Other·July 7, 2021

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.

F925 §483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents. On 5/19/2021, an unannounced visit was conducted at the facility to investigate a complaint about infection control. The facility failed to ensure an effective infection prevention and control program, led by the Infection Preventionist [IP] Nurse, to provide a clean, safe, and sanitary kitchen environment in which food was stored, prepared, and served by having: 1. Cockroach (small insects that carry and spread infectious diseases) infestation (presence of an unusually large number of cockroach population) in the kitchen and the employee lounge room. 2. Harborage conditions (locations and conditions where pests can live, thrive [grow strong], reproduce, and feed) such as holes, gaps, cracks, crevices (narrow openings) in the walls and floors, trash on the floor, and grease and grime (layer of dirt) on different surfaces throughout the kitchen. As a result, 99 of 103 residents who received food from the kitchen were placed at risk of food-borne illness (eating live bacteria, food containing toxins from bacteria) and vector-borne diseases (diseases that result from an infection transmitted to human by insects such as cockroaches) from ingesting (drinking/eating) contaminated food and unsanitary food preparation and storage that could lead to life-threatening complications and death. On 5/19/2021 at 12:00 p.m., the Los Angeles County (LAC) Department of Public Health (DPH) Environmental Health (EH) District Surveillance and Enforcement (DSE) Branch (department responsible for ensuring food provided for human consumption is safe and free of contamination) notified the State Agency (SA)about the closure of the facility kitchen due to cockroach infestation. A review of the Environmental Health Specialist 1 (EHS 1 - inspector) Official Inspection Report, dated 5/19/2021, indicated EHS 1 observed: - Three live adult German cockroaches (a small species of cockroach that can access food items and carry serious diseases) on the wall beneath the two-compartment sink, - Cockroach fecal (bowel movement) spotting under the two-compartment sink, - One live adult German cockroach on the floor under the kitchen oven, - One live adult German cockroach and egg attached located within a shelf under the steamtable (where cooked food is held before meal service), - Six live adult German cockroaches under the dishwashing machine drainboard, - One live nymph (baby) German cockroach on the wall under the dishwashing machine, and - One live German cockroach and two dead cockroaches on the floor of the mop sink room. On 5/19/2021, at 2:50 p.m., during an observation of the kitchen the following was found: - Two live adult cockroaches on the floor in the mop sink room (kitchen cleaning supply room), - Cracks on the wall under the dishwashing machine and drainboard, - Damaged base coving throughout the kitchen, - Broken tiles and gaps on the wall under the dishwashing sink, - Cracks in between the tiles (missing grout) on the floor next to stove and the two-compartment sink, - Grease and food debris on the surfaces of walls, - Grease and grime accumulated under the dishwasher machine drainpipes, - Grease and grime covering the garbage disposal, - Trash on the floor under the two-compartment sink, - Grease and grime attached to the drains under the two-compartment sink, - Dirt and grease on the stove control knobs, - Old and dirty dishwashing sponges, - Debris on the meat slicer, and - A block of plywood holding the drainpipe under the two-compartment sink. On 5/19/2021, at 3:15 p.m., during an interview, Infection Preventionist (IP) Nurse stated her role in the kitchen was to make sure staff have good handwashing practices and she checked on refrigerator temperatures and food temperatures. IP Nurse stated she did not monitor the kitchen for presence of pest as that was not her role. IP Nurse acknowledged presence of pest in the kitchen or anywhere in the facility presented infection risks for the residents. On 5/19/2021, at 3:20 p.m., during an interview, District Manager (DM) stated she was overseeing the kitchen because the Kitchen Supervisor (KS) resigned two weeks ago and the new hired KS was off. DM denied seeing cockroaches in the kitchen prior to 5/19/2021 and did not receive report from kitchen staff about cockroach sighting. On 5/19/2021 at 3:30 p.m., during an interview and concurrent observation in the kitchen, Dietary Aid 1 (DA 1) stated in the past few weeks (did not remember dates) she had seen cockroaches in the kitchen and pointed at the two-compartment sink. Upon closer look, underneath the sink there were two nymph (babies) cockroaches on a piece of plywood which was holding the drain in place. DA 1 stated whenever she saw cockroaches, she killed them and notified the KS. On 5/19/2021 at 3:45 p.m., during an interview, Cook 1 stated in the past few weeks (did not remember dates) she had seen cockroaches in the kitchen and had reported the sightings to the KS. On 5/19/2021, at 4:26 p.m., during an interview, DON stated she was not aware there were cockroaches in the kitchen. DON stated the KS would communicate with Maintenance Supervisor (MS) if there were pest issues and would report to pest control company. On 5/19/2021 at 4:42 p.m., during an interview, MS stated the facility had a contract with a pest control company to service monthly and the technician provided the service report after each visit. MS stated he did not review the reports because it was the KS's responsibility. MS stated the Administrator designated staff to conduct daily rounds in the facility including, the kitchen, residents' rooms, and common areas but the rounds did not include monitoring for pests. On 5/19/2021 at 5:29 p.m., an interview with MS and a concurrent review of the monthly pest control Customer Service Report forms from 10/4/2020 to 4/16/2021 was conducted. Each month, the report indicated there were structural concerns such as: - Holes or gaps under the steamtable, on multiple areas of the door frame of the storage closet (mop sink room). - Gaps under the dish machine area. - Missing or loose base coving under the dish area. Each month, the report included the recommendation for the facility to repair the structural concerns to eliminate potential pest harborage and breeding sites. MS stated he was aware of the recommendations to fix the structural problems in the kitchen, but he had not done the repairs yet. On 5/19/2021 at 5:49 p.m., during an interview, Registered Dietitian (RD) consultant stated no food or beverages should be used from the kitchen due to contamination from cockroach infestation. RD consultant stated she conducted monthly sanitation audits in the kitchen and had not seen any cockroaches. On 5/19/2021 at 7:20 p.m., during an interview, DM stated the kitchen did not have a cleaning schedule. On 5/20/2021 at 10:50 a.m., during an interview, Administrator stated there should be a communication log for kitchen staff to report pest sightings. On 5/20/2021 at 12 p.m., during a kitchen observation, there were two live cockroaches in the mop sink room. On 5/20/2021 at 5:20 p.m., during a dinner observation and concurrent interview with RD Consultant, coffee was prepared in the employee lounge area, adjacent to the kitchen. RD consultant stated the coffee was being prepared in the employees' breakroom since the kitchen remained closed. On 5/20/2021 at 5:25 p.m., during an observation of the employees' breakroom adjacent to the kitchen, there were two live cockroaches on the countertop next to the coffee maker. On 5/21/2021 at 11 a.m., during a kitchen observation and concurrent interview with the IP Nurse, there were three live cockroaches, two dead cockroaches, and one live nymph cockroach were observed in the mop sink room. IP Nurse confirmed the cockroaches sighting. On 5/22/2021 at 11:49 a.m., during a kitchen observation and concurrent interview with DON, four dead cockroaches were under the dishwashing area and one dead cockroach by the door of the dry storage area. DON confirmed the cockroaches sighting. On 5/24/2021 at 3:38 p.m., during an interview, the Administrator stated it was the administrator's responsibility to ensure the facility was clean and free from pests. Administrator stated he should have done frequent kitchen rounds and should have had more communication with the kitchen staff and pest control company. A review of the kitchen audit tool titled, "Sanitation Audit Report" dated 5/3/2021, indicated the audit did not include monitoring for presence of pest. A review of the 2017 U.S. Food and Drug Administration Food Code 6-202.15 indicated, insects and rodents are vectors of disease-causing microorganisms (living thing that is too small to be seen with the naked eye) which may be transmitted to humans by contamination of food and food contact surfaces. Food establishment shall be protected against the entry of insects and rodents by filling or closing holes and other gaps along floors, walls, and ceilings; closed, tight fitting windows and solid self-closing tight fitting doors. A review of the 2017 U.S. Food and Drug Administration Food Code 4-402.11 indicated, the inability to adequately or effectively clean areas under equipment could create a situation that may attract insects and rodents and accumulate pathogenic (disease-causing) microorganisms that are transmissible through food. A review of the Centers for Disease Control and Prevention (CDC), Guidelines for Environmental Infection Control in Health Care Facilities, updated on 7/23/2019, indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control included cockroaches found in health-care facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (carrier that transfers an infectious organism from one host to another). A review of the undated job description for KS indicated, "provides leadership, support and guidance to ensure that food quality standards, inventory levels, food safety guidelines and customer service expectations are met. Ensures that established sanitation and safety standards are maintained." A review of the job description for IP Nurse, revised in 2018, indicated the duties and responsibilities included, "Assesses infection prevention areas for improvement and makes recommendations for corrective action. Monitors or oversees infection prevention practices and employee compliance for all departments and personnel." A review of the job description for MS dated 7/19/2012 indicated the MS was responsible and accountable for maintaining the physical plant. A review of the facility's policy and procedures titled, "Infection Prevention Program Overview", revised 2/2018, indicated the goals of the infection prevention program was to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection. A review of the facility's policy and procedures titled, "Preventive Maintenance program," revised in 2010, indicated preventive maintenance was performed according to schedule and in compliance with regulations. A successful preventive maintenance system was dependent on a routine schedule. Areas that required preventive maintenance and on routine schedule were base coving, tiles, and oven. A review of facility's policy and procedures titled, "Pest Control," revised in 2/2018, indicated the purpose of the policy was to provide an environment free of pest with emphasis on the pest control program in kitchens and other areas prone to infestation such as areas of overgrowth in adjoining property. Dining Services Director (Kitchen Supervisor) would coordinate with maintenance to arrange pest control services monthly, or as needed. All food preparation, service, and storage areas would be monitored regularly for any signs of pest. Monitoring of the environment will be done by the facility staff. Pest control problems will be reported promptly to the contractor. A review of facility's policy and procedures titled, "Environment," revised 9/2017, indicated the Dinning Services Director (Kitchen Supervisor) would ensure the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation and a routine cleaning schedule is in place for all cooking equipment, food storage areas and surfaces. All equipment would be routinely cleaned and maintained in accordance with manufacturer's directions. All non-food contact equipment would be clean and free of debris. A review of the facility's policy and procedures titled "Preventative Maintenance Program", revised 12/2010, indicated preventative maintenance is performed according to schedule and in compliance with applicable regulation. The facility failed to ensure an effective infection prevention and control prog