Health inspection·November 28, 2023

F880 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. § 72523(a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 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 10/20/2023, the California Department of Public health (CDPH) received a complaint alleging the facility had 11 COVID-19 (a potentially severe respiratory illness caused by a coronavirus and characterized by fever, coughing, and shortness of breath) positive, symptomatic (when someone has the common symptoms associated with a disease or condition) residents and two COVID-19 positive, symptomatic staff. On 10/25/2023, an unannounced visit was made to the facility to investigate the complaint. The CDPH determined a COVID-19 outbreak (unusual increase in the number of a disease beyond what would normally occur) occurred at the facility on 10/10/2023 The facility failed to: Report a COVID-19 outbreak to the CDPH within 24 hours of the outbreak. This deficient practice resulted in a delay of the CDPH’s investigation of the facility’s COVID-19 outbreak and surveillance of the facility’s infection control practices. This deficient practice placed residents, staff, and visitors at an increased risk of acquiring and further spreading COVID-19. A review of the facility's COVID-19 Positive Residents list and the facility’s COVID-19 Positive Staff list dated 10/2023 indicated:  a. On 10/10/2023 four residents were positive for COVID-19.  b. On of 10/23/2023, there was a cumulative (the total amount of something when it's all added together) total of 18 residents and six staff members who were positive for COVID-19. During an interview on 10/25/2023 at 9:58 a.m., the Infection Preventionist Nurse (IPN) stated the first COVID-19 positive case occurred on 10/10/2023. The IP stated she did not report the outbreak to the district office because she was not working the day the outbreak occurred and thought the Director of Nursing (DON) had reported the COVID-19 cases. During a concurrent interview and record review on 10/25/2023 at 2:45 p.m., with the DON, the All Facilities Letter ([AFL] a letter to licensed facilities containing new updates, enforcements, or general information) 23-08, dated 1/18/2023 was reviewed. The AFL 23-08 indicated outbreaks of any condition should generally be reported to the DO (District Office). The DON stated she was unaware the COVID-19 outbreak should have been reported to the DO as stated in the AFL. A review of the facility’s undated Policy and Procedure (P&P) titled “Infection Control” indicated the facility will report any information regarding infection control to external agencies as required by State and Federal law and regulations. A review of the Requirement to Report Outbreaks and Unusual Infectious Disease Occurrences AFL 23-08 indicated health facilities licensed by the CDPH Licensing and Certification (L&C) were required to report outbreaks and unusual infectious disease occurrences to the local public health and their respective DO. The AFL 23-08 indicated that a facility outbreak of COVID-19 was an example of a reportable incident. The facility failed to: Report a COVID-19 outbreak to the CDPH within 24 hours of the outbreak. This deficient practice resulted in a delay of the CDPH’s investigation of the facility’s COVID-19 outbreak and surveillance of the facility’s infection control practices. This deficient practice placed residents, staff, and visitors at an increased risk of acquiring and further spreading COVID-19. These violations jointly, separately, or in any combination, presented had a direct relationship to the health, safety, or security of patients.