Health inspection·December 30, 2024

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)(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 §483.71 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; (vi) The hand hygiene procedures to be followed by staff involved in direct resident contact. 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 11/26/2024, the California Department of Public Health (CDPH) conducted and unannounced visit to the facility to investigate a complaint regarding infection control. As a result of the investigation, the CDPH determined that the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and/or diseases in the healthcare setting) were followed in accordance with the facility's policies and procedures (P&P) titled, "Hand Hygiene (procedures that included the use of alcohol-based hand rubs (containing 60%-95% alcohol) and hand washing with soap and water)," and "Management of COVID-19 (infections airborne disease caused by SARS-CoV-2 virus)". The facility failed to: 1. Ensure six of 12 sampled staff (Certified Nurse Assistant [CNA] 2, CNA 3, CNA 4, , and Treatment/Licensed Vocational Nurse [LVN] 6 wore appropriate personal protective equipment (PPE, specialized clothing or equipment such as grows, gloves, masks, face shields worn by an employee for protection against infectious materials) when entering residents' room and when providing care for residents on TBP (Transmission Based Precautions) for COVID-19. 2. Ensure four of nine sampled residents (Residents 5, 6, 7, and 8) who tested positive for COVID-19 wore a mask when these residents were outside of their room. 3. Ensure CNA 5, and CNA 6 wore appropriate PPE when providing patient/resident care and performed hand hygiene before and after providing care to Residents 5, 6, 7, and 8. These violations resulted in infectious agents being transmitted and spread from staff to residents that resulted in a spread of COVID infection in the facility. 1a. A review of Resident 4's Admission Record (AR) indicated the facility the admitted Resident 4, a 50-year-old female, on 5/10/2024 with diagnoses that included Huntington's disease (causes the nerve cells in the brain to decay over time that affects a person's movements, thinking ability, and mental health) and oral-pharyngeal dysphagia (difficulty or discomfort in swallowing) A review of Resident 4's Minimum Data Set (MDS- a resident assessment tool) dated 11/3/2024, indicated Resident 4 had severely impaired cognition (ability to think, remember, and reason). The MDS indicated Resident 4 was dependent (helper does ALL the effort. Resident does none of the effort to completely the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene, showering/bathing self, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 4 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half effort) with eating, oral hygiene, upper body dressing, personal hygiene, rolling left to right (in bed), sitting to lying, lying to sitting on side of bed, sitting to standing and chair/bed-to-chair transfers. During an observation on 11/27/2024 at 12:30 pm, outside of Resident 4's room in the hallway, CNA 3 and CNA 4 were inside of Resident 4's room. CNA 3 and CNA 4 were at Resident 4's bedside, touching Resident 4 and Resident 4's bedding. CNA 3 and CNA 4 were in the room with Resident 4 and was not wearing a face shield. There was a novel respiratory precautions sign (indicated to clean hands-on room entry, wear a gown on room entry, wear a N-95 mask and face shield, wear gloves on room entry, and clean hands when exiting) on the wall next to the room door. Another sign on the wall next to the door indicated Resident 4 was on quarantine (state, period, or place of isolation in which residents that may have been exposed to infectious disease are placed). There was an isolation cart outside the room in the hallway by the door that contained gowns. There were gloves and alcohol-based hand rub (ABHR, a liquid used to reduce the number of microorganisms on your hands) on top of the cart. During an interview on 11/27/2024 at 12:38 pm, CNA 3 stated CNA 3 was not wearing a face shield because there were no face shields in the isolation cart. CNA 3 stated CNA 3 was supposed to wear a face shield because the isolation sign on the wall next to Resident 4's door indicated to do so. CNA 3 stated Resident 4 had been exposed to COVID-19. CNA 3 stated CNA 3 was supposed to wear all PPE indicated on the novel respiratory precautions sign to keep CNA 3 safe. During an interview on 11/27/2024 at 12:45 pm, CNA 4 stated CNA 4 was not wearing a face shield because there were no face shields in the isolation cart. CNA 4 stated the sign on the wall next to Resident 4's door indicated CNA 4 was supposed to wear a face shield when inside Resident 4's room. CNA 4 stated CNA 4 should wear a face shield to protect CNA 4 from infection and was supposed to wear whatever PPE the isolation precaution sign indicated to wear. 1b. A review of Resident 2's AR indicated the facility initially admitted Resident 2, a 72-year-old female, on 8/14/2024 and readmitted on 9/24/2024, with diagnoses that included immunodeficiency (condition in which the immune system is unable to fight infection or other disease) due to conditions classified elsewhere and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement). A review of Resident 2's MDS dated 11/14/2024, indicated Resident 2 had moderately impaired cognition. The MDS indicated Resident 2 was dependent with toileting hygiene, showering and bathing self. The MDS indicated Resident 2 required partial to moderate assistance (helper does less than half the effort and lifts or holds trunk or limbs but provides less than half the effort) with oral and personal hygiene, and shower and tub transfers. The MDS indicated Resident 2 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity and may be provided throughout the activity or intermittently) eating, upper and lower body dressing, putting on/taking off footwear, rolling left and right (in bed), sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfers, and walking 50 feet (ft- unit of measurement). During an observation on 11/24/2024 at 1 pm, outside of Resident 2's room in the hallway, CNA 2 was sitting on a chair across from the foot of Resident 2's bed. CNA 2 was not wearing a face shield or gloves. CNA 2 had a phone in CNA 2's hands and was looking at the phone. There was an isolation cart in Resident 2's room door in the hallway. There were gowns and face shields in the cart. There were novel respiratory precautions sign on the wall next to the room door. During an interview on 11/27/2024 at 1:05 pm, CNA 2 stated Resident 2 was tested positive for COVID-19. CNA 2 stated CNA 2 was not wearing a face shield or gloves while inside the room as the novel respiratory precautions sign indicated to do so. CNA 2 stated CNA 2 was supposed to protect CNA 2 and other residents from spreading COVID-19 by wearing the correct PPE. 1c. A review of Resident 9's AR indicated the facility admitted Resident 9, a 54-year-old-female, on 3/26/2024 with diagnoses that included oral pharyngeal dysphagia (swallowing problems occurring in the mouth and/or the throat) and immunodeficiency due to conditions classified elsewhere [ a medical classification as listed by World Health Organization (WHO, a United Nations agency that works to improve global health and safety) under the range - Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism]. A review of Resident 9's MDS dated 11/25/2024, indicated Resident 9 had moderately impaired cognition. The MDS indicated Resident 9 was dependent with toileting and personal hygiene, showering/bathing self, upper and lower body dressing, putting on/taking off footwear, sitting to lying, lying to sitting on side of bed, sitting to standing, and chair/bed-to-chair transfers. During a concurrent observation and interview on 11/27/2024 at 1:08 pm, outside of Resident 9's room in the hallway, LVN 6 was with a vendor (would not provide surveyor with name) outside of Resident 9's room. There was a sign on the wall next to Resident 9's room indicating novel respiratory precautions sign. There was an isolation cart on the floor near the room door that was stocked with gowns and face shields. There were gloves and ABHR on top of the isolation cart. LVN 6 was wearing a N-95 mask. LVN 6 and the vendor walked into Resident 9's room without performing hand hygiene or donning (putting on) the appropriate PPE as indicated on the novel respiratory precautions sign. LVN 6 and the vendor were in Resident 9's room for approximately one minute. LVN 6 and the vendor exited Resident 9's room and did not perform hand hygiene. LVN 6 stated LVN 6 brought the vendor into Resident 9's room to show the vendor what mattress needed to be picked up. LVN 6 stated LVN 6 did not touch anything. LVN 6 stated Resident 9 was tested positive for COVID-19. LVN 6 stated the sign on the wall next to Resident 9's door indicated LVN 6 needed to perform hand hygiene and don a gown, face shield, and gloves when entering Resident 9’s room. LVN 6 stated LVN 6 needed to remove the PPE, except for the mask, and perform hand hygiene when exiting Resident 9's room. LVN 6 stated not performing hand hygiene and wearing the appropriate PPE could cause LVN 6 to get infected with COVID-19 or spread COVID-19 to other residents and staff. 2a. A review of Resident 5's AR indicated the facility initially admitted Resident 5, an 81-year-old-female, on 12/2/2021, and was readmitted on 4/5/2024, with diagnoses that included type II diabetes mellitus (DM2- A condition that happens because of a problem in the way the body regulates and uses sugar as fuel) and acute pulmonary edema (condition where too much fluid builds up in the lungs, making it difficult to breathe. A review of Resident 5's MDS dated 10/7/2024, indicated Resident 5 had severely impaired cognition. The MDS indicated Resident 5 was dependent with toileting hygiene, showering/bathing self, upper and lower body dressing, putting on/taking off footwear, and toilet transfers. The MDS indicated Resident 5 required substantial/maximal assistance with eating, oral and personal hygiene, rolling left and right (in bed), sitting to lying, lying to sitting on side of bed, sitting to standing, and chair/bed-to-chair transfers. 2b. A review of Resident 6's AR indicated the facility admitted Resident 6, a 90-year-old female, on 7/27/2024, with diagnoses that included acute kidney failure (AKF- when the kidneys suddenly stop working due to complication of another serious illness) and malignant neoplasm of breast (breast cancer- disease that occurs when abnormal cells grow uncontrollably). A review of Resident 6's MDS dated 10/28/2024, indicated Resident 6 had severely impaired cognition. The MDS indicated Resident 6 required substantial/maximal assistance with toileting hygiene and showering and bathing self. The MDS indicated Resident 6 required partial/moderate assistance with upper and lower body dressing, putting on/taking off footwear, sitting to standing, chair/bed-to-chair transfers, toilet transfers and walking 150 ft. The MDS indicated Resident 6 required supervision or touching assistance with oral and personal hygiene, rolling from left to right (in bed), and walking 50 ft. 2c. A review of Resident 7's AR indicated the facility admitted Resident 7, a 77-year-old male, on 3/7/2024 with diagnoses that included AKF and congestive heart failure (CHF- serious condition that occurs when the heart cannot pump enough blood to meet the body's needs). A review of Resident 7's MDS dated 9/9/2024, indicated Resident 7 had severely impaired cognition. The MDS indicated Resident 7 required partial/moderate assistance with showering/bathing self. The MDS indicated Resident 7 required supervision or touching assistance with toileting hygiene, lower body dressing, putting on/taking off footwear, sitting to standing, chair/bed-to-chair transfers, toilet transfers and walking up to 150 ft. The MDs indicated Resident 7 required setup or clean-up assistance (helper sets up or cleans up while the resident completes the activity and helper assists only prior to or following the activity) with eating, oral and personal hygiene. 2d. A review of Resident 8's AR indicated the facility admitted Resident 8, a 71-year-old male, on 9/4/2024, with diagnoses that included Alzheimer's disease (progress disease that affects through, memory, and language, beginning with mild memory loss that leads to the loss of the ability to carry on conversation and respond to the environment) and hypertension (occurs when blood pressure is more than 130-80 milliliters of mercury [mm Hg]). A review of Resident 8's MDS dated 9/8/2024, indicated Resident 8 had severely impaired cognition. The MDS indicated Resident 8 was dependent with toileting hygiene and showering/bathing self. The MDS indicated Resident 8 required substantial/maximal assistance with upper and lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 8 required partial/moderate assistance with oral hygiene, sitting to standing, chair/bed-to-chair transfers, toilet transfers and walking 10 ft. 3. During an observation on 11/27/2024 at 1:24 pm, in the hallway of the station three red zone (area of facility with COVID-19 positive residents), Residents 5, 6, 7, and 8 were observed in the hallway, without masks on, nor were there masks near them. CNA 5 was assisting Resident 7 to walk across the hallway and sit down in a chair in the hallway. Resident 7 was coughing. CNA 5 was not wearing a gown, gloves, or face shield while assisting Resident 7. CNA 5 proceeding to touch Resident 8 on the shoulders without performing hand hygiene who was to the right of Resident 7. Resident 6 was observed sitting on a chair next to Resident 8 and was coughing. CNA 6 was observed pushing Resident 5 in a wheelchair across from Residents 6 and 8. CNA 6 was not wearing a face shield, gown, or gloves. CNA 6 was observed to not perform hand hygiene after pushing Resident 5 in a wheelchair and before talking to Resident 6. During an interview on 11/27/2024 at 1:40 pm, CNA 5 stated the hallway where Residents 5, 6, 7, and 8 were standing was the red zone. CNA 5 stated Residents 5, 6, 7, and 8 were all positive with COVID-19. CNA 5 stated Residents 5, 6, 7, and 8 were outside their rooms unmasked because they would not wear one. CNA 5 stated CNA 5 was assisting Resident 7 to walk and sit down in the chair. CNA 5 stated CNA 5 thought PPE and hand hygiene for COVID-19 positive residents were only required when inside the residents' rooms providing patient care such as brief changes. CNA 5 stated CNA 5 did not know what novel respiratory precautions me