Health inspection·February 9, 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. § 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. The Department received a complaint on 12/20/21 regarding a new COVID-19 (an illness caused by a virus that can easily spread from person to person) outbreak. On 12/21/21, an unannounced complaint investigation was conducted at the facility. The facility failed to implement interventions to prevent and control the spread of the coronavirus disease (COVID-19) per the facility's Mitigation Plan (MP) including but not limited to: 1. Perform N95 respirator (a type of mask worn over the face to cover the nose and mouth that provides respiratory protections against aerosols [a suspension of fine solid particles or liquid droplets in air] and prevent infections) fit testing (a method of ensuring the mask properly fits the face of the wearer to protect from inhaling infectious particles) with the new N95 brands used in the facility for fifty-two (52) out of seventy-four (74) staff members. 2. Ensure certified nursing assistants (CNA) 1 and CNA 2 wore a properly fitted N95 mask, isolation gown (a garment worn to protect the body or clothing from transfer of infectious agents), and gloves while providing direct care to Resident 4 in the yellow zone (an area housing COVID-19 suspected, symptomatic or exposed residents). 3. Screen eight (8) staff members (CNA 3, CNA 4, CNA 5, and CNA 6], activities director [AD], restorative nurse assistant [RNA 1], licensed vocational nurse (LVN) 2 and 3 for COVID-19 sign and symptoms, and risks, including temperature check, before entering the facility. 4. Ensure an unvaccinated resident (Resident 1) and a partially vaccinated (received only one dose and needed another dose of the COVID-19 vaccine) resident (Resident 2) did not attend indoor group activities during a COVID-19 outbreak (presence of least one confirmed COVID-19 resident) in the facility. 5. Screen Resident 3 in the green zone (a designated area for residents who did not have COVID-19) for signs and symptoms of COVID-19 and vital signs, such as heart rate, temperature, respiration rate, and oxygen saturation by pulse oximetry [a test to measure oxygen level in the blood]) and document the screening results and vital signs. As a result, sixty-eight (68) residents in the yellow and green zone residents (16 in the yellow zone and 52 in the green zone), seventy-four (74) staff, and the community were placed at 1 higher risk for COVID-19. a. During an interview on 12/22/2021 at 1:08 p.m., the Infection Preventionist Nurse (IP) stated CNA 7 and Licensed Vocational Nurse (LVN) 1 were both working in the yellow zone. The IP stated CNA 7 and LVN 1 were both using a Brand Name 1 N95 in the yellow zone and had not been fit tested for this N95 brand prior to use. During a concurrent interview and review of the Certified Nurse Assistant staffing sheets with the Director of Staff Development (DSD) on 12/22/2021 at 1:20 p.m., the staffing sheets indicated, 1. CNA 7 worked: in the red zone on 12/20/2021 during the 7 a.m. to 3 p.m. shift (morning [AM] shift), and in the yellow zone on 12/21/2021 during the AM shift. 2. CNA 8 worked in the red zone on 12/20/2021 during the 3 p.m. to 11 p.m. shift (afternoon [PM] shift), and in the red zone on 12/21/2021 and 12/22/2021 during the AM shift. 3. CNA 9 worked in the red zone on 12/21/2021 during PM shift. 4. CNA 10 worked in the red zone on 12/20/2021 during the 11 p.m. to 7 a.m. shift (night or NOC shift), and in the red zone on 12/21/2021 during the night shift. During a concurrent interview and review of the Respirator Training Program Attendance Roster, dated 9/8/2021, 9/10/2021, 9/17/2021, 12/1/2021, and 12/16/2021, with the DSD on 12/22/2021 at 1:20 p.m., the DSD stated she had not been fit tested for over a year with any N95 mask. The DSD stated CNA 7, CNA 8, CNA 9, and CNA 10 had not been fit tested. The DSD stated that these CNAs (CNA 7, CNA 8, CNA 9, and CNA 10) were not wearing properly fitted N95 masks while providing direct care to residents in the yellow and red zone as specified on the assignment sheets. During a concurrent interview and review of All Facilities Letter (AFL) 21-37 from the California Department of Public Health dated 9/22/2021, with the IP on 12/22/2021 3:10 p.m., the IP stated after receiving this AFL on 9/22/2021 which indicated a mask manufacturer N95 was defective, the facility decided to use new masks from four different brands and manufacturers. The IP stated all staff started using the masks from the new N95 brands on 9/23/2021 and the defective N95 masks were thrown away. The IP stated after receiving the N95 masks from the new brands, the staff were not fit-tested before they started using the masks. During a concurrent interview and review of the facility's Respirator Training Program Attendance Roster, dated 9/8/2021, 9/10/2021, 9/17/ 2021, and 12/1/2021, with the IP on 12/22/2021 at 3:10 p.m., the IP stated the rosters indicated only eighteen (18) staff out of 74 staff had been fit tested for N95 in 2021 (after 9/22/2021, when the facility started using the new brands of N95). The IP stated 56 staff (including CNA 1 and CNA 2) required N95 fit testing because they were not fit tested for the N95 masks they were using. IP also stated not fit testing the staff could lead to the spread of COVID-19 in the facility and community. The IP stated that the facility's COVID-19 mitigation plan dated 9/17/2021 indicated initial and annual N95 respiratory fit testing should be conducted for all staff per California Division of Occupational Safety and Health (Cal-OSHA). A review of the California Division of Occupational Safety and Health (Cal OSHA) Interim Guidance Interim Guidance for Protecting Workers of Skilled Nursing and Long-Term Care Facilities from Exposure to Coronavirus Disease (COVID-19), dated 5/7/2021, indicated employers must provide and ensure employees use appropriate personal protective equipment and respiratory protection when entering a room or area where a suspected or confirmed COVID-19 resident was located, if the resident was not wearing a mask. Employers would provide employees with a fit-tested N95 mask whenever the employee was in the area where COVID-19 residents were located and that the employer would implement a respiratory protection program to ensure employees were medically evaluated for respirator use, trained and fit-tested. b. During a review of Resident 4's admission record (face sheet), the face sheet indicated the facility admitted Resident 4 on 9/23/2021 with diagnoses including pneumonia (an infection of the lungs), hemiplegia (paralysis on one side of the body), encephalopathy (brain disease), type 2 diabetes (a disorder that results in high blood sugar), and essential hypertension (high blood pressure). During a review of Resident 4's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/29/2021, the MDS indicated Resident 4 had severely impaired cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. The MDS indicated Resident 4 was totally dependent on staff with eating, bed mobility, dressing, transfer, personal hygiene, and toilet use. During an interview and review of the facility census for 12/22/2021 with the Administrator (ADM), on 12/22/2021 at 10:10 a.m., the ADM stated Resident 4 was among the sixteen residents in the yellow zone, who had a potential to be positive for COVID-19. During a concurrent observation and interview with CNA 1 on 12/22/2021 at 1 p.m., CNA 1 was sitting next to Resident 4 in the yellow zone hallway without wearing gloves and a gown while feeding the resident. CNA 1 stated she was not wearing gloves or a gown because gowns and gloves were not allowed in the hallway. CNA 1 stated that when providing direct care to residents in the yellow zone, the staff was supposed to wear full personal protective equipment (PPE) including gown, mask, and gloves. During an interview with Registered Nurse 1 (RN 1) on 12/22/2021 at 1:19 p.m., RN 1 stated CNA 1 was feeding Resident 4 in the yellow zone hallway. RN 1 stated CNA 1 should have worn full PPE including a gown and gloves while rendering direct resident care to prevent the spread of COVID-19 and other infections. During a concurrent observation and interview with CNA 2 on 12/22/2021 at 1:26 p.m., CNA 2 was sitting a few inches away from Resident 4. CNA 2 removed Resident 4's blanket, placed a surgical mask on the resident's face, and adjusted Resident 4's legs in the wheelchair without wearing gloves or gown. CNA 2 stated Resident 4 was in the yellow zone because the resident was exposed to another resident (not identified) who had COVID-19. CNA 2 stated she should have worn gloves and a gown before providing care to Resident 4 to be safe and to help prevent the spread of COVID-19. During a concurrent interview and review of the facility's COVID-19 mitigation plan dated 9/17/2021 with the IP, on 12/22/2021 at 1:56 p.m., the IP stated when providing direct care to residents in the yellow or red zones, staff must wear gowns and gloves to protect themselves and residents as well as prevent the spread of COVID-19 in accordance with the facility's COVID-19 mitigation plan. c. During a concurrent interview and review of the facility's "Staff Weekly Time Sheet and the Healthcare Provider COVID-19 Screening log" with the IP on 12/22/2021 at 1:15 p.m., the IP stated CNA 5 worked on 12/18/2021, 12/20/2021, and 12/21/2021 (3 opportunities to screen) and was not screened for COVID-19 symptoms prior to entering the facility. AD worked on 12/16/2021 (1 opportunity to screen) and was not screened for COVID-19 symptoms prior to entering the facility. RNA 1 worked on 12/16/2021 and 12/18/2021 (two opportunities to screen) and was not screened for COVID-19 symptoms prior to entering the facility. LVNs 2 and 3 worked for four days from 12/16/2021 to 12/19/2021 (eight opportunities to screen) and they were not screened for COVID-19 symptoms prior to entering the facility on all four (4) days. CNA 6 worked on 12/16/2021 (1 opportunity to screen) and was not screened for COVID-19 symptoms prior to entering the facility. CNAs 3 and 4 worked three days from 12/17/221 to 12/19/2021 (6 opportunities to screen) and were not screened for COVID-19 symptoms prior to working those three days. During an interview on 12/22/2021 at 1:15 p.m. with the IP, the IP stated between the eight (8) staff members (CNA 2, CNA 3, CNA 4, CNA 5, CNA 6, RNA 1, LVN 2, LVN 3), there were a total of twenty-one (21) missed opportunities for COVID-19 screening prior to the staff entering the facility. The IP stated that the facility's failure to screen staff could lead to a facility-wide COVID-19 outbreak. During a concurrent interview on 12/22/2021 at 3:03 p.m., the IP stated the MP indicated that all staff should be screened for COVID-19 signs and symptoms prior to entering the facility regardless of vaccination status. d. During a review of Resident 1's face sheet, the face sheet indicated the facility admitted Resident 1 on 7/23/2021 with diagnoses including diabetes, iron deficiency anemia (too few red blood cells in the body), osteoarthritis (joint problem causing pain), abnormalities of gait (a manner or walking) and mobility, and acute kidney failure (when body cannot filter waste from the blood). During a review of Resident 1's MDS dated 9/27/2021, the MDS indicated Resident 1 had intact cognitive skills for daily decision making and was independent in eating. The MDS indicated Resident 1 needed limited to extensive staff assistance with bed mobility, dressing, personal hygiene, transfer, toilet use, and bathing. During a review of Resident 2's face sheet, the face sheet indicated Resident 2 was admitted to the facility on 11/17/2021 with diagnoses including urinary tract infection (infection of the bladder, kidneys), fracture of the tibia (broken shin bone), hypertension, reduced mobility, and history of falling. During a review of Resident 2's MDS, dated 11/24/2021, the MDS indicated Resident 2 had severely impaired cognitive skills for daily decision making. Resident 2 was totally dependent on staff for eating, bed mobility, dressing, personal hygiene, transfer, toilet use, and bathing. During an interview on 12/22/2021 at 10:05 a.m., with the ADM, the ADM stated the facility had a COVID-19 outbreak after a resident's COVID-19 lab test result (Resident 5's) was positive on 12/19/2021. During an interview and review of the facility's resident vaccination log on 12/22/2021 at 10:45 a.m., with the IP, the IP stated Resident 1 was not vaccinated, and Resident 2 was only partially vaccinated against COVID-19. During a concurrent interview and review of facility's log of activities on 12/22/2021, at 11:06 a.m., with the AD, the AD stated Resident 1 attended a group activity on 12/21/2021 at 2:08 p.m., and Resident 2 attended a group activity on 12/20/2021 at 5:16 p.m. The AD stated on 12/21/221 at 1:54 p.m., Resident 2 attended a group activity. During an interview and review of the facility's mitigation plan dated 9/17/2021 with the IP, on 12/22/2021 at 3:20 p.m., the IP stated the facility's mitigation plan indicated the residents in the green zone who were not fully vaccinated could not participate in indoor communal dining and group activities while there was a COVID-19 outbreak in the facility. The IP stated Resident 1 and Resident 2 should not have participated in indoor group activities because they were not adequately vaccinated (did not receive 2 doses of a COVID-19 vaccine) against COVID-19. e. During a review of Resident 3's face sheet, the face sheet indicated the facility admitted Resident 3 on 12/2/2021 with diagnoses including diabete