Health inspection·February 5, 2025

F882 §483.80(b) Infection preventionist The facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's IPCP. The IP must: §483.80(b)(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field. §483.80(b)(2) Be qualified by education, training, experience or certification. §483.80(b)(3) Work at least part-time at the facility; and §483.80(b)(4) Have completed specialized training in infection prevention and control. §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(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. §72523(a) 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. On 1/15/2025 the California Department of Public Health (CDPH) received a complaint alleging the facility had no Infection Preventionist Nurse ([IPN] a healthcare professional who works to prevent the spread of infections in healthcare facilities) and no one was following infection control protocols such as handwashing and disinfecting medical devices. On 1/16/2025 CDPH conducted an unannounced visit to the facility to investigate the complaint allegations. During the investigation the CDPH determined the facility had no designated IPN since 11/2024 and after receiving a report of a resident testing positive for Legionella [bacteria that causes disease such as pneumonia] it was discovered the facility's water management plan (a program that identifies and addresses hazardous conditions in a water system) was not implemented. The facility failed to: 1. Ensure the water management plan team (a group of individuals responsible for overseeing and implementing the facility's water management plan) met regularly to discuss issues related to water management in the facility. 2. Ensure control measures (actions taken in the facility's water systems to limit growth and spread of Legionella which could include adding disinfectant, cleaning, and heating) were acceptable and being monitored, logs and documentation were accessible for review and were discussed amongst the team during meetings. 3. Designate a fulltime IPN to perform IPN responsibilities and duties as indicated by the facility's job description titled "Infection Preventionist (IP)." 4. Ensure the facility followed their Policy and Procedure (P/P), titled" Water Management" revised on 5/23/2023, that indicated the team would meet regularly to review the plan and discuss any issues relating to water management in the facility. 5. Ensure the facility followed their P/P, titled "Water Management Plan for Legionella Control" revised on 7/8/2024, that indicated the Water Management plan would maintain logs and documents to track the regular cleaning and maintenance of the ice machine, packaged terminal air conditioner units, juice management, respiratory therapy equipment, water coolers, eye wash stations, faucet aerator, shower heads, hot water holding tanks, and less frequently used areas. 6. Ensure the facility followed their P/P, titled "Infection Prevention and Control Program Description" revised on 11/8/2024, that indicated the IPN oversees, implements, monitors and maintains the Infection Prevention and Control Program, the IPN must also fulfill the basic regulatory and professional requirements for the role. These deficient practices resulted in a lack of oversight to ensure the facility's water management plan team met regularly to discuss any issues related to the facility's water management to ensure changes that may lead to Legionella growth did not occur and the inability of the facility to determine if there were issues related to the facility's water management program that were recognized and addressed. These deficient practices had the potential for undetected water contamination, delayed response to water born disease outbreaks causing risk of death to all residents and a delay in implementing infection control measures that could lead to the increased risk of infection for all the residents in the facility. A review of a facility email from the local Public Health (PH), dated 11/27/2024, indicated a resident from the facility tested positive for Legionella. During an interview on 1/16/2024 at 2 p.m., and a subsequent interview at 4 p.m., the Regional Management Quality Nurse Consultant (RNC) stated in 11/2024, the facility's fulltime IPN nurse resigned, and she (RNC) was the facility's regional management quality consultant designated to oversee several facilities and to be present onsite as directed by management. The RNC stated the IPN role was being shared between herself and the Director of Staff Development ([DSD] a person who plans, organizes, and teaches educational programs for staff to improve their skills and knowledge). The RNS stated the DSD also had to manage her responsibilities related to her position as a DSD as well as the IPN duties. The RNC stated she was unable to provide documentation to reflect the hours that she spent in direct performance as the facility's IPN after the IPN role was vacated in 11/2024. The RNC stated the IPN duties had not been clearly outlined between herself and the DSD which could cause confusion and delays in implementing infection control measures, including the facility's water management plan. The RNC stated as of 1/15/2025, she had also been acting as the Director of Nursing (DON) after the DON resigned. The RNC stated the facility's P/P indicated the facility must have a dedicated IPN who acts as the resource, educator to staff, collaborator with public health department to implement and oversee the facility's infection prevention and control program. During an interview on 1/16/2024 at 2 p.m., and a subsequent interview at 4 p.m. The Maintenance Supervisor (MS) stated he was aware of the facilities water management plan to prevent waterborne pathogens such as Legionella and stated he periodically flushed the water boiler, checked and cleaned the ice machines and shower heads to ensure the water was safe for the residents. The MS stated he did not have a log to demonstrate how the facility monitored and implemented control measures (processes, procedures, actions that maintain quality within established limits). The MS stated he had not reviewed the tracking logs with the RNC, DSD or the Administrator (ADM), and he was not aware of any team meetings involving the IPN and the ADM where they discussed the facility's water infection risk control assessment. The MS stated a few weeks ago (date unknown), he received an email regarding a Legionella concern from the local Department of Public Health, however, there was no team meeting to discuss the issue. During a concurrent interview and record review, on 1/17/2025 at 3 p.m., with the RNC, the facility's Water Management P/P, revised on 5/25/2023 was reviewed. The P/P indicated the team would meet regularly to review the plan and discuss any issues related to water management in the facility. The RNC stated the P/P indicated the team which included at least the IPN, Director of Nursing (DON), ADM and MS should meet regularly. The RNC stated she could not locate any documentation or notes from meetings held by the team. During a concurrent interview and record review, on 1/17/2025 at 3:15 p.m., with the RNC, the facility's Water Management Plan for Legionella Control, revised on 7/8/2024 was reviewed. The Water Management Plan for Legionella Control indicated the water management plan team members included the ADM, IPN, Medical Director, Maintenance Director/Supervisor, and the DSD. The RNC stated the individuals listed as the team members had all resigned or left the role and the plan had not been revised to reflect the current members of the water management plan team. The RNC stated the current team members had not held a meeting and therefore the team had not reviewed the facility's water infection control risk assessments (a tool used to evaluate water resources, modes of transmission, resident susceptibility, patient exposure, and readiness program). The RNC stated because they did not have a dedicated IPN to provide oversight to the team meetings, the meetings had not occurred which could lead to the facility failing to identify potential risks affecting the facility's water system, which could lead to the proliferation (a rapid increase in numbers) of water borne pathogens (microorganisms or other biological agents that can cause disease in a host organism) resulting in an outbreak (more cases of a disease than expected in a specific area and time period). During a concurrent interview and record review, on 1/17/2025 at 4:15 p.m., with the RNC and the ADM, the facility's Water Management Plan for Legionella Control, revised on 7/8/2024 was reviewed. The Water Management Plan for Legionella Control indicated to ensure the water management program was running as designed and was effective. The facility would use the "X" preventative maintenance program as well as internal facility logs to monitor the implementation of control measures. The ADM stated it was important for the water management plan team to review the logs to ensure the plan was successful and to review any areas that needed to be examined in order to prevent waterborne illness from occurring. The ADM and the RNC stated the water management plan team had not met to review any logs. The Adm stated failure for the team to meet regularly to review the waste infection control risk assessment and logs could result in undetected contamination and outbreaks that could negatively affect the health of the residents. A review of the facility's P/P, titled, "Water Management" revised on 5/23/2023, the P/P indicated the facility would develop and utilize water management strategies using the core elements of a water management plan to reduce the growth and spread of Legionella and other opportunistic water-borne pathogens in facility's water system. The P/P indicated the team would meet regularly to review the plan and discuss any issues relating to water management in the facility. A review of the facility's P/P, titled, "Water Management Plan for Legionella Control" revised on 7/8/2024, the Water Management plan indicated Legionella could grow in the following areas, ice machines, juice machines, packaged terminal air conditioner units (a self-contained unit that heats and cools a room), respiratory therapy equipment (devices that assists residents to breathe), faucet aerators (a screen that screws onto the end of a faucet to reduce water flow and control the stream), shower heads, and eye wash stations. The Water Management plan indicated the facility would maintain logs and documents to track the regular cleaning and maintenance of the following: ice machine, packaged terminal air conditioner units, juice management, respiratory therapy equipment, water coolers, eye wash stations, faucet aerator, shower heads, hot water holding tanks, and less frequently used areas. The Water Management plan indicated the documentation of the activities program was crucial to review, to make improvements that might be necessary on an annual basis. The facility would maintain records of the following in relation to the water management plan: The water management team regular meetings, including the minutes, attendance and roles of the team. The building schematics and description; including its location, age, uses, number of occupants and general visitors. Any changes to the control measures including where critical limits could be monitored to be updated immediately with any changes, confirmatory logs and documentation, what labs, if necessary, would provide water testing, if it became necessary to due legionella pneumonia. The Water Management plan indicated the employees and interested stakeholders would be informed monthly of the facility water management plan regularly, with any changes to the plan and they would be trained and would be accessible to all individuals who needed to participate in the implementation, management, monitoring of the water management program. Communication would be used to identify strategies for improving the water management systems efficiency. A review of the facility's P/P, titled, "Infection Prevention and Control Program Description" revised on 11/8/2024, the P/P indicated the Infection Prevention and Control Program Description was developed to provide staff with a coordinated organizational structure, technical procedures, comprehensive work practices, and evidence-based guidelines to reduce the risk and spread of infectious pathogens. The Infection Prevention and Control Program Description facilitated by a coordinated effort between the facility IPN, ADM, DON, DSD as well as the entire healthcare team. The IPN oversees, implements, monitors and maintains the Infection Prevention and Control Program, the IPN must also fulfill the basic regulatory and professional requirements for the role. A review of the facility's Job Description titled, "Infection Preventionist (IP)" dated 7/2022, the Job Description indicated the position summary as follows : serves as the facility's infection prevention and control officer with oversight of the facility infection prevention and control program, the IP serves as a practitioner, resource, consultant, and facility educator, focusing on the following areas, infection prevention and control activities as outlined in the infection prevention and control program summary, outcome and process surveillance, outbreak management, resident safety employee health. The IP collaborates with teams and individuals to create and sustain infection prevention strategies as well as provide feedback. The IP conducts ongoing quality assurance performance improvement monitoring to insure adherence with organizational standards, evidence-based practice, professional guidelines and state, local and federal regulations. The job description indicated the IP role was full-time equaling 40 hours a week. The facility failed to: 1. Ensure the water management plan team met regularly to discuss issues related to water management in the facility. 2. Ensure control measures were acceptable and being monitored, logs and documentation were accessible for review and were discussed amongst the team during meetings. 3. Designate a fulltime IPN to perform IPN responsibilities and duties as indicated by the facility's job description titled "Infection Preventionist (IP)." 4. Ensure the facility followed their P/P, titled" Water Management" revised on 5/23/2023, that indicated the team would meet regularly to review the plan and discuss any issues relating to water management in the facility. 5. Ensure the facility followed their P/P, titled "Water Management Plan for Legionella Control" revised on 7/8/2024, that indicated the Water Management plan