Health inspection·January 7, 2026

§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(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 10/15/2025 the California Department of Public Health (CDPH) received a complaint alleging the facility had been in a COVID-19 outbreak since 10/16/2025 with 19 residents and 13 facility staff positive with COVID-19 and on 10/22/2025 the CDPH received a Facility Reported Incident (FRI) reporting two residents tested positive for COVID. On 10/23/2025, CDPH conducted an unannounced visit to the facility to investigate the FRI and complaint allegation. Upon investigation, CDPH determined the facility's COVID-19 outbreak occurred on 10/16/2025 with two residents (Resident 3 and Resident 10) and one facility staff who tested positive for COVID-19. The facility failed to: 1. Ensure CDPH was notified within 24 hours of the facility's Covid-19 outbreak that occurred on 10/16/2025, involving Residents 3, Resident 10 and one facility staff. 2. Follow their Policy and Procedure (/P/P), titled, "COVID-19 Preventions and Control" dated 6/17/2025 that indicated the facility shall follow current guidelines and recommendations for the prevention and control of COVID-19. The Infection Preventionist or Designee will report per Los Angeles County Department of Public Health's COVID-19 Reporting Requirements Health Officer Order CDPH AFLs 23-08 any suspected COVID-19 outbreak. The threshold is reportable to local Public Health and Licensing and Certification District office; Greater than or equal to two facility-acquired COVID-19 cases among residents in seven days. Greater than or equal to one resident case and two or more staff suspect, probable or confirmed COVID-19 cases in staff with epi-linkage and no other more likely sources of exposure for at least two of the cases (investigation and reporting of Healthcare Personnel (HCP) cases only when associated with facility-acquired case(s) in residents) These deficient practices resulted in an increase of Covid-19 positive residents and staff, when as of 10/23/2025 there were 18 residents and 15 staff who were positive for Covid-19, without CDPH knowledge or oversight. These deficient practices had the potential for Covid-19 to continue spreading amongst residents, staff and visitors due to potentially ineffective infection control practices. a. A review of Resident 3's Admission Record (Face sheet) indicated Resident 3 was admitted to the facility on 3/20/2025 with diagnosis including Parkinson's and failure to thrive. A review of Resident 3's Minimum Data Set ([MDS] a resident assessment tool) dated 9/17/2025 indicated Resident 3 was able to make decisions that were reasonable and consistent. A review of Resident 3's SBAR (Situation, Background, Assessment and Recommendation- a communication tool used by healthcare workers when there is a chang in condition among the residents) dated 10/15/2025 indicated Resident 3 was dizzy, had a sore throat and runny nose and tested positive for Covid-19. b. A review of Resident 10's Admission Record (Face sheet) indicated Resident 10 was admitted to the facility on 8/18/2025 with a diagnosis of hypothyroidism During a review of Resident 10's MDS dated 8/24/2025, the MDS indicated Resident 10 was able to make decisions that were reasonable and consistent. A review of Resident 10's SBAR dated 10/15/2025 indicated Resident 10 had no symptoms of a respiratory infection but tested positive Covid-19. A review of an email from the Public Health Nurse (PHN) to the facility's Infection Preventionist Nurse (IPN) and the facility's Administrator (ADM) dated 10/16/2026 and timed at 2:35 p.m., indicated the facility met the criteria for a Covid-19 outbreak because of two or more Covid-19 cases amongst the residents and staff. The email indicated the facility should report the Covid-19 outbreak to CDPH. During an interview on 10/23/2025 at 12:59 p.m., the IPN stated on 10/15/2025, Resident 3 and Resident 10 tested positive for Covid-19 along with the facility's receptionist who tested positive for Covid-19 on 10/16/2025. The IPN stated as of 10/23/2025, there were 18 residents and 15 staff who were positive for Covid-19. The IPN stated the PHN gave the facility guidance to report the Covid-19 outbreak to the State Agency (CDPH) but stated she did not report the incidence to CDPH until 10/22/2025 because she thought the other government entities would be notified including CDPH, once she reported the Covid-19 outbreak to the local public health office. The IPN stated she should have reported the Covid-19 outbreak to CDPH on 10/16/2025 (within 24 hours) of the facility's initial Covid-19 outbreak so CDPH could monitor the facility's infection control procedures and/or practices and their compliance with the PHN's guidance. During an interview on 10/23/2025 at 1:30 p.m., the Director of Nursing (DON) stated the IPN should have followed the guidance of the PHN regarding reporting the Covid-19 outbreak to CDPH because the State agency could investigate the infection control procedure and policies of the facility to determine how effective the facility's monitoring process and efforts of preventing further spread of Covid-19 amongst residents, staff and visitors. During an interview on 10/23/2025 at 1:51 p.m., the ADM stated he and the IPN were aware of the guidance from the PHN on 10/16/2025 regarding the facility's Covid-19 outbreak. The ADM stated the current Covid-19 outbreak was considered an unusual occurrence and the IPN and he should have reported it to CDPH within 24 hours based on the facility's policy and procedure. A review of the facility's P/P, titled "COVID-19 Preventions and Control" dated 6/17/2025 indicated the facility shall follow current guidelines and recommendations for the prevention and control of COVID-19. The Infection Preventionist or Designee will report per Los Angeles County Department of Public Health's COVID-19 Reporting Requirements Health Officer Order CDPH AFLs 23-08 any suspected COVID-19 outbreak. The threshold is reportable to local Public Health and Licensing and Certification District office; Greater than or equal to two facility-acquired COVID-19 cases among residents in seven days. Greater than or equal to one resident case and two or more staff suspect, probable or confirmed COVID-19 cases in staff with epi-linkage and no other more likely sources of exposure for at least two of the cases (investigation and reporting of Healthcare Personnel (HCP) cases only when associated with facility-acquired case(s) in residents). The facility failed to: 1. Ensure CDPH was notified within 24 hours of the facility's Covid-19 outbreak that occurred on 10/16/2025, involving Residents 3, Resident 10 and one facility staff. 2. Follow their P/P, titled, "COVID-19 Preventions and Control" dated 6/17/2025 that indicated the facility shall follow current guidelines and recommendations for the prevention and control of COVID-19. The Infection Preventionist or Designee will report per Los Angeles County Department of Public Health's COVID-19 Reporting Requirements Health Officer Order CDPH AFLs 23-08 any suspected COVID-19 outbreak. The threshold is reportable to local Public Health and Licensing and Certification District office; Greater than or equal to two facility-acquired COVID-19 cases among residents in seven days. Greater than or equal to one resident case and two or more staff suspect, probable or confirmed COVID-19 cases in staff with epi-linkage and no other more likely sources of exposure for at least two of the cases (investigation and reporting of HCP cases only when associated with facility-acquired case(s) in residents) These deficient practices resulted in an increase of Covid-19 positive residents and staff, when as of 10/23/2025 there were 18 residents and 15 staff who were positive for Covid-19, without CDPH knowledge or oversight. These deficient practices had the potential for Covid-19 to continue spreading amongst residents, staff and visitors due to potentially ineffective infection control practices. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security and welfare of Resident 1.