Health inspection·November 6, 2023

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. (iii) Standard and transmission-based precautions to be followed to prevent spread of infections. 22CCR § 72321. Nursing Service -Patients with Infectious Diseases. (a) Patients with infectious diseases shall not be admitted to or cared for in the facility unless the following requirements are met: (1) A patient suspected of or diagnosed as having an infectious or reportable communicable disease or being in a carrier state who the attending officer determines is a potential danger, shall be accommodated in a room, vented to the outside, and provided with a separate toilet, hand-washing facility, soap dispenser and individual towels. (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 in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public 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 §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. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. On 9/21/2023, the California Department of Public Health (CDPH) received a complaint indicating two positive residents’ cases of the corona virus (COVID-19, a highly contagious infection that easily spreads from person to person) which met the COVID-19 outbreak (a sudden rise in the incidence of a disease criteria). On 9/27/2023, the CDPH conducted an unannounced visit at the facility to investigate the COVID-19 outbreak. The facility failed to: 1. Implement interventions for infection prevention and control for Resident 1, who was positive for COVID-19. Resident 1 walked out of her isolation room, grabbed a cup from the top of the facility's medication cart and touched other clean medical supplies on the left side of the medication cart performing hand hygiene. 2. Implement its policy and procedure (P&P) titled “Isolation Precautions” which indicated the facility would take appropriate precautions to prevent transmission of infectious agents, when three COVID-19 positive residents (Residents 1, 2, and 3) co-mingled with five COVID-19 negative residents (Residents 4, 5, 6, 7, and 8) who were smoking in the patio. 3. Report the facility’s COVID-19 positive cases to the Department of Public Health Licensing and Certification (CDPH). As a result, there was a high risk for an increase in COVID-19 cases in the facility, and placed residents, staff, and the community at risk for contracting the COVID-19 virus. 1. A review of Resident 1's Face Sheet (admission record), dated 9/1/2023, indicated Resident 1, a 30-year-old resident, was originally admitted to the facility on 6/26/2023 and readmitted on 8/31/2023 with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities). A review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 7/7/2023, indicated Resident 1 could understand and be understood by others. The MDS indicated Resident 1 required supervision for all activities of daily living such as bathing, dressing and toilet use. A review of Resident 1's Situation Background Assessment and Recommendation (SBAR) report, dated 9/17/2023, indicated Resident 1 had symptoms of COVID-19 on 9/13/2023 such as headache and sore throat and Resident 1 tested positive for COVID-19 on 9/17/2023. A review of Resident 1’s care plan titled, COVID-19 dated 9/17/23, indicated Resident 1 was on contact and droplet precautions. The care plan interventions indicated staff would monitoring the resident frequently. During a concurrent interview and review with a Licensed Vocational Nurse (LVN 1), on 9/26/2023 at 8:25 a.m., the facility’s census dated 9/26/2023 was reviewed. LVN 1 stated the facility had a total of 169 residents. During a concurrent observation and interview with the Assistant Infection Preventionist (AIP) nurse on 9/26/2023 at 12:06 p.m., a yellow, plastic, waist-high (safety barrier) barrier was observed in the hallway separating the back of the hallway from the rest of the facility. A medication cart was observed in the front area of the hallway. Resident 1, who was a COVID- 19 positive resident, came out of her room, moved the safety barrier, walked to the front area of the hallway, and grabbed a cup from the medication cart. Resident 1 then went back behind the barrier to her room without the AIP nurse’s intervention. The AIP nurse stated Resident 1 was not supposed to come out of her room because the resident was positive for COVID-19. The AIP nurse stated the COVID-19 positive residents were supposed to stay in their rooms and facility staff was supposed to redirect COVID-19 positive residents back to their rooms. The AIP stated, she did not redirect Resident 1 back to her room and it might lead to the spread of COVID-19 in the facility. During an interview with the Director of Nurses (DON) on 9/27/2023 at 4:04 p.m., the DON stated Resident 1, a COVID-19 positive resident, who went out of the barrier and touched the medication cart exposed other residents and staff to COVID-19. 2. During a concurrent observation and interview on 9/27/2023 at 11:33 a.m. with the DON and AIP nurse in the smoking patio, eight (8) residents were observed smoking. The DON stated out of the 8 residents, Residents 1, 2, and 3 were COVID-19 positive and Residents 4, 5, 6, 7, and 8 were negative for COVID 19. The DON stated the COVID-19 residents should not have been allowed to smoke at the same time with COVID-19 negative residents, to prevent the spread of infection. During an interview with the AIP nurse and DON on 9/27/2023 at 11:53 a.m., the AIP nurse stated the COVID-19 positive residents (Residents 1, 2, and 3) were isolated in Hallway 2 and were not supposed to cross over to another hallway (Hallways 3, 4 and 5). The AIP nurse stated Residents 1, 2 and 3, were noncompliant and could spread the virus to non-COVID-19 residents. The AIP nurse stated COVID-19 could cause severe breathing problems, hospitalization, and death. During a telephone interview on 9/29/2023 at 11:00 a.m., the Public Health Nurse (PHN), stated while waiting for the COVID-19 Polymerase chain reaction ([PCR] a more sensitive test that can detect small amounts of the virus that the antigen test could not detect) test residents who have been exposed to the COVID-19 virus, must wear a surgical mask when out of their rooms. The PHN stated, COVID -19 negative and COVID -19 positive residents should be separated and should not be smoking together in the patio to prevent the spread of the COVID -19 virus. a. A review of Resident 2's Face Sheet, dated 9/26/2023, indicated Resident 2, a 47-year-old resident, was admitted to the facility on 5/6/2022 and readmitted on 9/27/2022 with diagnoses including chronic obstructive pulmonary disease [(COPD), a group of lung diseases that block airflow and make it difficult to breathe], schizophrenia, and anxiety disorder. A review of Resident 2's H&P, dated 9/15/2023, indicated Resident 2 could make needs known but could not make medical decisions. A review of Resident 2's MDS, dated 8/11/2023, indicated Resident 2 had an intact cognition. The MDS indicated Resident 2 required supervision for all activities of daily living. A review of Resident 2's SBAR report, dated 9/19/2023, indicated Resident 2 tested positive for COVID-19 on 9/19/2023. A review of Resident 2’s COVID-19 care plan dated 9/24/22, indicated Resident 2 was positive for COVID-19 and the resident was noncompliant with wearing a facemask. The care plan interventions indicated to observe infection prevention and control at all times and avoid outdoor activity and encourage resident to social distance as much as possible. b. A review of Resident 3's Face Sheet, dated 9/26/2023, indicated Resident 3, a 72-year-old resident, was admitted to the facility on 5/12/2023 with diagnoses including metabolic disorder (disorder with the body's metabolism - the ability to turn food into energy and get rid of waste) and schizophrenia. A review of Resident 3's H&P, dated 5/14/2023, indicated Resident 3 had alternating ability to understand and make medical decisions. A review of Resident 3's MDS dated 8/17/2023, indicated, Resident 3's cognition (ability to think and understand) was severely impaired. The MDS indicated Resident 3 required supervision and/or extensive assistance (resident involved in activity, staff provide weight-bearing support) for most activities of daily living. A review of Resident 3's SBAR report, dated 9/19/2023, indicated Resident 3 tested positive for COVID-19 on 9/19/2023. A review of Resident 3’s care plan titled Smoking, dated 5/12/23, indicated Resident 3 needed constant supervision and observation while smoking. A review of Resident 3’s care plan titled, COVID-19, indicated Resident 3 was on contact, droplet and airborne precautions. c. A review of Resident 4's Face Sheet, dated 7/20/2023, indicated Resident 4, a 59-year-old resident, was admitted on 11/22/2022 and re-admitted on 7/18/2023 to the facility with diagnoses including, severe sepsis (is the body's extreme response to an infection) with septic shock (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection) and schizophrenia. A review of Resident 4's MDS, dated 6/1/2023, indicated, Resident 4's cognition was moderately impaired. The MDS indicated Resident 4 required supervision and/or limited assistance (resident involved in activity, staff provide some weight-bearing support) for most activities of daily living. d. A review of Resident 5's Face Sheet, dated 7/11/2023, indicated, Resident 5, a 47-year-old resident, was admitted on 6/27/2023 and re-admitted on 7/6/2023 to the facility with diagnoses including, polyneuropathy (is a condition in which multiple nerves in the body are not working), and major depressive disorder. A review of Resident 5's H&P, dated 7/6/2023, indicated Resident 5 was able to understand and make medical decisions. A review of Resident 5's MDS dated 7/14/2023, indicated, Resident 5's cognition was intact. The MDS indicated Resident 5 required supervision and/or limited assistance for most activities of daily living." e. A review of Resident 6's Face Sheet, dated 6/28/2023, Resident 6, a 63-year-old resident, was admitted on 9/8/2021 and re-admitted on 6/23/2023 to the facility with diagnoses including, chronic obstructive pulmonary disease and schizophrenia. A review of Resident 6's H&P, dated 6/23/2023, indicated, Resident 6 did not have the ability to understand and make medical decisions. A review of Resident 6's MDS dated 8/17/2023, indicated, Resident 6's cognition was intact. The MDS indicated Resident 6 required supervision and/or limited assistance for most activities of daily living. f. A review of Resident 7's Face Sheet, dated 9/1/2023, indicated, Resident 7, a 70-year-old resident, was admitted on 8/24/2020 and re-admitted on 6/23/2021 to the facility with diagnoses including, hypertensive heart disease (high blood pressure) and paranoid (is a pattern of behavior where a person feels distrustful and suspicious of other people) schizophrenia. A review of Resident 7's MDS dated 8/15/2023, indicated, Resident 7's cognition was intact. The MDS indicated Resident 7 required supervision and/or limited assistance for most activities of daily living. g. A review of Resident 8's Face Sheet, dated 12/28/2021, indicated, Resident 8, a 50-year-old resident, was admitted to the facility on 6/23/2021 with diagnoses including, type 2 diabetes mellitus (abnormal blood sugar) and schizophrenia. A review of Resident 8's H&P, dated 6/11/2023, indicated, Resident 8 had alternating ability to understand and make medical decisions. A review of Resident 8's MDS dated 8/17/2023, indicated, Resident 8's cognition was mildly impaired. The MDS indicated Resident 8 required limited to extensive assistance for most activities of daily living." A review of the facility's undated P&P, titled "Isolation Precautions," indicated the facility would take appropriate precautions, including isolation, to prevent transmission of infectious agents. The P&P indicated the isolation refers to the practices employed to reduce the spread of an infectious agent and/or minimize the transmission of infection. A review of the facility's P&P, titled "Coronavirus Surveillance," dated 2023, indicated COVID-19 was spread between people less than six feet apart through respiratory droplets when an infected person coughed or sneezed and between people more than six feet apart through airborne transmission in an enclosed space with inadequate ventilation. A review of the COVID-19 Outbreak Notification, dated 9/21/2023, indicated per the Department of Public Health, residents who have confirmed COVID-19 infection should be isolated in the designated COVID-19 isolation area of the facility. A review of the Centers for Disease Control and Protection's recommendation titled, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic," dated 5/8/2023, the recommendation indicated facilities should limit transport and movement of residents outside of the room to medically essential purposes. 3. During an interview on 9/26/2023, at 10:38 a.m., with the AIP nurse, the AIP nurse stated, the facility did not notify the CDPH that the facility had a COVID-19 outbreak.