stated that all the results indicated Legionella bacteria had been found in the facility’s water since 2/26/2024. The IP Nurse stated that maintenance staff handled the interventions by performing daily flushing in Room 1, Room 2, Room 3, Room 4, Nurse Station 1, Nurse Station 2, Bathtub 1, and Bathtub 2 and by conducting annual (every year) water testing for Legionella bacteria. During a concurrent interview and record review on 11/13/2025, at 2:31 p.m., with the Director of Nursing (DON), IP Nurse, and MS 1, the recommended actions from the “Annual Analytical Validation Viable Legionella Bacteria” Reports dated 2/26/2024, 12/9/2024, 1/24/2025, 2/19/2025, and 3/17/2025, the facility’s “Domestic Water Flushing Log” since 1/2024, and the facility’s “Water Management Program Water Safety Plan,” dated 2025 (specific month and day not indicated) were reviewed. The IP Nurse stated that the Water Management Program Water Safety Plan indicated to “Isolate the system to minimize exposure of water to patients (residents) as directed by Infection Prevention.” The “Water Management Program Water Safety Plan” indicated to “Isolate” means “Disabling the water supply to the fixture until remediation (act of correcting an error or a fault) has been conducted.” The IP Nurse further stated that the Water Management Program Water Safety Plan indicated to resample the water for Legionella bacteria within five to 10 days after corrective actions were implemented. The DON, IP Nurse, and MS 1 stated that the facility did not follow or act on the recommendations outlined in the “Annual Analytical Validation Viable Legionella Bacteria” Reports dated 2/26/2024, 12/9/2024, 1/24/2025, 2/19/2025, and 3/17/2025, or in the “Water Management Program Water Safety Plan,” dated 2025 and that there was no documented evidence indicating these actions were implemented. During an interview on 11/13/2025, at 3:13 p.m. with Administrator 1, Administrator 1 stated that he (Administrator 1) began working at the facility on 4/11/2025. Administrator 1 stated that MS 1 was responsible for the facility’s Water Management Program. Administrator 1 stated that the water testing company (third party) had been reporting the water test results to the previous administrator (Administrator 2), which was why he (Administrator 1) was not aware of the water test results. Administrator 1 further stated that he (Administrator 1) did not contact the water testing company to inform them that he (Administrator 1) was the new administrator of the facility because no issues had been reported to him (Administrator 1). During a concurrent observation and interview on 11/19/2025, at 10:55 a.m., the facility’s water system in randomly selected residents rooms (Room 7 and Room 8), shower tubs (Bathtubs 3, 4, 5, and 6), Station 1 utility faucet, Station 2 utility faucet, kitchen ice machine, and the beauty shops (Beauty Shop 1 and Beauty Shop 2), was observed with LACDPH-ACDC team (ACDC Medical Doctor (MD) 2, ACDC MD 3, ACDC Team Member 1, ACDC Team Member 2, ACDC Team Member 3, and ACDC Team Member 4) together with the facility’s DON, IP Nurse, and Nurse Consultant. ACDC MD 2 stated that the facility’s water system had a lot of faucets (number of faucets not specified) that were not in use. During an interview with ACDC MD 2 on 11/19/2025, at 12:12 p.m., ACDC MD 2 stated that he (ACDC MD 2) was concerned that the facility’s water system had a lot of “dead leg” (a section of potable [safe to drink] water pipe which contains water that has no flow or does not circulate). During an interview on 11/19/2025, at 3:14 p.m., with the IP Nurse, the IP Nurse stated that her (IP Nurse) responsibility as an IP Nurse regarding monitoring Legionella was to assist the administration and maintenance management with any potential or suspected exposure to Legionella bacteria. She (IP Nurse) reviews the “Annual Analytical Validation Viable Legionella Bacteria” reports with the team, along with the accompanying recommendations. She (IP Nurse) did not carry out her role in managing Legionella, and that there was no documented evidence that the facility developed or implemented a plan to address facility-specific infection control n