Health inspection·February 21, 2025

California Code of Regulations, Title 22,  § 72321. Nursing Service -Patients with Infectious (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. (2) There shall be: (A) Separate provisions for handling contaminated linens. (B) Separate provisions for handling contaminated dishes. (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. § 72523. 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. (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. Code of Federal Regulations, Title 42  F880  §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.  An unannounced visit to the facility on 1/24/2025 to investigate an allegation of infection control - COVID-19 noncompliance. The facility failed to implement its policy and procedure on infection prevention and control by failing to:  1. Screen visitors for symptoms of COVID-19 (a highly contagious respiratory disease caused by the SARS-CoV-2 virus) including cough, fever, or headache before entering the facility.  2. Conduct biweekly (twice a week) mass PCR testing (a polymerase chain reaction (PCR) laboratory test used to detect if a person is infected with Covid-19) for all residents and staffs.  3. Allow only 1-2 residents at a time in the rehabilitation room while wearing a facemask and are distanced from each other. 4. Ensure breakrooms do not have extra chairs, has a maximum occupancy of two (2) people sitting across from each other, have a signage reminding staff to change their masks after eating, have an air purifier (a device that removes pollutants and contaminants from the air in a room), facemasks, hand sanitizers, and wipes in the breakroom, and windows cracked open.  These deficient practices resulted to a total of 31 out of 52 residents confirmed with COVID-19 cases in the facility as of 1/23/2025.  During an observation on 1/24/2025 at 1 PM, the facility did not screen visitors for symptoms of COVID-19 before entering the building.  During an interview with the Administrator (ADM) on 1/24/2025 at 12:50 PM, the ADM stated that visitors do not need to be screened for symptoms of Covid-19 and only need to log in and wear a facemask before entering the building.  During an interview with a licensed vocational nurse (LVN) 1 on 1/24/2025 at 1:05 PM, LVN 1 stated that they do not screen visitors who enter the facility. LVN 1 stated that they only provide a logbook where visitors sign-in and a disposable N95 facemask (an air purifying respirator) to use while in the building. LVN 1 stated that they do not ask visitors if they have symptoms of Covid-19 or test them with an antigen test (a diagnostic test that detects the presence of Covid-19) to check if they were infected or were previously infected with the virus.   During an interview with the facility’s infection preventionist (IP) on 1/24/2025 at 1:17 PM, the IP stated that a public health nurse (PHN) and an LA County physician conducted a virtual tour of the facility on 1/14/2025 and provided the facility with instructions after the tour on how to mitigate (control) the spread of Covid-19 that included the testing of all staffs and residents with a PCR test twice a week.   During an interview with the ADM on 1/24/2025 at 2:15 PM, the ADM stated that for the facility to initiate the PCR testing, the laboratory required a signature from the facility’s medical director (MD) to execute the procedure. However, the ADM stated that the MD was on vacation and could not be reached. The ADM stated that she tried to call the MD on 1/22/2025, but was unable to reach the MD. During a facility tour with the IP on 1/24/2025 at 2:30 PM, the breakrooms used by staffs who provide care to non-infected and infected residents were observed without hand sanitizers, facemasks, wipes, or a signage reminding the staff to change their masks after eating. There were five (5) chairs in one of the breakrooms and six (6) chairs in the other, with two staffs observed working on their laptops next to each other in the breakroom for the staffs providing care to infected residents. The windows and doors of the breakroom were closed, and the room did not have an air purifier.  During a concurrent observation and interview with LVN 2, who was in the breakroom, LVN 2 stated that he and the MDS nurse (minimum data set nurse) were working in the breakroom because they had a meeting with another group of staffs earlier. LVN 2 stated he was not aware there should only be two (2) people inside the room at any given time and should be across each other at the table.  During an observation on 1/24/2025 at 2:30 PM, three (3) residents, one (1) visitor, and four (4) staffs (total of eight people) were observed occupying the Rehabilitation Room (a room used by the rehabilitation staff when providing rehabilitation therapy exercises to the residents). A signage was posted in the room indicating that the room capacity was limited to three (3) people. The three residents and the visitor who were inside the room were not wearing facemasks and were not at least six feet apart from each other.  During an observation on 1/24/2025 at 2:45 PM, the kitchen was observed without a PPE cart and supplies available for use.  During an interview on 1/24/2025 at 2:55 PM, the ADM stated the facility was having difficulty acquiring air purifiers and air filters due to a supply shortage caused by the recent fires. The ADM stated that the facility shares kitchen services with the assisted living facility next door, and they do not have the capacity to make the kitchen staff comply with the recommendations of the PHN.  During an interview on 1/24/2025 at 3:55 PM, the IP stated she thought three (3) residents were allowed in the rehabilitation room. The IP stated there were five (5) chairs in the break room because the staff brought in the chairs from the patio despite giving them instructions not to bring more than two (2) chairs in the room. The IP stated she failed to ensure that a signage was in place in each breakroom to remind the staff to change their masks after eating. The IP stated she thought washing hands with soap and water was a better alternative to using hand sanitizers. The IP stated that she thought placing the facemasks at the nurses’ station was more effective than having them available in the breakrooms. The IP stated the facility had difficulty acquiring air purifiers since the wildfires started due to a shortage of supply. The IP stated she does not know why the windows were not cracked open in the breakrooms and does not recall receiving instructions from the PHN to leave them slightly open.  A review of an email sent to the IP by the PHN on 1/14/2025 at 10:27 AM, indicated that the PHN’s post-site visit recommendations include:  1. Arrange for a lab to conduct PCR testing and begin PCR testing twice a week.  2. Create a testing station in the room adjacent to the front entrance where visitors and staff can sign in, conduct symptom checks, and test for Covid using an antigen test.  3. Allow only 1-2 masked residents and distanced residents in the rehabilitation room at a time.  4. Remove extra chairs and limit occupancy to two (2) people, seated across from each other.  5. Add signage reminding staff to change their masks after eating.  6. Provide masks, hand sanitizers, and wipes in the breakrooms.  7. Add an air purifier to the breakroom and keep windows cracked open.  A review of a facility’s Covid-19 Update Report, dated 1/23/25, indicated the total number of confirmed Covid-19 cases in the facility was thirty-one (31), with five (5) staff and twenty-six (26) residents. The report indicated the staff and residents were tested with an antigen test.  A review of a list of residents the IP provided, dated 1/24/2025, indicated 32 residents were not tested for Covid-19 with a PCR test. A review of the facility’s undated policy titled, “Infection Prevention and Control Program,” revised in 12/2023, indicated that the program would be carried out by the facility’s infection preventionist with a goal to decrease the risk of infection to residents and personnel and to ensure compliance with the state and federal regulations related to infection  The facility failed to implement its policy and procedure on infection prevention and control by failing to:  1. Screen visitors for symptoms of Covid19 (a highly contagious respiratory disease caused by the SARS-CoV-2 virus) with symptoms of cough, fever, or headache before entering the facility.  2. Conduct biweekly (twice a week) mass PCR testing (a polymerase chain reaction (PCR) laboratory test used to detect if a person is infected with Covid-19) for all residents and staff.  3. Allow only 1-2 distanced residents with a facemask in the rehabilitation room at a time. 4. Ensure the breakrooms do not have extra chairs, has a maximum occupancy of two (2) people sitting across from each other, have a signage reminding staff to change their masks after eating, have an air purifier (a device that removes pollutants and contaminants from the air in a room), facemasks, hand sanitizers, and wipes in the breakroom, and windows cracked open.  These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients.