Other·March 11, 2022

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. §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(c)(3) Patient Care Policies and Procedures (c) Each facility shall establish and implement policies and procedures, including but not limited to: (3) Infection control policies and procedures. The facility failed to provide a safe and sanitary living environment to prevent the spread of Coronavirus (COVID-19, a respiratory illness that can spread through respiratory droplet from an infected person a non-infected to person) for 24 residents as indicated in the facility's infection control policies and COVID-19 mitigation plan (plan to reduce loss of life and limit the impact of COVID-19 in the facility) during the COVID-19 pandemic (spread of a disease worldwide) by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) donned (worn) proper Personal Protective Equipment (PPE, gowns, gloves, N95 masks, and face shields worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) while providing incontinent care to Resident 5 in the Yellow Zone (area for residents who have been in close contact with known cases of COVID-19, newly admitted or re-admitted residents, residents who have symptoms of possible COVID-19 pending test results and for residents with indeterminate tests). 2. Ensure Restorative Nursing Assistant 1 (RNA 1) and Housekeeper 1 (HK 1) were designated for the Red Zone (area for residents who tested positive for COVID-19) and followed Infection Control Protocol by working in the Yellow Zone first and then the Red Zone at the end of the shift. 3. Ensure CNA 2 and CNA 3 donned proper PPE while feeding Resident 1 and Resident 2 in the Yellow Zone. 4. Ensure CNA 2 performed hand hygiene (cleaning one’s hands using alcohol-based hand rub or using soap and water when hands are visibly soiled with dirt, blood, body fluids) between residents in the Yellow Zone. 5. Ensure CNA 4 & CNA 5 completed self-screening (assessing yourself for COVID-19 symptoms) prior to beginning of the shift. On 1/28/2022, the California Department of Public Health made an unannounced visit at the facility to investigate a complaint related to infection control. During a concurrent interview and observation on 1/29/2022, the Registered Nurse (RN) Supervisor stated there were 36 residents in the Yellow Zone and 20 residents in the Red Zone. There was a plastic barrier in (clear barrier that is widely used to stop the spread of COVID-19) between the Red Zone and Yellow Zone. 1. During a concurrent observation and interview on 1/29/2022 at 1:31 pm in the Yellow Zone, CNA 1 was observed inside Room 3A (Resident 5's room in the Yellow Zone). CNA 1 was wearing an N95 mask, face shield, and gloves. CNA 1 was not wearing an isolation gown. CNA 1 stated she just cleaned the resident and provided peri-care (cleaning the private area between the legs) to Resident 5 and stated there was no need to wear an isolation gown because Resident 1 did not have COVID-19. CNA 1 stated Room 5 is in the Yellow Zone. During an interview and review of CNAs' assignment on 1/29/2022 at 1:35 pm, CNA 1 stated she was assigned to take care Residents 3, 4, 5, 6, 7, 8, 9, 10. The CNAs' assignment indicated CNA 1 was assigned to take care Residents 3, 4, 5, 6, 7, 8, 9, 10 in the Yellow Zone. During an interview on 1/29/2022 at 5:40 pm, the Administrator stated facility staff should wear an isolation gown when providing care to residents residing in the Yellow Zone. A review of the local Guidelines for Preventing & Managing COVID-19 in Skilled Nursing Facilities, updated 1/2/2022, indicated isolation gowns should be used for each resident encounter in the yellow and red cohorts for COVID-19 precautions. A review of the facility's Policy titled "COVID-19," dated 9/6/2021, indicated Healthcare Personnel should wear full PPE (mask, face shield, gloves, and gown) for the care of all residents irrespective of COVID-19 diagnosis or symptoms. The Policy indicated the facility has adopted and are following Public Health and/or CDC guideline. This policy will be updated based on guideline changes and facility needs. A review of the facility's Mitigation Plan, dated 9/7/2021, indicated If there are COVID-19 cases identified in the facility, health care professionals are provided and are wearing recommended PPE for care of all residents, in line with the most recent CDPH PPE guidance. 2-A. During an observation on 1/29/2022 at 1:34 pm in the Yellow Zone, there was a plastic barrier separating the Red Zone and Yellow Zone with an opening in the middle of the barrier. There was a cart placed in front of the barrier to prevent residents from going through the opening. RNA 1 was inside the Red Zone. During an observation on 1/29/2022 at 1:57 pm through an opening in the barrier between the Yellow Zone and Red Zone, RNA 1 was inside Red Zone. During a concurrent observation and interview on 1/29/2022 at 2:28 pm, RNA 1 was in the Yellow Zone. RNA 1 stated he assisted 2 residents in the Yellow Zone (Residents 6 and 18) and Resident 26 who was in the Red Zone. During an interview on 1/29/2022 at 2:40 pm, RNA 1 stated he provided RNA services to 2 residents in the Red Zone in the morning and then came back to the Yellow Zone to assist with lunch. RNA 1 stated he had to go back and forth the Red Zone and Yellow Zone because he had to get isolation gowns that were kept in the two closets in the Red Zone. A review of the Line Listing (an organized list containing information of staff or residents diagnosed or exposed to COVID-19) indicated Resident 26 was positive for COVID-19 from a swab collected on 1/26/2022. A review of the Census dated 1/29/2022, indicated the resident was in a room located in the Red Zone. 2-B. During an observation on 1/29/2022, Housekeeper 1 (HK 1) was observed in the Yellow Zone picking up trash from resident rooms. During an interview on 1/29/2022 at 5:15 pm in the Yellow Zone, Housekeeper 1 stated she went inside the Red Zone in the morning to pick up linens, trash and when staff would call for cleaning in the Red Zone. HK 1 stated there were 2 housekeepers that day and they were both cleaning in the Yellow Zone. On 1/29/2022 at 5:30 pm, during an interview, the Administrator stated the facility discouraged moving in between Red Zone and Yellow Zone but if it is unavoidable for staffing shortage then facility staff might have to enter the Red Zone. The Administrator stated it is best practice to care for residents in the Yellow Zone first then go to the Red Zone last. A review of the local Guidelines for Preventing and Managing COVID-19 in Skilled Nursing Facilities updated 1/2/2022, indicated staff assigned to the red cohort should not care for residents in other cohorts if possible. If staff must care for residents in multiple cohorts, they should visit the Red Cohort last and should doff PPE and perform hand hygiene prior to moving between cohorts. A review of the facility's COVID-19 Mitigation Plan, dated 9/7/2021, indicated there will be no rotation of staff between floors or wings during the period they are working each day. A review of the facility's Policy, title "COVID-19," dated 9/6/2021, indicated one housekeeper will be assigned for the designated area. 3. During an observation on 1/29/2022 at 12:58 pm in the Yellow Zone, CNA 2 was feeding Resident 1. CNA 2 was wearing an N95 mask and face shield without an isolation gown and her scrubs touching Resident 1's bed. During an observation on 1/29/22 at 1:00 pm in the Yellow Zone, CNA 3 was feeding Resident 2. CNA 3 was wearing an N95 mask and face shield, she was not wearing gloves and gown while feeding Resident 2. During a concurrent observation and interview on 1/29/22 at 1:03 pm in the Yellow Zone, Licensed Vocational Nurse 1 (LVN 1) verified that CNA 3 was not wearing gloves and isolation gown while feeding Resident 2. LVN 1 stated facility staff were supposed to don proper PPE when providing care in the Yellow Zone, LVN 1 stated proper PPE would be N95 mask, face shield/goggles, gown, and gloves. During an interview on 1/29/22 at 1:04 pm, CNA 3 stated she would only use an isolation gown when providing direct patient care. During an interview on 1/29/2022 at 1:10 pm, CNA 2 stated she was assigned to Residents 1, 2, 11, 12, 13, 14, and Resident 16 in the Yellow Zone. A review of the local Guidelines for Preventing & Managing COVID-19 in Skilled Nursing Facilities, updated 1/2/2022, indicated isolation gowns should be used for each resident encounter in the yellow and red cohorts for COVID-19 precautions. A review of the facility's Policy, title "COVID-19," dated 9/6/2021, indicated Healthcare Personnel should wear full PPE for the care of all residents irrespective of COVID-19 diagnosis or symptoms. The Policy indicated the facility has adopted and are following Public Health and/or CDC guideline. This policy will be updated based on guideline changes and facility needs. A review of the facility's Mitigation Plan, dated 9/7/2021, indicated If there are COVID-19 cases identified in the facility, health care professionals are provided and are wearing recommended PPE for care of all residents, in line with the most recent CDPH PPE guidance. 4. During an observation on 1/29/2022 at 12:58 pm in the Yellow Zone, CNA 2 was feeding Resident 1. CNA 2 was wearing an N95 mask and face shield, she was not wearing an isolation gown and her scrubs touching Resident 1's bed. CNA 2 removed her gloves and left the room without performing hand hygiene. CNA 2 then approached Resident 25 who was not eating. CNA 2 took Resident 25's tray and left to open the door towards the kitchen. CNA 2 brought the tray to the kitchen. During an interview on 1/29/2022 at 1:10 pm, CNA 2 stated she washed her hands when she went inside the kitchen, she stated she was supposed to sanitize her hands after feeding Resident 1. A review of the local Guidelines for Preventing & Managing COVID-19 in Skilled Nursing Facilities, updated 1/2/2022, indicated Healthcare Personnel (HCP) and all other staff members should perform hand hygiene before and after all resident encounters. All staff, residents, and visitors should perform hand hygiene frequently including every time they enter and exit the facility, resident rooms, and common areas; before and after eating; after using the restroom etc. A review of the Policy on COVID-19, dated 9/6/2021, indicated the facility is utilizing guidance from CDC and Department of Public Health. 5. A review of the Employee Screening for COVID-19, dated 1/29/2022, indicated CNA 4 was working in the Yellow Zone and CNA 5 was working in the Red Zone on 1/29/22 and they did not complete the self-screening for COVID-19 symptoms. During an interview on 1/29/2022 at 12:26 pm, CNA 4 stated she reported to work late so she just checked her temperature, and she did not complete the self-screening process. CNA 4 stated facility staff just screen themselves. During a concurrent review of the Employee Screening Log and interview with the Registered Nurse Supervisor on 1/29/2022 at 11:50 am, she stated it was difficult to be on the floor (to be physically present in resident care areas) and leave the work area to screen staff at the entrance because it could get very busy. During a concurrent interview and review of CNAs' assignment, on 1/29/2022 at 1:25 pm, CNA 4 stated she was assigned to care for Residents 17, 18, 19, 20, 21, 22. A review of CNA 5's assignment indicated she was assigned to care for residents in the Red Zone. A review of the Staffing Assignment and Screening Log indicated the following: a. CNA 4 was assigned in the Yellow Zone and there was no documentation she was screened for COVID-19. b. CNA 5 was assigned in the Red Zone and there was no documentation she was screened for COVID-19. A review of the local Guidelines for Preventing & Managing COVID-19 in Skilled Nursing Facilities, updated 1/2/2022, indicated all staff should be checked for symptoms and fever at least once per shift, including at the beginning of shifts. The facility should screen all Healthcare Personnel for symptoms of COVID-19 prior to start of shifts. A review of the facility's Policy on COVID-19, dated 9/6/2021, indicated the facility shall conduct daily temperature checks for staff. All staff should be checked twice daily, once prior to coming to work and second at the end of each shift. Staff working double shifts will be checked again prior to reaching their 12th hour of work. The facility failed to provide a safe and sanitary living environment to prevent the spread of Coronavirus (COVID-19, a respiratory illness that can spread through respiratory droplet from an infected person a non-infected to person) for 24 residents as indicated in the facility's infection control policies and COVID-19 mitigation plan (plan to reduce loss of life and limit the impact of COVID-19 in the facility) during the COVID-19 pandemic (spread of a disease worldwide) by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) donned (worn) proper Personal Protective Equipment (PPE, gowns, gloves, N95 masks, and face shields worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) while providing incontinent care to Resident 5 in the Yellow Zone (area for residents who have been in close contact with known cases of COVID-19, newly admitted or re-admitted residents, residents who have symptoms of possible COVID-19 pending test results and for residents with indeterminate tests). 2. Ensure Restorative Nursing Assistant 1 (RNA 1) and Housekeeper 1 (HK 1) were designated for the Red Zone and followed Infection Control Protocol by working in the Yellow Zone first and then the Red Zone at the end of the shift. 3. Ensure CNA 2 and CNA 3 donned proper PPE while feeding Resident 1 and Resident 2 in the Yellow Zone. 4. Ensure CNA 2 performed hand hygiene between residents in the Y