Health inspection·March 12, 2026

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; (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. (4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. California Code of Regulations, title 22, § 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, 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. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (3) Infection control policies and procedures. On 1/26/2026, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding infection control concerns. The facility failed to implement contact isolation precautions when Resident 1 was suspected of having and exhibited signs and symptoms consistent with Clostridiodes Difficile infection (CDI or C. difficile - bacteria that causes severe, diarrhea [loose, watery stools], and inflammation [swelling] of the colon) on 1/18/2026 and subsequently tested positive for CDI on 1/20/2026. The facility failed to: 1. Establish and maintain infection prevention and control when Resident 1, who showed signs and symptoms of CDI on 1/18/2026, shared the same room with Resident 2 and Resident 3. Resident 2 was immunocompromised due to a diagnosis of diffuse large B-cell lymphoma and actively undergoing antineoplastic chemotherapy (the use of medication designed to treat cancer by inhibiting or killing rapidly dividing malignant cells). 2. Identify care needs based upon infection risk assessments (assessments of risk factors that place residents at higher risk for infections) for Resident 2 and Resident 3 before cohorting (an infection control strategy that involves grouping residents together based on their infection status to prevent the spread of illness to healthy residents) them with Resident 1 who was suspected with CDI on 1/18/2026 and tested positive for CDI on 1/20/2026. 3. Develop adequate infection risk interventions for Resident 2 and implement Resident 2's care plan, which indicated that Resident 2 is at high risk for infection secondary to immunocompromised status and Resident 2 is at risk for nosocomial infection. 4. Ensure the facility performed monitoring of Residents 2 and 3 for signs and symptoms of CDI after their roommate, Resident 1, was suspected with CDI on 1/18/2026 and tested positive for CDI on 1/20/2026. 5. Follow the facility's policy and procedure (P&P) titled, "Clostridium Difficile," with revised date of 10/2018 and last review date of 8/15/2025, indicating, "Residents with diarrhea associated with C. difficile (i.e. [an abbreviation for the Latin phrase id est, which translates to "namely"], residents who are colonized [when someone has germs on or in their body but does not have symptoms of an infection] and symptomatic [exhibiting symptoms]) are placed on contact precautions. Residents with diarrhea and suspected CDI are placed on contact precautions while awaiting laboratory results." 6. Follow facility's P&P titled, "Isolation (separating residents with contagious or infectious diseases from others to prevent spreading) - Categories of Transmission-Based Precautions (measures implemented in addition to standard precautions [basic level of infection control] for residents known or suspected to be infected with highly transmissible pathogens [tiny organisms that can make you sick if they get inside your body])," revised date of 9/2022 and last review date of 8/15/2025, indicating, "The individual on contact precaution is placed in a private room if possible. If a private room is not available, the infection preventionist will assess various risks associated with other resident placement options (e.g. [an abbreviation for the Latin phrase exempli gratia, which means "for example"], cohorting, placing with a low risk roommate). Staff and visitors wear gloves (clean, non-sterile) when entering the room.... Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room...." As a result, there was a potential for Resident 1, who was infected with CDI, to transmit the infection (CDI) to Resident 2 (who was immunocompromised) and Resident 3, who were placed in the same room with Resident 1. Transmission of CDI to Resident 2 and Resident 3 could result in serious complications, including severe infection, dehydration, sepsis, hospitalization, or death. A review of Resident 1's Face Sheet (Admission Record), undated, indicated the facility admitted Resident 1, an 83-year-old female, on 1/17/2026 with diagnoses including other pulmonary embolism without acute cor pulmonale (indicates a blockage in the pulmonary arteries by a blood clot reducing blood flow but not severe enough to cause right heart failure) and sepsis. The Face Sheet indicated Resident 1 had a diagnosis of enterocolitis (inflammation of both the small intestines and colon, causing symptoms like severe diarrhea, abdominal pain, fever, vomiting, and dehydration) due to CDI with onset date of 1/20/2026. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/24/2026, indicated Resident 1's cognitive functioning was intact. The MDS indicated Resident 1 was "dependent" on staff for eating, oral hygiene, toileting hygiene, showering/bathing self, upper body dressing, lower body dressing, and putting on/taking off footwear. A review of Resident 1's Change in Condition (COC) Evaluation form, dated 1/20/2026 timed at 11:30 a.m., indicated Resident 1 had CDI with onset of symptoms on 1/18/2026. The COC form indicated Resident 1 met the following criteria for CDI: Diarrhea: three or more liquid or watery stools above what is normal for the resident within a 24-hour period and a stool sample yields a positive laboratory test result for CDI. The COC indicated the facility placed Resident 1 on contact isolation on 1/20/2026. A review of Resident 1's Order Summary Report, dated 1/18/2026, indicated that the physician ordered a stool sample to be collected from Resident 1 for testing of CDI as soon as possible (ASAP). A review of Resident 1's Order Summary Report, dated 1/20/2026, indicated that the physician ordered Resident 1 to be placed on contact isolation for CDI (positive result) for a duration of 21 days. A review of Resident 1's care plan titled "Clostridium Difficile", with date initiated on 1/20/2026, indicated Resident 1 had CDI, and included interventions specifying that facility staff will place Resident 1 on contact isolation precaution. A review of Resident 1's Laboratory Results Report, dated 1/21/2026, indicated that a stool sample was collected from Resident 1 on 1/20/2026 at 3:41 a.m., received by the laboratory on 1/20/2026 at 11:56 p.m., and reported on 1/21/2026 at 3:38 a.m. The results indicated that Resident 1 tested positive for CDI. During an observation on 1/26/2026 at 9:30 a.m., in Resident 1's room, Resident 1 was observed sharing the same room with Resident 2 and Resident 3, with an isolation cart positioned outside the room and a contact precaution sign posted. A review of Resident 2's Face Sheet, undated, indicated the facility originally admitted Resident 2, a 77-year-old female, on 6/20/2019 and readmitted on 11/11/2025, with diagnoses including diffuse large B-cell lymphoma, encounter for antineoplastic chemotherapy, and acquired absence of kidney (two bean-shaped organs responsible for filtering waste, toxins and excess water from the blood). A review of Resident 2's MDS, dated 11/18/2025, indicated Resident 2's cognitive functioning was intact. The MDS indicated Resident 2 needed substantial/maximal assistance (helper does more than half the effort with helper lifting or holding trunk or limbs and providing more than half the effort) from staff with toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. A review of Resident 2's COC, dated 1/27/2026, timed at 6 p.m., indicated Resident 2 was at risk for nosocomial infection (infections acquired in hospitals or healthcare facilities that were not present at the time of admission). A review of Resident 2's care plan titled "Risk for Infection", with date initiated on 1/27/2026, indicated that Resident 2 is at high risk for infection secondary to immunocompromised status and Resident 2 is at risk for nosocomial infection. The care plan indicated that facility staff will perform hand hygiene (process of cleaning one's hands with soap and water or using alcohol-based hand sanitizers to prevent the spread of infectious diseases), wear gowns and gloves while performing high contact activities. A review of Resident 3's Face Sheet, undated, indicated the facility originally admitted Resident 3, a 78-year-old female, on 11/27/2024 and readmitted on 12/11/2025 with diagnoses including other hypertrophic cardiomyopathy (a genetic condition where the heart muscle thickens but does not physically block blood flow out of the heart), chronic kidney disease (long-term, progressive loss of kidney function), type 2 diabetes mellitus (DM - chronic disorder characterized by high blood sugar caused by the body's inability to produce or effectively use insulin [hormone that regulates blood sugar]), depression, and anxiety disorders. A review of Resident 3's MDS, dated 12/16/2025, indicated Resident 3 had moderate cognitive impairment (involves noticeable memory, language, or thinking problems that exceed normal aging but do not yet severely disrupt daily independence). The MDS indicated Resident 3 needed substantial/maximal assistance from staff with toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. During an interview on 1/26/2026 at 10:15 a.m., with Resident 3, Resident 3 stated she (Resident 3) did not understand why her room was on isolation. When she (Resident 3) asked the nursing staff (did not specify) for an explanation, she (Resident 3) was not provided with any information regarding the reason for the isolation. During a concurrent observation and interview on 1/26/2026 at 11:30 a.m., with Resident 2, in Resident 1's (shared) room, observed Resident 1 still sharing the room with Resident 2 and Resident 3. Resident 2 stated that she (Resident 2) was unaware why an isolation sign was posted on the door and was concerned because she (Resident 2) has a tumor and is receiving chemotherapy. She (Resident 2) asked the nurses and nurse assistants (did not specify) why they were wearing gowns while caring for Resident 1 but was told it had nothing to do with her and not to worry. Resident 2 stated that she continued to express her (Resident 2) concern because she Resident 2) is aware that her immune system (the organs and processes of the body that provide resistance to infection and toxins) is compromised. During an interview on 1/26/2026 at 2 p.m. with the Infection Preventionist Nurse, the Infection Preventionist Nurse stated that the physician (MD 1) ordered a laboratory test for Resident 1 on 1/18/2026 because he (MD 1) had a suspicion that Resident 1 might be positive for CDI. Resident 1 was not placed on isolation precautions when the CDI test was ordered on 1/18/2026. The Infection Preventionist Nurse stated that because Resident 1 was not on contact precautions, there was an increased risk of transmitting the infection to other residents and staff. Resident 2 should not have been sharing a room with Resident 1, as Resident 2 is immunocompromised and therefore at higher risk for infection. The Infection Preventionist Nurse stated that an infection in Resident 2 could result in severe complications, including hospitalization or death, due to an inability of Resident 2's immune system to effectively respond to infection. During a telephone interview on 1/28/2026 at 12 p.m., with the Medical Director, the Medical Director was asked about Resident 1, who had CDI, sharing a room with Resident 2 and Resident 3. The Medical Director stated that facility staff were aware of the appropriate infection control measures but failed to implement them. Staff should have followed facility policy and Centers for Disease Control and Prevention guidelines and should not have cohorted Resident 1 with residents who had high-risk conditions and diagnoses, including Resident 2, who was immunocompromised. The Medical Director stated Resident 1 should not have been placed in the same room as Resident 2, who was highly vulnerable, and stated that there was no excuse for this failure. During an interview on 1/30/2026 at 12:45 p.m., with the Infection Preventionist Nurse, the Infection Preventionist Nurse stated that the facility did not follow its policy on CDI because Resident 1, who was positive for CDI, was cohorted with Resident 2, who was immunocompromised. During a concurrent interview and record review on 1/30/2026 at 2:04 p.m., with the Director of Nursing (DON), Resident 2 and Resident 3's Infection Risk Assessment records from 1/17/2026 to 1/30/2026 were reviewed. The DON stated that there was no documented evidence that infection risk assessments were completed for Residents 2 and 3. The facility should have cohorted residents correctly based on infection risk assessments and the suitability of potential roommates. The DON further stated that the infection risk assessments should have been completed by the Infection Preventionist Nurse or in their absence, by a licensed nurse to determine whether Residents 2 and 3 were appropriate roommates for Resident 1, who had CDI infection, prior to cohorting the residents. The failure to complete these Infection Risk Assessments placed Residents 2 and 3 at increased risk for transmission of CDI. During a concurrent interview and record review o