Health inspection·July 2, 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 5/17/2021, during a Recertification Survey an inspection of the kitchen was conducted. 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 as per facility’s policies and failed to ensure an effective pest control service to prevent and eradicate (destroy/kill) pests, by: 1. Having cockroach (small insects that carry and spread infectious diseases) infestation (presence of an unusually large number of cockroaches [small insects that carry and spread infectious diseases]) and harborage conditions (locations and conditions where pests can live, thrive, reproduce, and feed). 2. Having one of one ice maker machine, located in the kitchen, with buildup matter inside the ice collection bin and throughout the areas in contact with water and ice. As a result, all 75 residents living in the facility and who consumed food including iced water, prepared in the kitchen, were placed at risk of developing food-borne illness (eating live microorganisms, food containing toxins from bacteria), water-borne illnesses (from drinking contaminated ice and water), and vector-borne diseases (diseases that result from an infection transmitted to human by insects such as cockroaches) that could lead to life-threatening complications and death. 1. On 5/17/2021 at 8:30 a.m., during a kitchen observation with the Dietary Supervisor (DS), there was one cockroach on the floor. The DS stated cockroaches showed up occasionally, one at a time. One more cockroach was on the floor and then three more were between the dishwasher counter and a wall. There were five live German cockroaches (a small species of cockroach that can access food items and carry serious diseases) and fecal (bowel movement) spotting in the dishwashing area between the counter and the wall. On 5/17/2021 at 8:58 a.m., during an observation with DS, there were 30 live nymph (baby) cockroaches behind the stove. There were structural cracks and crevices in the walls, around plumbing, and peeling paint on the walls and ceilings. On 5/17/2021 at 10:15 a.m., during an interview with Maintenance Supervisor (MS) and a concurrent review of the most recent pest control company Service Inspection Report dated 4/17/2021, the report indicated no pest was found in the kitchen, dishwashing areas, cookline and dry storage area. The Conditions/Observations section indicated there were cracks and holes along the walls and floorboard and loose wall coverings at the dishwashing area. The Actions section indicated to seal any cracks and holes and repair loose was coverings. The General Comments/Instructions indicated follow-up with possible treatment scheduled on 4/19/2021. There was no report for 4/19/2021. MS stated the pest control technician came monthly and on 4/17/2021, the technician recommended to come on 4/19/2021 but it did not happen. MS stated he did not know why the second visit did not take place. The State Agency (The Department) notified the Los Angeles County Department of Environmental Health (LAC DEH, the agency that approves operation of kitchens [licensing] and conduct periodic kitchen inspections [restaurants, health facilities, any public venue that serves food]) of the facility's kitchen condition. The Environmental Health Specialist (EHS - inspector) report titled, "Official Inspection Report," dated 5/17/2021, and timed at 3:30 p.m., indicated the EHS observed live cockroaches under the ware wash machine drain boards and in the wall that is soaked with water from the ware wash machine (dish washing area). EHS also observed over 10 live baby cockroaches on the floor coming from behind the wet wall at the ware wash machine area and one live medium cockroach running on the wall behind the three-compartment sink near the hanging pots and pans. The EHS closed the facility's kitchen on 5/17/2021 at 4:00 p.m. The EHS report also indicated that cockroaches also spread different forms of gastroenteritis [food poisoning, diarrhea, and other illnesses], plus they carry a number of allergens which may cause people to exhibit skin rashes, watery eyes, sneezing, congestion of nasal passages, and asthma (a respiratory condition in which a person's airways become inflamed which makes it difficult to breathe). A review of the EHS's report titled, "Retail Food Service Inspection Report," indicated inspection date of 5/17/2021 indicated EHS observed a total of 29 live adult and nymph German cockroaches. EHS also observed six ootheca casings (egg sacs of cockroaches). On 5/18/2021 at 9:05 a.m., during an observation of the structural condition of the kitchen and concurrent interviews with DS and Registered Dietitian (RD) Consultant, DS stated cracks and crevices in dishwashing and stove areas were repaired. On 5/18/2021 at 9:33 a.m., Kitchen Staff 1 (KS 1) stated she had observed a cockroach or two recently (did not recall dates) and would kill them and had reported to DS. On 5/19/2021 at 12:04 p.m., during a kitchen observation with DS present, there was one medium live cockroach behind the stove and one dead juvenile (young) cockroach in front of stove. DS confirmed seen the two cockroaches. A review of article from the Los Angeles County Department of Public Health (LAC DPH) titled, "Effective Management of Cockroach Infestation," retrieved on 5/25/2021, indicated the cockroaches may become pests in any structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high enough numbers. When cockroaches that live outdoors come into contact with human excrement in sewers or with pet droppings, they have the potential to transmit bacteria that cause food poisoning if they enter into structures. 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 facility's policy and procedure titled, "Pest Control," revised on 05/2008, indicated "the facility maintains an ongoing pest control program to ensure the building is kept free of insects and rodents. The Maintenance services assist in providing pest control services." A review of facility's contract with the Pest Management Company, dated 1/6/2016, indicated ongoing service for pest night service for kitchen. In the terms and conditions section, the agreement indicated that moisture conditions in and around structures can be conducive to a variety of pests and wood destroying insects. A review of the facility's undated policy and procedure titled, "Sanitation Audit," indicated the RD and/or DS will conduct audit a minimum of once per month or more often if deemed necessary. A form would be competed as specific as possible with comments then review findings with staff and administrator as appropriate. Develop a plan of correction for any problems and follow up within one to two weeks. 2. On 5/17/2021 at 8:43 a.m., during an observation of the ice machine and concurrent interview with DS, there was dark substance underneath the running water and the collection bin had buildup matter of light-yellow color. Upon interview, DS stated maintenance staff cleaned the ice machine monthly. DS stated kitchen staff did not have the manufacturer's guidelines for cleaning and disinfecting the ice machine and they did not open the upper compartment to clean the inner components or the lower bin. DS stated the ice machine was used to provide ice to the residents in the water pitcher at bedside and iced water or drinks with or between meals. DS was not sure who was responsible to ensure the ice machine was in sanitary condition to prevent contamination of the ice and subsequent risk for the resident to develop water-borne illness. On 5/17/2021 at 10:15 a.m., during an interview, Maintenance Supervisor (MS) stated the contracted pest control technician came monthly and last month the technician recommended to come twice a month to treat the cockroach infestation, but this was not implemented. MS also stated he cleaned the ice machine once a month with the last cleaning on 4/22/2021. MS stated he saw a video from the manufacturer on how to clean the ice machine and the process included emptying all the ice from the machine, using a cleaning product, then a disinfectant to run through in the machine's cleaning load, and remove the front panel to put it in the dishwasher. MS stated he did not follow the manufacturer's cleaning and sanitizing recommendations. On 5/17/2021 at 2:56 p.m., during an observation and concurrent interview, MS opened the ice machine upper compartment and removed the stainless-steel cover. There was thick and dark substance buildup on the inner cover (water curtain), lower and upper plastic where ice was produced, and on the water trough. There was black, brown, and pink residue buildup, heavy black substance buildup inside the crevices of the lower section towards the back. MS stated he had never gone that far back into the machine because he could not reach that far and did not know it had to be done. MS stated monthly cleaning was not enough and he could not be sure if it was 100% clean after running the machine with cleaner and sanitizer because he could not see the back section. MS stated he thought it was normal to have buildup and did not know there were professional cleaning services for ice machines. MS stated he had not followed the manufacturer's recommendations for cleaning and disinfecting. On 5/18/2021 at 9:18 a.m., a concurrent interview with RD consultant and a review of a kitchen report dated 9/8/2020 and 4/2/2021 indicated the ice machine was clean. The RD consultant stated the report did not specify an inspection of the ice machine internal components was conducted to ensure cleanliness. The RD Monthly Kitchen Rounds Checklist forms dated 2/17/2021, 3/10/2021, and 4/23/2021, were reviewed with RD consultant. RD consultant verified the checklist form did not include an inspection of the ice machine condition. RD consultant stated she was responsible to ensure staff followed the ice machine manufacturer's cleaning and sanitizing guidelines to prevent ice contamination. A review of the ice machine manufacturer's manual titled, "Maintenance," indicated cleaning and sanitizing of ice machine procedure must be performed a minimum of once every six months ... machine and bin must be disassembled, cleaned, and sanitized. The procedure states to clean all components in the water flow path. All ice produced must be discarded and mineral deposits should be removed from areas or surfaces that are in direct contact with water. Removing the ice machine top cover may allow easier access. Use a soft bristle nylon brush, sponge, or cloth to carefully clean the parts, soak for 5 minutes, then rinse with clean water. While components soaking, use nylon brush or cloth to thoroughly clean the following ice machine areas including side walls, base (area above water trough), evaporator plastic parts(top, bottom, and sides), bin or dispenser and rinse all thoroughly with clean water. Spray a mix of sanitizer and water on all the components and areas without rinsing after. After waiting 20 minutes, the ice machine could be used again. 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 and failed to ensure an effective pest control service to prevent and eradicate (destroy/kill) pests, by: 1. Having cockroach (small insects that carry and spread infectious diseases) infestation (presence of an unusually large number of cockroaches [small insects that carry and spread infectious diseases]) and harborage conditions (locations and conditions where pests can live, thrive, reproduce, and feed). 2. Having one of one ice maker machine, located in the kitchen, with buildup matter inside the ice collection bin and throughout the areas in contact with water and ice. As a result, all 75 residents living in the facility and who consumed food including iced water, prepared in the kitchen, were placed at risk of developing food-borne illness (eating live microorganisms, food containing toxins from bacteria), water-borne illnesses (from drinking contaminated ice and water), and vector-borne diseases (diseases that result from an infection transmitted to human by insects such as cockroaches) th