Health inspection·February 10, 2022

T22 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. 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; The facility failed to establish, maintain, and implement an infection control program which included the current updated local health department’s “Order of the Health Officer for Control of COVID-19 ([Coronavirus] a disease that can trigger a respiratory [lung] tract infection affecting the upper respiratory tract [sinuses, nose, and throat] and/or lower respiratory tract [windpipe and lungs] the virus spreads mainly through person-to-person contact)” dated 12/3/21 with effective date 12/15/21 for additional screening and testing requirements to facilitate safe in-room and indoor visitation for the appropriate general and essential visitors for 64 of 64 patients residing in the facility. Patients 1, 2, and 3’s visitors (Visitors 3, 4, 5, and 6) and Visitors 1 and 2, were not asked for additional screening and testing requirements as indicated in the Order of the Health Officer for Control of COVID-19 to facilitate safe in-room and indoor visitation such as a negative test PCR ([Polymerase Chain Reaction] detects genetic material of the virus) test taken within 72 hours prior to entry, or negative FDA-approved Antigen test result taken within 24 hours prior to entry, or show documentation of recovery from COVID-19 within the last 90 days. This deficient practice had the potential to expose Patients 1, 2, and 3 and all other 61 other patients residing in the facility and lead to uncontrolled spread of infection related to Covid-19, that can lead to life-threatening conditions, including hospitalizations and death. 1. A review of Patient 1’s Admission Record indicated , a 95-year old patient admitted to the facility on 12/20/2021 with a diagnosis that included Malignant neoplasm (a tumor is cancerous) of mandible (lower jaw), pressure ulcer of sacral region (injuries to skin’s underlying tissue resulting from prolonged pressure on the skin) Stage II (a sore that expands into deeper layers of the skin), hyperlipidemia (high concentration of fats in the blood). A review of Patient 1’s History and Physical (H&P) dated 12/23/2021, indicated the patient is alert and oriented to person only (knows their name and that of a significant other). The H & P indicated Patient 1 had no capacity to understand and make decisions due to dementia (a group of symptoms that affects memory, thinking and interferes with daily life). A review of Patient 1’s Minimum Data Set (MDS, a care area screening tool and assessment) dated 12/27/2021, indicated Patient 1 required total dependence from staff (full staff performance every time during entire 7-day period) during activities of daily living (walking, dressing, bed mobility, dressing, eating). 2. A review of Patient 2’s Admission Record indicated , a 79 year-old patient was originally admitted to the facility on 11/20/2017, and readmitted on 12/30/2020 with a diagnosis of hypothyroidism (a condition resulting from decreased production of thyroid hormones), hyperlipidemia (high concentration of fats in the blood), major depressive disorder (a mental health disorder characterized by depressed mood or loss of interest in activities) single episode, schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly). A review of Patient’s 2 MDS dated 11/23/2021, indicated Patient 2 had severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). A review of Patient 2’s most current Interdisciplinary (an approach to healthcare that integrates multiple disciplines through collaboration) Notes dated 08/25/21, indicated Patient 2’s ADLs and functional limitations require one-person limited assistance during care and ADL’s. The IDT Notes indicated Patient 2 had no mood/behavioral concerns observed/listed. A review of Patient 2’s Admission Social Service Assessment dated 01/05/21, indicated Patient 2’s mood/affect to be pleasant, a bit suspicious, a mental health history of Schizophrenia. The Social Service Assessment did not indicate a determination of who and the need of Patient 2’s essential visitor. The Social Service Assessment did not indicate behavioral interventions for the patient’s mental/mood health. 3. A review of Patient 3’s Admission Record indicated a 93-year old patient was admitted to the facility on 12/20/21 with diagnoses that included orthopedic surgery (focuses on the treatment of the musculoskeletal system. That includes bones, joints, ligaments, tendons, muscles, nerves, and even the skin) artherosclerotic heart disease of native coronary artery without angina pectoris (severe pain in the chest), urinary tract infection (an infection in any part of the urinary system). A review of Patient 3’s MDS dated 11/23/21, indicated the patient had severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). A review of Patient 3’s Social Service Assessment dated 11/20/2021 indicated Patient 3’s mood and behavior to be pleasant and cheerful, adjustment to environment indicated Patient 3 understands need. The Social Service Assessment’s Mental Health History indicated unknown and did not indicate any behavioral interventions were required. On 12/28/2021 9:59 AM, during the facility’s initial tour, two visitors (Visitors 1 and 2) were observed entering the facility. During the observation, Receptionist 1 asked Visitors 1 and 2 if they were experiencing any COVID-19 symptoms and asked to take their temperature. Receptionist 1 did not ask Visitors 1 and 2 to show their COVID-19 immunization cards and to show proof of negative COVID-19 test or recovery from COVID-19 within the last 90 days. On 12/28/2021 at 10 AM, during an interview, Receptionist 1 stated the facility’s current visitor screening process for COVID-19 involved checking visitors’ temperature, asking COVID-19 screening questions, and checking the visitors COVID-19 immunization cards. Receptionist 1 stated if the visitor was unvaccinated, the visitors would be asked to take a “facility sold” COVID-19- Rapid Antigen test before entering the facility. On 12/28/2021 at 10:09 AM, Patient 3 was observed in the facility’s Dining Room during a visitation with Visitors 5 and 6 standing next to her. On 12/28/2021 at 10:15 AM, during an interview, the facility’s administrator stated the facility was currently offering COVID-19 Rapid Antigen testing (detect the presence of a specific viral protein in a collected sample. This protein is known as an antigen and is on the surface of the COVID-19 virus) only to those visitors who were “unvaccinated” and did not bring a COVID-19 negative test result. The Administrator stated that all visitors that comes into the facility through the main/shared Residential Area (Assisted Living and Nursing Home) and were screened by Receptionist 1 prior to entering the facility’s Nursing home. On 12/28/21 at 11 AM, during a concurrent interview and observation of the facility’s Yellow Zone (quarantine area), a room were observed occupied by Patient 1 and Patient 4. During the observation, Patient 1’s visitor (Visitor 3) was observed in Patient 1’s room. During a concurrent interview, Visitor 3 stated Receptionist 1 did not ask or verified his COVID-19 vaccination and/or asked COVID-19 screening questions. On 12/28/2021 at 11:09 AM, during an interview and observation of an In-room visitation observed for Patient 2, Patient 2’s visitor (Visitor 4) stated she had been Patient 2’s companion and visits Patient 2 at least four times per week. Visitor 4 stated she had never been asked to provide or to take a COVID-19 test by the facility. Visitor 4 stated she was screened everyday upon entering the facility by having her temperature checked and answering COVID-19 screening questions. Visitor 4 stated the facility staff had not invited her for any IDT meeting or conference about Patient 2’s health status in the facility. On 12/28/2021 at 11:45 AM, during an interview with Certified Nursing Assistant (CNA) 1, CNA 1 stated Patient 3 frequently receives visitations and were accepted inside the facility, in the main Dining Room or inside Patient 3’s room. On 12/28/21 at 12:40 PM, during a telephone interview with Visitor 5 (Patient 3’s visitor), Visitor 5 stated he had never been asked by the facility to provide proof of a negative COVID-19 test and had never been offered a Rapid Antigen test by the facility. Visitor 5 stated he had visited Patient 3 that morning (12/28/21) with another family member (Visitor 6) who just came from out of state for the holidays. Visitor 5 stated that Visitor 6 was also not asked to provide a negative COVID-19 test results or offered to take a test. Visitor 5 stated that the facility screened visitors by taking temperature, asking COVID-19 screening questions and verifying their COVID-19 immunization status. On 12/28/21 at 1:10 PM, during an interview, the Administrator stated that all visitors entering the facility were considered “Essential” and were exempted from the current testing requirement by Los Angeles County’s Health officer Order. On 12/29/21 at 8:52 AM, during an interview with Receptionist 1, Receptionist 1 stated she had never heard of the term “Essential Visitors” nor received a list of who qualified as an “Essential Visitor for the skilled nursing facility.” Receptionist 1 stated she does not ask any visitors if they are considered “essential.” On 12/29/21 at 8:58 AM, during an interview with I infection Preventionist (IP), IP stated facility’s current determination of who qualifies as an essential visitor is determined by the resident’s visitor. IP stated she had not participated in any IDT assessing what patients qualify to have essential visitations or who is an essential visitor. On 12/29/21 at 9:16 AM, during an interview with the Assistant Director of Nursing (ADON), ADON stated she did not participate in any IDT meeting that determined which residents required compassionate care visits (type of visits for those patients on end-of-life situations, and those patients experiencing weight loss, dehydration, failure to thrive, psychological distress, functional decline, or struggling with a change in environment) for essential visitors. The ADON stated she was not aware the facility was considering all visitors essential and not following the local public health’s current Health officer Order, until recently. The ADON stated she asked the DON why the facility was not following the local public health’s updated current Health Officer Order. The ADON stated the facility’s administrator informed her that they would not be testing any visitors because all visitors were “essential visitors.” On 12/29/21 at 10:38 AM, during a telephone interview with the DON, the DON stated she had never participated in any IDT meeting that discussed who was the appropriate essential visitors for residents that needed them. The DON stated she was told by the Administrator that the facility would not be testing or asking for proof of negative test for any visitors coming into the facility because all visitors were considered “Essential.” On 12/29/2021 at 11 AM, during an interview and record review of the facility document titled “Resident Visitor Screening Log,” wherein all the visitors of the Assisted Living Facility and Skilled Nursing facility were combined. The Director of Residential Wellness (DRW) identified and highlighted the visitations conducted for the Skilled Nursing facility from 12/15/21 to 12/28/21. The Log indicated there were 94 visits for the Skilled Nursing Facility side from 12/15/21 to 12/28/21. On 12/29/21 at 12:23 PM, during an interview with the Administrator, the Administrator stated a verbal IDT meeting had been conducted by the Administrator, Chief Executive Officer (CEO) and the facility’s general council and determined that all the visitors of the 64 patients in the facility were considered “Essential” and should be exempted from the current LA County Health Officer Order testing requirement for visitors. During the interview, the Administrator did not indicate when the IDT meeting were conducted and were not documented. A review of the local health department’s Order of the Health Officer for Control of COVID-19, Prevention of COVID-19 Transmission in Skilled Nursing Facilities with revised order dated 12/3/2021 and effective as of 12:01 AM on 12/15, 2021, indicated “Due to the introduction of the newly identified Omicron variant of the SARS-CoV-2 virus in Los Angeles County, California and other states and until more information is known about this variant’s transmissibility, it’s impact on vaccine effectiveness and breakthrough infections, including in individuals who have received booster doses, whether it is associated with more severe disease, and whether it is susceptible to currently available COVID-19 treatments, additional infection control precautions are indicated and necessary for Skilled Nursing Facilities because patients are at heightened risk for poor health outcomes should transmission occur within the facility.” The Order indicated that “Between December 15, 2021 and January 31, 2022, prior to entry into a facility for indoor visits, all visitors who are two years of age or older, regardless of vaccination status, must provide the facility with their proof of either: 1. A negative test PCR test taken within 72 hours prior to entry, or 2. A negative FDA-approved Antigen test result taken within 24 hours prior to entry. 3. Visitors who have not undergone testing for COVID-19 prior to the visit should not be refused entry to the Facility and should be provided an FDA-approved antigen test at the Facility at the time of entry. 4. Visitors who show documentation of recovery from COVID-19 within the last 90 days are exempt from this requirement. The Order further indicated that visitors who are 18 years of age or older must present photo identification with their proof of a negative test result, and visitors who are unable or unwilling to provide proof of the required negative test result may not be permitted entry into the Facility. However, the facility should be prepared to offer visitation in an outdoor space…” The Order also indicated that “Essential visitors as defined in All Facilities Letter (AFL) 20-22 are exempt from the testing requirement above and cannot be restricted access to any zone within the facility. A review of the local health department’s “Guidelines for Preventing & Managing COVID-19 in Skilled Nursing Facilities,” updated 12/15/21, indicated that general visitation should be supported by the facility… The Guidelines indicated that residents or their designated representative when the resident does not have capacity, should be involved, and have their preferences prioritized in the determination of essential visitors (e.g., caregivers/essential support persons, compassionate care visitors). The Guidelines indicated the definition of essential and general visitors: “1. Essential visitors are exceptions to visitation restrictions and should be permitted visitation regardless of facility’s outbreak status or COVID-19 status of the resident receivi