Health inspection·December 27, 2024

F880 Code of Federal Regulations, Title 42, §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: (iii) Standard and transmission-based precautions to be followed to prevent spread of infections. California Code of Regulations, Title 22, Section 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. On 12/4/2024, the California Department of Public Health (CDPH) conducted and unannounced visit to the facility to investigate a complaint regarding infection control. Based on observation, interview, and record review, the facility failed to ensure: 1. Air purifiers were in working condition or set to "on." 2. Ventilation system was set to "on" and not on "auto" or "off." 3. A Licensed Vocational Nurse (LVN) 1 was wearing proper personal protective equipment (PPE- protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) while in a Covid-19 (an infectious disease caused by the SARS-CoV-2 virus) room. 4. LVN 1 wore a N95 (a disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) mask properly while in the Red Zone (unit with Covid-19 confirmed positive residents). 5. Trash was emptied and not overflowing onto the floor in the Red Zone (designated a contaminated area used for isolation and the management of COVID-19 positive residents). These deficient practices had the potential to cause the spread of Covid-19 infection to other residents and staff members in the facility during an active outbreak. During a review of the email sent from the Local Health Department (LHD) to the facility’s Infection Preventionist (IP) regarding the recommendations to mitigate the spread of COVID outbreak, dated 11/26/2024 and timed at 2:32 pm, the recommendations indicated to have the fans to be on for all vents, at all times, and the air purifiers to be on in a maximum setting. During an interview on 12/4/2024 at 9:09 am with the Public Health Physician (PHP), the PHP stated the facility's ventilation system was not adequate. The PHP stated the thermostats were set to auto or off. The PHP stated the air purifiers were not plugged in. The PHP stated the recommendations were sent to the facility last week, but the facility was not following the recommendations. The PHP stated there were 40 residents in the Red Zone and that LVN 1 was not wearing PPE. During an observation on 12/4/2024 at 9:12 am, LVN 1 was not wearing a gown while standing in the doorway of a room in the Red Zone. During an interview on 12/4/2024 on 9:21 am with the IP, the IP stated the IP had a virtual tour with the PHP. The IP stated the PHP advised to ensure the thermostat was set to "on" and not "auto." The IP stated when the PHP came to the facility today, the thermostat was set to "auto." The IP stated the PHP advised facility’s staff to set the thermostat to "on" so the air would be circulating for ventilation. The IP stated the string hanging from the vents were not moving so it prompted the PHP to look at the thermostat. The IP stated the PHP would like the facility to obtain more air purifiers, but “we (the facility)” have not received them (additional air purifiers) yet. During a concurrent observation and interview on 12/4/2024 at 9:30 am with the IP, a yellow gown was on the floor next to an overfilled trash bin in the Red Zone. The IP stated there was a designated housekeeper in the Covid-19 unit and the trash bin should not be overfilled. During an observation tour on 12/4/2024 at 9:32 am with the IP, the following were observed: a. Air purifier in between Station 5 and Station 6 (Red Zone) was not working. b. The string hanging from Station 4 vent was not moving. The IP went to the nearest thermostat and set it to "on." The IP stated, "Now the string is moving." c. LVN 1 was not properly wearing a N95 while in the Red Zone. d. Air purifier in the hallway prior to entering the locked unit was not working. During an interview on 12/4/2024 at 10:43 am with the IP, the IP stated according to the PHP when there is poor ventilation, all the germs could be stuck in one station or one room. The IP stated there will not be clean ventilation. The IP stated according to the PHP facilities with poor ventilation have higher numbers of residents and staff with COVID during a Covid-19 outbreak. The IP stated the same thing could happen if the air purifiers are not working or not turned on. The IP stated the PHP requested the facility to get additional air purifiers. During an observation tour of the facility's Red Zone on 12/4/2024 at 4:19 pm with the IP, the following were observed: I. The vent in the center of the unit was set to "auto." II. The air purifier next to Room 603 was not working properly. III. The air purifier next to Room 610 was turned off. IV. A bedside table in front of a resident's room was wrapped with a PPE gown. In front of the same room, two chairs had PPE gowns wrapped onto the chairs. During an interview on 12/5/2024 at 10:24 am with housekeeping (HOUSE 1) regarding the overfilled trash bin, HOUSE 1 stated the problem with an overfilled trash bin is “more infection” and that the trash should be emptied. During an interview on 12/5/2024 at 2:09 pm with the IP, The IP stated LVN 1 was not wearing the N95 mask correctly. The IP stated when the IP made rounds in the Red Zone, the trash bin was overflowing again. The IP stated the issue with the overflowing trash bins in the Red Zone is infection control and “it should not be like that.” During an interview with the Environmental Supervisor (ES) on 12/5/2024 at 3:52 pm, the ES stated the issue with the trash overflowing was infection control and nothing outside of the trash can/bin should be on the floor. The ES stated the facility staff's (used/contaminated) masks or gowns should not be on the floor. The ES stated used/contaminated masks or gowns should be placed in the trash can and should not be thrown on the floor. During a review of the facility's policy and procedure (P&P) titled, "Policies and Practices- Infection Control," revised on 07/2014, the P&P indicated, the facility’s infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The P&P indicated, the objectives of the facility's infection control policies and practices were to prevent, detect, investigate, and control infections in the facility. During a review of the facility's P&P titled, "Coronavirus Disease (Covid-19)- Infection Prevention and Control Measures," revised 4/2020, the P&P indicated, the facility follows recommended standard and transmission-based precautions, environmental cleaning, and social distancing practices to prevent the transmission of Covid-19 within the facility. The P&P indicated, while in the building, personnel are required to strictly adhere to established infection prevention and control policies, including appropriate use of PPE. The P&P indicated, if there are Covid-19 cases in the facility, staff would wear all recommended PPE (i.e., gloves, gown, eye protection and respirator or facemask) for the care of all residents on the unit (or facility-wide based on the location of affected residents), regardless of symptoms (based on availability). During a review of the facility's Covid 19 Mitigation and Testing Plan (MATP), updated on 11/16/2024, the MATP indicated, all trash and dirty linen shall be bagged and placed in designated bins. The MATP indicated, it is the policy of the facility to protect their residents, staff and others who may be in their facility from harm during emergency events. The MATP indicated, to accomplish this, the facility has developed procedures for infection prevention and control to manage a COVID-19 outbreak. The MATP indicated, the guidance the infection preventionist will follow will be heavily influenced from the LHD, CDPH (California Department of Public Health), and the CDC (Centers for Disease Control and Prevention). The MATP indicated, the facility will ensure IP reviews guidance and recommendations provided by CDC, CDPH and/or LHD to maintain consistent situational awareness with highly evolving nature of COVID. The MTP indicated, the IP will monitor and collect all guidance from the LHD, CDPH, and CDC and educate all staff on best practices to ensure consistent application of safe IP practices. The facility failed to ensure: 1. Air purifiers were in working condition or set to "on." 2. Ventilation system was set to "on" and not on "auto" or "off." 3. A Licensed Vocational Nurse 1 was wearing proper personal protective equipment while in a Covid-19 room. 4. LVN 1 wore a N95 mask properly while in the Red Zone. 5. Trash was emptied and not overflowing onto the floor in the Red Zone. These deficient practices had the potential to cause the spread of Covid-19 infection to other residents and staff members in the facility during an active outbreak. This violation jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of all residents and staff in the facility.