Health inspection·September 27, 2024

The following reflects the findings of the California Department of Public Health (Department) during the investigation of a complaint. Complaint number: CA00913650. A Class B citation was issued. Regulatory Violations: 22 CCR §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 patients, 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. 22 CCR §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 8/7/2024, the Department of Public Health (State Survey Agency [SSA]) made an unannounced visit to the facility to conduct an abbreviated survey for a complaint. The facility failed to report a coronavirus Disease (COVID-19, a contagious disease caused by the severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2].) outbreak (a higher-than-expected number of occurrences of a disease in a specific location and time) within 24 hours to the SSA. As of 8/7/24, 28 residents and 21 staff had tested positive for COVID-19. During a concurrent interview and record review of the facility Infection Control Matrix (an excel spread sheet that indicates the total number of residents in the facility, total COVID positive residents as well as staff) with Infection Prevention Nurse (IPN) on 8/7/24 at 12:03 pm, IPN confirmed and stated that there were in an outbreak for COVID-19 given that 28 residents and 21 staff were affected. IPN stated that an outbreak must be reported to the Department of Public Health (DPH). The IPN confirmed and stated that the outbreak was not reported to DPH. The IPN further stated that COVID-19 outbreaks must be notified within 24 hours for a proper investigation. IPN stated that the failure to report within 24 hours of the outbreak could delay the investigation and potentially result in an increase in the number of staff and residents affected. During an interview with the Director of Nursing (DON) on 8/7/24 at 3:30 pm, the DON confirmed and stated the facility was in an active outbreak. The DON stated outbreaks must be reported to DPH for a proper investigation of what may be causing an increase in the COVID-19 outbreak. During a review of the facility's policy and procedure titled "Reportable Diseases," revised 1/29/2024, the P&P indicated, Certain infectious, contagious, or communicable diseases are reported to appropriate city, county and/or state health department officials. The policy interpretation and implementation listed the following: 1. Should any resident(s) or staff be suspected or diagnosed as having a reportable communicable/infectious disease according to state-specific criteria, such information is promptly reported to appropriate local and/or state health department officials. 2. If the disease or condition is listed as a nationally notifiable infectious disease according to the Centers for Disease Control and Prevention (CDC), the infection preventionist, or designee, notifies the state health department. The facility failed to report a COVID-19 outbreak within 24 hours to the SSA. As of 8/7/24, 28 residents and 21 staff had tested positive for COVID-19. This violation had a direct or immediate relationship to the health, safety, or security of the residents.