**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure a safe and sanitary environment which promoted the prevention of the spread of infection for 11 of 12 sampled residents (Residents 1, 2, 3, 4, 5, 7, 8, 9, 10, 11 and 12) when: 1. Resident 3 and Resident 4 had Clostridium difficile infections (C-Diff, a highly contagious bacteria in their intestines that causes severe diarrhea, inflammation of the colon, abdominal discomfort, lack of appetite, weight loss, isolation, extended hospital stays, and death); and a. Housekeeping Staff (HSK) had not disinfected Resident 3 and Resident 4's rooms which were contaminated with C-diff, with a disinfectant that was approved to kill C-diff. (According to the Centers for Disease Control (CDC), C-diff bacteria produces spores that can live on surfaces for months and years), and continued to clean 21 other resident rooms on 2 of 3 facility units; and b. Licensed Nurse (LN) C used a glucometer (a machine used to check blood sugar levels in diabetics), on Resident 4 and did not have a disinfectant approved to kill C-diff available to clean the glucometer after she used it. LN C then placed the contaminated glucometer back in her medication cart, where medications were kept for 17 other residents, and the glucometer was available to be used on other residents; and c. Certified Nursing Assistant (CNA) E, used a thermometer and a pulse oximeter (a device placed on a finger that checks oxygen levels), on Resident 4, and had not disinfected the equipment and then used that same equipment on 9 other residents. These failures had the likelihood to spread C-Diff infections to all 27 residents who resided on 2 of the 3 units of the facility and spread C-diff infections to staff and visitors with the likelihood to negatively impact their health, safety and welfare by serious illness, harm, impairment and death. Due to the facility's likelihood to cause injury, harm, impairment, and death by spreading C-Diff infections to 27 of 27 residents who resided on 2 of 3 units where there were C-diff infections, an Immediate Jeopardy situation was identified on 1/27/23 at 4:45 pm, in the presence of the Director of Nursing (DON) and by phone to the Corporate Nurse Consultant (NC) and an immediate corrective action plan was requested. On 2/1/23 at 12:00 pm, an immediate corrective action plan was accepted from the DON. On 2/2/23 at 10:30 am, the California Department of Public Health (CDPH) conducted an on-site visit to the facility and verified that the facility had implemented their immediate corrective action plan and ensured that there was no longer any immediate threats to the health, safety, and welfare of their residents, staff and visitors by means of spreading C-Diff infections. 2. Resident 3 was suspected of having C-diff and was not placed on Contact Isolation (precautions and the use of personal protective equipment to prevent the spread of infection by touching the resident and surfaces in th room), for 2 days. 3. Personal laundry for 5 of 10 residents (Residents 2, 3, 10, 11, and 12) that was contaminated with urine and feces, was lying on the floor of a cabinet in their rooms and not contained in a closed bag to prevent the spread of germs. 4. Two of 5 dining room tables on the Cottage unit had nicks and dents, 2 of 3 resident dining room counter tops on the Villa and Cottage units were pitted, dented, chipped and cracked, and 1 of 3 cloth chairs in the Villa dining room was torn. 5. Five of 8 resident's rooms (Residents 1, 2, 3, 5, and 7) had brown substances and gray dust balls on their floors and under their beds, corn chips and other food crumbs on the floors, and 2 of 4 bathrooms observed had brown smears of feces on the toilet and walls. 6. Two of 2 resident's (Resident 8 and 9) oxygen concentrators (a machine that provides oxygen to a resident), were observed to have thick brown dust on their filters. Findings: The facility's policy titled, Clostridium Difficile dated October 2018, was reviewed The policy indicated, Measures are taken to prevent the occurrence of Clostridium difficile infections (CDI) among residents. Precautions are taken while caring for residents with C. difficile to prevent transmission to other residents. The primary reservoirs for C. difficile are infected people and surfaces. Spores can persist on resident-care items and surfaces for several months and are resistant to some common cleaning and disinfection methods. C-difficile is transmitted via the fecal-oral route. Therefore, any resident-care activity that involves contact with the resident's mouth when hands or instruments are contaminated may provide an opportunity for transmission Residents with diarrhea associated with C. difficile are placed on Contact Precautions: A category of transmission-based precautions when transmission of a germ can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care item in the resident ' s environment. Precautions include, isolating the resident by a private room or other means, staff and visitors wear gloves and gowns when entering room and dispose of gloves and gowns when leaving room and washing hands with soap and water. Environmental cleaning in rooms of residents with CDI is done with a disinfecting agent recommended for C. difficile (e.g., household bleach and water solution or an EPA [Environmental Protection Agency, an agency that is responsible for the protection of human health and the environment], registered germicidal [a substance or other agent that destroys harmful germs] agent effective against C. difficile spores. The facility's policy titled, Isolation -Categories of Transmission-Based Precautions dated October 2018, was reviewed and indicated, Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection When transmission-based precautions are in effect, non-critical resident-care equipment (thermometers, pulse oxygen machines, and glucometers) will be dedicated to a single resident when possible. If re-use of items is necessary, then the items will be cleaned and disinfected according to current guidelines before use with another resident. The facility's policy titled, Cleaning and Disinfecting Residents' Rooms dated August 2013, was reviewed and indicated, 1. Housekeeping surfaces (floors and tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 2. Environmental surfaces will be disinfected on a regular basis .and when surfaces are visibly soiled. 4. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. 1. A review of Resident 3's admission record dated 1/6/23, indicated that Resident 3 was admitted on [DATE] with diagnoses that included, COVID-19 (Coronavirus disease, a respiratory infection), urinary tract infection, and dementia (a loss of memory, language, problem-solving and other thinking abilities). A review of Resident 3's lab results for C.diff testing indicated that Resident 3 had tested positive for C-Diff on 1/14/23. On 1/24/23 at 11:59 pm, a sign was observed on Resident 3's door that indicated, Contact Enteric [vomiting or diarrhea] Precautions, Everyone Must: Clean hands with sanitizer when entering room, wash with soap and water upon leaving room. Gown and glove when entering the room. Doctors and staff must: Use patient dedicated or disposable equipment. Clean and disinfect shared equipment before leaving room. A review of Resident 4's admission record dated 1/13/23, indicated that Resident 4 was admitted on [DATE] with diagnoses that included diabetes, muscle weakness and the need for assistance with personal care. A review of Resident 4's lab results dated 1/17/23, indicated that Resident 4 had tested positive for C-Diff. During an observation and interview on 1/27/23 at 12:08 pm, with CNA F, Resident 4's door was observed to have a sign posted titled, Contact Enteric Precautions . CNA F confirmed that Resident 4 was on isolation for C-Diff and had been for about a week. a. On 1/24/23 at 1:47 pm, an interview was conducted with HSK C. HSK C indicated that she was assigned to clean Resident 3's room, but did not know why the resident was on isolation. HSK C indicated that she was not aware of any special cleaning products that needed to be used in Resident 3's room, and continued to clean 10 other rooms after that. On 1/24/23 at 2:18 pm, an interview was conducted with the Housekeeping Supervisor (HSKS). HSKS indicated that he was not aware of any residents in the facility who had C-diff, or that rooms with C-diff contamination required any special cleaning solutions. On 1/27/23 at 1:07 pm, an observation and interview was conducted with HSK D. HSK D indicated that he cleaned Resident 4's room, and 11 other rooms after that. HSK D indicated that he was not aware that Resident 4 had C-diff or that rooms contaminated with C-diff required disinfectants that killed C-diff spores. HSK D indicated that he had cleaned Resident 4's room earlier in the day with, Room Sense 200 Disinfectant and Neutral Multi-Purpose Floor Cleaner. An observation with HSK D of the labels on the Room Sense and Neutral Multi-Purpose cleaners indicated that they would not kill C-diff. HSK D confirmed the cleaning solutions he had used to clean Resident 4's room would not kill C-diff. On 1/27/23 at 1:30 pm, an inteview and concurrent observation was conducted with the DON and HSKS. The Environmental Protection Agency (EPA registered cleaning products, their uses, and protection of the environment and humans), List K: Antimicrobial products Registered with EPA for Claims Against Clostridium Diffficile dated June 15, 2016, was reviewed with the DON and HSKS and both confirmed that Room Sense and Neutral Multi-Purpose floor cleaner were not listed as cleaners on the EPA's list that would kill C-diff. The DON indicated that a bleach product or EPA registered product specifically to kill C-diff should have been used and was not. The HSKS confirmed the facilty was out of bleach and bleach containing products. b. On 1/27/23 at 12:59 pm, an observation and interview was conducted with LN C. LN C indicated that she had checked Resident 4's blood sugar earlier that day with a glucometer that she was not able to disinfect afterwards because she did not have any disinfecting supplies available. LN C confirmed that her medication cart held medications for 17 other residents, and that she had put the contaminated glucometer back into her medication cart after checking Resident 4's blood sugar, without disinfecting it. LN C indicated that she did not know what disinfectant should have been used to kill C-Diff. On 1/27/23 at 1:27 pm, the HSKS and DON were interviewed. The HSKS indicated that the glucometers could be disinfected with Purell Food Service Surface Sanitation wipes (alcohol) and/or Health Care Clorox (Bleach) wipes, but confirmed that the facility did not have the Health Care Clorox wipes available, they are on backorder. The DON indicated that Purell Food Service Surface Sanitation wipes would not kill C-diff, because they are alcohol based and alcohol does not kill C-diff. The DON indicated that the Clorox bleach wipes would have been the appropriate disinfectant to use to disinfect the glucometer in order to kill C-diff, I expect my nurses to know this. The DON confirmed that LN C should not have put the contaminated glucometer back into her medication cart after she used the device on Resident 4. The DON indicated that he was not aware that the facility had ran out of Clorox wipes. c. On 1/27/23 at 12:54 pm, CNA E was interviewed. CNA E confirmed that she was aware that Resident 4 had C-diff. CNA E indicated that she had used a thermometer and pulse oximeter on Resident 4 that day and several days before that, and had used alcohol to wipe off the equipment. CNA E confirmed that she continued to use the same thermometer and pulse oximeter on the rest of her 9 residents. CNA E indicated that she did not know that alcohol would not kill C-diff and stated, we should have adequate cleaning stuff and this patient should have dedicated equipment and they should have provided us with that, they should have told us. 2. The facility's policy titled, Clostridium Difficile dated October 2018, was reviewed and indicated, Residents with diarrhea and suspected CDI [C-Diff Infections], are placed on Contact Precautions while awaiting laboratory results. The facility's policy titled, Isolation-Categories of Transmission-Based Precautions dated October 2018, was reviewed and indicated, The individual on contact precautions will be placed in a private room . During a review of Resident 3's nursing progress notes dated 1/12/23 at 10:07 am, LN L documented, Resident is having more than three loose stools per day for the third day .send a stool specimen to the lab to check for C-Diff. During a review of Resident 3's lab results for C-Diff dated 1/14/23, the results revealed that Resident 3 was positive for C-diff from the stool sample that was collected on 1/12/23. During a review of Resident 3's nursing progress notes dated 1/14/23 at 1:04 pm, the DON documented, Results of stool testing show C-Diff. Resident moved to a private room for contact precautions. On 2/10/23 at 3 pm, an interview and concurrent review of Resident 3's record was conducted with the Infection Prevention nurse (IP). The IP confirmed that Resident 3 was having symptoms of C-diff (diarrhea) and was therefore, suspected to have C-diff on 1/12/23, but was not placed in a private room with Contact Precautions until 1/14/23. The IP indicated that Resident 3 should have been placed in a private room and on Contact Precautions on 1/12/23, when she was first suspected to have C-diff, to avoid spreading the infection to others and that was not done. On 2/10/23 at 4:15 pm, the DON confirmed during an interview that Resident 3 should have been moved to a private room and placed on Contact Precautions on 1/12/23 instead of on 1/14/23, and that the facility had not followed their infection prevention policies. 3. The facility's policy titled, Appendix D-Linen and laundry management dated March 27, 2020, was reviewed and indicated, Always place it [soiled laundry] in the designated container. Carefully rollup soiled linen to prevent contamination of the air, surfaces, and cleaning staff. Place soiled linen into a clearly labeled, leak proof container (e.g., bag, bucket). The facility's policy titled, Appendix G-Laundry and Bedding dated November 5, 2015, was reviewed and indicated, The contaminated textiles and fabrics are placed into bags or other appropriate containment .these bags are then securely tied or otherwise closed to prevent leakage. On 1/24/23 at 11:13 am, an interview and observation was conducted with Resident 2. A pair of wet pants were observed laying on the floor of a cabinet under the TV in Resident 2's bedroom and not contained in a bag or laundry basket. Resident 2 indicated that the cabinet was where his dirty laundry was kept and indicated that his pants were wet with urine from that morning and his CNA threw the wet pants in the cabinet. On 1/24/23 at 11:52 am, during an interview and observation, CNA E confirmed that she had put those urine soaked pants of Resident 2 on the floor of the cabinet in his bedroom. CNA E confirmed that there was no laundry basket in the cabinet and indicated that she should have put them in a bag. On 1/24/23 at 11:59 am, an observation and interview was conducted with Resident 3. A pair of wet flannel pants were observed on the floor of the cabinet under her TV, and were not contained in a plastic bag and there was no laundry basket in the cabinet. Resident 3 indicated that those flannel pants were soaked with urine from the night before and her CNA threw them in the cabinet. On 1/24/23 at 2:18 pm, during an interview with HSKS, he indicated that dirty, wet or soiled laundry should be put into plastic bags before going into the cabinet. On 1/27/23 at 12:54 pm, an observation and interview was conducted with Resident 10. A wet blanket was observed in the cabinet under the TV in Resident 10's bedroom. Resident 10 indicated that his blanket was wet with urine and thrown into the cabinet without being put into a plastic bag. On 1/27/23 at 3:51 pm, an inteview was conducted with the IP. The IP indicated that the residents' dirty laundry should be put in a plastic bag before being placed in their cabinets to contain germs. The IP indicated she had been doing monitoring of this and confirmed that this practice was not being done. The IP explained that the facility did not have laundry facilities and that residents' personal laundry was being done every other day at another skilled nursing facility. She indicated the cabinet was considered a dirty area and should be disinfected by housekeeping. On 1/31/23 at 2:30 pm, an observation was conducted in Resident 11 and 12's bedroom. Soiled laundry was observed on the floor of their cabinets where the facility was also keeping their slippers, foot pedals to their wheelchairs, clean briefs (adult diapers), wash basins, and a coloring book. On 1/31/23 at 3:05 pm, an interview and concurrent observation was conducted with CNA J. CNA J confirmed that the cabinet in Resident 3's bedroom had dirty laundry, clean briefs and wheelchair foot pedals all stored together. CNA J indicated that none of those clean items should be stored with dirty laundry. 4. The facility's policy titled, Cleaning and Disinfection of Environmental Surfaces dated June 2009, was reviewed and indicated that, Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standards. The CDC Guidelines for Disinfection and Sterilization in Healthcare Facilities dated 2008, was reviewed and indicated, 2.f. Inspect equipment surfaces for breaks in integrity that would impair either cleaning or disinfection/sterilization. Discard or repair equipment that no longer functions as intended or cannot be properly cleaned and disinfected or sterilized. On 1/27/23 at 12:59 pm, an observation was conducted in the Cottage unit. A counter that was measured to be 9 feet long in the resident's dining room, was pitted, dented, cracked and chipped on over half of the surface. On 1/27/23 at 1:05 pm, an observation and interview was conducted on the Cottage unit with CNA E. Two of 5 resident dining room tables were observed covered with pits and dents. CNA E confirmed that the resident dining room table surfaces contained pits and dents and could not be disinfected in that condition. On 1/27/23 at 2:50 pm, an observation and interview was conducted on the Villa unit with LN H. One cloth swivel chair in the dining room was observed to be torn and stained. LN H confirmed that the material on the swivel chair was ripped up and was filthy and could not be cleaned or disinfected in that condition. On 1/27/23 at 4:37 pm, during an interview and observation with the DON, he confirmed that the damaged countertop and resident dining room tables on the Cottage unit could not be disinfected in their current condition and needed to be replaced. On 1/31/23 at 2:45 pm, an observation and interview on the Villa unit was conducted with LN H. A counter that measured 9 feet in the resident's dining rooming was observed to be pitted, dented, cracked and chipped. LN H indicated that the countertop was not sealed anymore and confirmed there were many pits and dents on it. LN H indicated that the counter could not be disinfected anymore and was, filthy and gross. 5. The facility's policy titled, Cleaning and Disinfecting Residents Rooms dated August 2013, was reviewed and indicated, Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. On 1/24/23 at 11:13 am, an observation and interview was conducted with Resident 2. Resident 2's bedroom had a large amount of corn chips, gray balls of dust, brown spots, and papers on his floor. His bathroom had a brown smear on the toilet seat. Resident 2 indicated that his room had not been cleaned for a couple of days. He indicated that he had dropped corn chips on his floor a couple of days ago and had asked a housekeeper to clean it up, but it had not been done yet. On 1/24/23 at 11:33 am, an interview was conducted with Resident 5 who indicated that her room was not cleaned every day and that there was dust and food on her floor. On 1/24/23 at 11:36 am, an interview was conducted with HSK C. HSK C indicated that there was no daily cleaning schedule for resident rooms and indicated that she was unable to clean all of the resident's rooms during her shift therefore, some rooms did not get done. On 1/24/23 at 11:47 am, Resident 7's room was observed to have balls of dust on his floor and under his bed. On 1/24/23 at 11:52 am, during an interview and observation with CNA I, she confirmed that there was corn chips, balls of dust, and brown spots on Resident 2's bedroom floor. CNA I confirmed that Resident 2's toilet had a dried smear of a brown substance on the seat. CNA I indicated that she did not know when Resident 2's room had been last cleaned. On 1/24/23 at 1:33 pm, an interview and observation was conducted with CNA E. Resident 3's bathroom was observed to have a dried brown substance on her toilet and bathroom wall. CNA E confirmed that Resident 3's toilet and bathroom wall had a dried brown substance smeared on them and indicated she did not know when Resident 3's bathroom was last cleaned. On 1/24/23 at 2:07 pm, an interview and record review was conducted with the HSKS. The HSKS indicated that he had not been monitoring if resident rooms were getting cleaned daily and that there was not a daily room cleaning schedule. A review of the HSKS, room cleaning check off list showed that the last entry was 1 year and 1 month ago. HSKS stated that he, had not been able to get to this yet. On 1/24/23 at 2:35 pm, an interview was conducted with the DON. The DON confirmed that Resident 3 was on Contact Isolation for C-Diff and indicated that her room and bathroom should have been disinfected with bleach or an EPA approved C-Diff killing disinfectant, and that the housekeeping staff should have known this. On 1/27/23 at 11:02 am, Resident 1's Family Member (FM) 2 was interviewed. FM 2 stated that Resident 1's room was, filthy, with food on the floor and the counters and tables were always dirty. On 1/27/23 at 12:17 pm, an observation and interveiw was conducted with Resident 1. Potato chips were observed on his floor and Resident 1 stated, they clean the room about every three to four days. 6. The facility's policy titled, Concentrator Maintenance dated 8/5/09, was reviewed and indicated, clean the gross particle filter when visibly dirty. On 1/27/23 at 11:28 am, an observation of Resident 9 and Resident 10's oxygen concentrator filters (filters prevent dust, pollen, hair, mites and other contaminants from getting into the machine and infecting the resident). Resident 9 and 10's oxygen concentrator filters were observed covered in a thick brown dust. On 1/31/23 at 2:45 pm, an observation and interview was conducted with LN H. LN H confirmed that Resident 9 and 10's oxygen concentrator filters were covered in a thick brown dust and indicated that it was up to the housekeeping staff to clean them. On 1/31/23 at 4:00 pm, an observation and interview was conducted with the HSKS. The HSKS confirmed that the oxygen concentrator filters for Resident's 9 and 10 were covered with a thick brown dust and stated, they need to be cleaned. HSKS indicated that the concentrator could malfunction if too much dust got into the machine. The HSKS indicated that the nurses were responsible for keeping the filters clean and that his department did not have a policy for this procedure. On 2/10/23 at 4:15 pm, during an interview the DON indicated that the oxygen concentrator filters were to be cleaned by the housekeeping staff.