Health inspection·October 14, 2025

§ 72541. Unusual Occurrences. Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of residents, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. Note: Authority cited: Sections 208(a) and 1275, Health and Safety Code. Reference: Section 1276, Health and Safety Code. 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 §483.71     On 9/11/2025 at 10:10AM, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding a COVID- 19 outbreak.   As a result, CDPH determined that the facility failed to report a Coronavirus 2019 (COVID-19, a contagious disease) outbreak (two or more linked cases of the same illness) to the California Department of Public Health (CDPH) within 24 hours, in accordance with the facility’s policy and procedure (P&P) titled Communicable Diseases – Outbreak. As of 8/16/2025, three facility-acquired COVID-19 cases had been confirmed: * Resident 1 (positive on 8/13/2025) * Resident 2 (positive on 8/15/2025) * Resident 3 (positive on 8/16/2025) This deficient practice resulted in delayed public health response and created the potential to delay outbreak containment measures, such as testing, isolation, and contact tracing, increasing the risk of further transmission. Without timely reporting, appropriate infection control interventions may not be implemented promptly, putting vulnerable residents and staff at greater risk of exposure and illness. Findings:    During a review of the facility provided document titled, Covid – 19 Contact information form for long -Term Care Facilities Resident, dated 8/13/2025, the Form indicated a total of three residents were positive for Covid – 19. The Form indicated the following:  1. Resident 3 was confirmed COVID -19 positive on 8/13/2025  2. Resident 5 was confirmed COVID-19 positive on: 8/15/2025  3. Resident 4 was confirmed COVID-19 positive on: 8/16/2025  A review of Resident 3’s Admission record indicated the facility originally admitted the 99-year-old female on 2/9/2024, with a diagnosis of Poly-osteoarthritis (pain, swelling, and stiffness in the joints), heart disease (Problems with the heart, such as blocked arteries or heart damage) and hypertensive heart disease (Heart problems caused by long-term high blood pressure).  A review of Resident 3’s History and physical (H&P) dated 2/25/2025, indicated this resident has the capacity to understand and make decisions.  A review of Resident 3’s Change in Condition Evaluation dated 8/15/2025, indicated Resident 3 had a runny nose, voice hoarsening, occasional cough and weakness. The Evaluation Covid antigen test performed on 8/13/2025 indicated a positive COVID-19 result.  A review of Resident 4’s Admission record indicated the facility initially admitted the 93-year-old female on 10/2/2023, with a diagnosis of a fracture to the shaft of the right femur (a break in the long, straight part of the thigh bone on the right side).  A review of Resident 4’s History and physical (H&P) dated 11/1/2024, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 4’s Change in Condition Evaluation dated 8/16/2025, indicated Resident 4 had a runny nose. Resident 4 was tested for COVID-19 on 8/16/25 and a positive result. A review of Resident 5’s Admission record indicated the facility initially admitted the 92-year-old female to the facility on 3/8/2021, with a diagnosis of congestive heart failure (the heart isn’t pumping blood as well as it should, so fluid can build up in the body). A review of Resident 5’s Progress notes dated 8/15/2025, indicated Resident 5 was tested for COVID- 19 on 8/15/2025 and had a positive test result.    A review of the facility provided document from the local public health officer, titled “Viral Respiratory Illness Outbreak Notification,” dated 8/18/2025, the document indicated the facility had an active outbreak for COVID-19. A review of the facility provided document from the local public health office, titled Respiratory Illness Outbreak Clearence Letter, dated 8/25/25 indicated the facility was cleared for COVID-19 outbreak as of 8/25/2025. During an interview on 9/11/2025 at 11:15 AM with infection preventionist nurse (IP) 1, IP 1 stated since Residents 3, 4, and 5 were symptomatic and were positive for COVID-19, the facility should have reported the positive COVID- 19 residents to the California Department of Public Health within 24 hours. The IP stated CDPH was not notified regarding the facility’s COVID-19 Outbreak declared by the local health department on 8/18/25. The IP stated the COVID-19 outbreak involved three residents. During an interview on 9/11/2025 at 12:35 with the Administrator (ADM), the ADM stated the facility had a COVID-19 outbreak and stated that CDPH should have been notified regarding the COVID-19 outbreak. During a concurrent interview and record review on 9/11/2025 at 12:35 with the ADM, the ADM, the undated facility’s policy and procedure (P&P) titled, “Communicable diseases – outbreak” was reviewed. The P&P indicated, “the administrator will be responsible for reporting to the California Department of Public Health (Licensing and Certification Program) and local public health officer a single case of a communicable disease requiring immediate reporting and epidemiology investigation.”??The Administrator stated not reporting to CDPH since she thought the facility’s IP had reported the COVID-19 positive residents to CDPH. During an interview on 9/11/2025 at 12:45PM with Infection Preventionist (IP) 1, IP 1 stated not notifying CDPH because IP 1 thought IP 2 had notified CDPH regarding Resident 3, 4, and 5’s positive COVID-19 status.    During an interview on 9/11/2025 at 12:50PM with the Director of Nursing (DON), the DON stated that the Department of Public health and the Public Health Nurse had been notified. No document could be provided by DON indicating the California Department of Public Health and the local public health officer had been notified. During an interview on 9/11/2025 at 1:30PM with IP 2, IP 2 not reporting the COVID-19 outbreak to the California Department of Public Health. IP 2 stated not knowing that the facility had to report the COVID-19 cases to CDPH, and by not reporting the COVID-19 cases there would be a lack of outbreak support.    During a review of the facility’s undated policy and procedure (P&P) titled, “Communicable Diseases – Outbreak,” the P&P indicated the purpose of Policy was to ensure that outbreaks of communicable disease are identified, handled, and reported as required. The P&P indicated outbreaks of communicable diseases within the Facility was promptly identified as appropriate, treated and reported. The P&P indicated that the Administrator was responsible for reporting to the Department of Public Health, which included facility outbreak of COVID-19. The P&P indicated outbreak definition was one or more facility acquired COVID-19 case in a resident and/or three or more suspect, probable or confirmed COVID-19 cases. The Policy indicated reporting outbreaks related to a communicable disease, the facility must report the communicable disease data to CDPH.  As a result, CDPH determined that the facility failed to report a Coronavirus 2019 (COVID-19, a contagious disease) outbreak (two or more linked cases of the same illness) to the California Department of Public Health (CDPH) within 24 hours, in accordance with the facility’s policy and procedure (P&P) titled Communicable Diseases – Outbreak. As of 8/16/2025, three facility-acquired COVID-19 cases had been confirmed: * Resident 1 (positive on 8/13/2025) * Resident 2 (positive on 8/15/2025) * Resident 3 (positive on 8/16/2025) This deficient practice resulted in delayed public health response and created the potential to delay outbreak containment measures, such as testing, isolation, and contact tracing, increasing the risk of further transmission. Without timely reporting, appropriate infection control interventions may not be implemented promptly, putting vulnerable residents and staff at greater risk of exposure and illness. This violation had a direct or immediate relationship to the health, safety, to security of residents.