Health inspection·February 5, 2025

42 CFR §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 §483.70(e) 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. 22CCR § 72321. Nursing Service -Patients with Infectious Diseases. (b) The facility shall adopt, observe, and implement written infection control policies and procedures. These policies and procedures shall be reviewed at least annually and revised as necessary. 22CCR §72523- Patient Care Policies and Procedures (b) All policies and procedures required of these regulations shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (3) Infection control policies and procedures. 22CCR § 72537 Reporting Communicable Diseases All cases of reportable communicable diseases shall be reported to the local health officer. 22CCR § 72539 Reporting of Outbreaks Any outbreak or undue prevalence of infectious or parasitic disease or infestation shall be reported to the local health officer. 22CCR §72541- Unusual Occurrences Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. On 12/31/2024, the California Department of Public Health (CDPH) received a complaint indicating a coronavirus (COVID-19, a highly contagious respiratory infection caused by a virus that could easily spread from person to person) outbreak (a sudden rise in the incidence of a disease criteria) in the facility, with 24 COVID positive residents. On 1/6/2025, the CDPH conducted an unannounced visit at the facility to investigate the allegation. The facility failed to: 1. Report the total of 21 COVID-19 positive cases to the CDPH as indicated in the facility's policy and procedure (P&P) titled, "COVID-19 Facility Mitigation Management Plan," which indicated the facility will report data pertaining to COVID-19 to CDPH no later than 12 p.m., daily via online the survey tool. As a result, there was a risk for an increase in COVID-19 cases in the facility, and placed all residents, staff, and the community at risk for contracting the COVID-19 virus. A review of Resident 1's COVID-19 test result, dated 12/13/2024, indicated a positive result for SARS-COV-2 antigen (a protein found in the SARS-CoV-2 virus that can be detected using a COVID-19 rapid antigen test). A review Resident 2's COVID-19 test result, dated 12/13/2024, indicated a positive result for SARS-COV-2 antigen. A review Resident 3's COVID-19 test result dated 12/13/2024, indicated a positive result for SARS-COV-2 antigen. A review Resident 4's COVID-19 test result dated 12/16/2024, indicated a positive result for SARS-COV-2 antigen. A review Resident 5's COVID-19 test result dated 12/13/2024, indicated a positive result for SARS-COV-2 antigen. A review Resident 6's COVID-19 test result dated 12/13/2024, indicated a positive result for SARS-COV-2 antigen. A review Resident 7's COVID-19 test result dated 12/13/2024, indicated a positive result for SARS-COV-2 antigen. A review Resident 8's COVID-19 test result dated 12/13/2024, indicated a positive result for SARS-COV-2 antigen. A review Resident 9's COVID-19 test result dated 12/13/2024, indicated a positive result for SARS-COV-2 antigen. A review Resident 10's COVID-19 test result dated 12/13/2024, indicated a positive result for SARS-COV-2 antigen. A review Resident 11's COVID-19 test result, dated 12/16/2024, indicated a positive result for SARS-COV-2 antigen. A review Resident 12's COVID-19 test result, dated 12/16/2024, indicated a positive result for SARS-COV-2 antigen. A review Resident 13's COVID-19 test result, dated 12/16/2024, indicated a positive result for SARS-COV-2 antigen. A review Resident 14's COVID-19 test result, dated 12/17/2024, indicated Coronavirus was detected. A review Resident 15's COVID-19 test result dated 12/17/2024, indicated Coronavirus was detected. A review Resident 16's COVID-19 test result dated 12/17/2024, indicated Coronavirus was detected. A review Resident 17's COVID-19 test result dated 12/17/2024, indicated Coronavirus was detected. A review Resident 18's COVID-19 test result dated 12/20/2024, indicated Coronavirus was detected. A review Resident 20's COVID-19 test result dated 12/20/2024, indicated Coronavirus was detected. A review Resident 23's COVID-19 test result dated 12/20/2024, indicated Coronavirus was detected. A review Resident 24's COVID-19 test result dated 12/20/2024, indicated Coronavirus was detected. A review of Residents 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 "Medical Provider Report of COVID-19 Laboratory Results," dated 12/15/2024, indicated the facility faxed the results to the Acute Communicable Disease Control Agency (ACDC, a public health agency that investigates and monitors communicable diseases) on 12/15/2024. The report did not indicate Residents 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 documentation the COVID-19 positive results were reported to CDPH. During a telephone interview on 1/6/2025 at 3:55 p.m., with the Infection Prevention Nurse (IP), the IP stated she (IP) did not report to the District Office (DO) Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 20, 23, and 24's COVID-19 positive test results. The IP stated she was unaware that COVID-19 outbreak was supposed to be reported to the DO. The IP stated the DO was unaware of the severity of the COVID-19 outbreak in the facility. During a telephone interview on 1/14/2025 at 8 :50 a.m., with the Public Health Nurse (PHN), the PHN confirmed the facility had COVID 19 outbreak. The PHN stated she spoke with the IP nurse and instructed her to report the outbreak to the CDPH. A review of the facility's P&P titled, "COVID-19 Facility Mitigation Management Plan," dated 01/2024, indicated it is the policy of this facility to protect the residents, staff and others who may be in the facility from harm during emergency events. The P&P indicated; the facility reports data pertaining to COVID-19 to California Department of Public Health, no later than 12 p.m. daily, including Saturday and Sunday, via online survey tool, the number of confirmed positive COVID-19 patients and number of suspected COVID-19 patients. A review of the All Facilities Letter ([AFL] a letter from the Center for Health Care Quality (CHCQ), Licensing &Certification (L&C) Program to health facilities that are licensed or certified by L&C with information including changes in requirements in healthcare, enforcement, new technologies, scope of practice, or general information that affects the health facility) 23-08, dated 1/18/23, indicated licensed healthcare facilities will report outbreaks and unusual infectious disease occurrences to their Local Health Department and L&C DO. The facility failed to: 1). Report the total of 21 COVID-19 positive cases to the CDPH as indicated in the facility's P&P titled, "COVID-19 Facility Mitigation Management Plan," which indicated the facility will report data pertaining to COVID-19 to CDPH no later than 12 p.m., daily via the online survey tool. As a result, there was a risk for an increase in COVID-19 cases in the facility, and placed all residents, staff, and the community at risk for contracting the COVID-19 virus. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.