Based on observation, interview, and record review the facility failed to ensure one (1) of 1 sampled resident (Resident 1) who was assessed at risk for elopement (a resident who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected) did not elope after going out- on- pass (OOP, temporary permission of a resident to leave the facility in a specified time) on 4/15/2025 at 6 PM by failing to: 1. Develop a care plan and interventions to address Resident 1's risk for elopement. 2. Implement procedures based on the facility's Elopement Risk policy to search for Resident 1 when Resident 1 did not return to the facility while OOP. 3. Ensure facility staff implement its elopement policy by failing to report to local police, administrator, and resident representative within two (2) hours and to California Department of Public Health (CDPH) within 24 hours from when Resident 1 eloped on 4/15/2025. 4. Ensure the facility has a system in place to identify risks for residents who independently go OOP such as wandering, falling, and/or injuries. As a result, Resident 1 left the faciity on OOP unsupervised on 4/15/2025 and did not return. This had the potential to be exposed to harsh environmental conditions including excessive heat and or cold, potential of being hit by a car and medical complications including malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat), dehydration (body loses too much water and other fluids that it needs to work normally), heat stroke (a life-threatening condition where the body's temperature rises dangerously high), and death. On 4/17/2025 at 10:16 PM, while onsite at Facility 1, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) was called in the presence of Director of Nursing (DON) and Administrator ( ADM) due to the facility's failure to supervise Resident 1 to prevent Resident 1's elopement from the facility. On 4/19/2025 at 4:35 PM the facility submitted an acceptable IJ removal plan (IJRP). After verification of IJRP implementation through observation, interview, and record review, the IJ was in the presence of the DON and ADM The IJ Removal Plan dated 4/19/2025, included the following: A. On 04/18/2025, all seven residents with out on pass order was reviewed and updated including the duration, purpose, and companion. If the resident will not return after specified duration, facility will call resident/family/companion for update on whereabouts and the time of return. If resident request to go out on pass independently, resident must meet all of the following criteria to be considered eligible and Interdisciplinary Team will review request to go out unaccompanied and document in Interdisciplinary notes. a. Cognitive Competency (Recent BIMS) b. Behavioral Stability (No recent history of elopement) c. Medical Stability (Medically cleared by Attending Physician) d. Functional Mobility B. MDS Coordinator and Registered Nurse Supervisor, re-assessed all seven residents with out on pass order and baseline care plan was updated. Elopement Risk Assessment was done for all 56 residents. Of those, 54 residents were identified as low risk for elopement and two residents were identified as high risk. C. Elopement Risk Policy and Procedures was revised and updated on 04/18/2025. The license personnel were in-serviced and educated on 04/18/2025 regarding timely assessment and identification of residents with high risk of elopement. Any episode of elopement reported and communicated to the Director of Nursing and Administrator so the facility leadership will be able to inform residents family, physician, regulatory Police Department, Ombudsman, California Department of Public Health and other regulatory agencies. D. Director of Staff Development/Director of Nursing in-service the license personnel regarding Policy and Procedure for elopement to emphasize in reporting to local police, administrator, and residents' representative within 2 hours and to California Department of Public Health within 24 hours when resident elopement. E. All residents with out on pass order was reviewed and updated including the duration, purpose, companion, and return time within four hours. A log was available to both nursing stations, regarding the time out and estimated time to return to the facility. Other residents who have potential to be affected by the deficient practice: A. Residents on high risk for elopement are potentially affected by the deficient practice. There were two residents identified as high risk after reviewing clinical records. The identified residents were re-assessed, care plan was developed and implemented, including monitoring every two hours. Log was available in the nursing station. B. An in-service was provided to License Nurses and direct care giver on 04/18/2025 by the Director of Staff Development and Social Service Director pertaining to: How to alert staff about resident elopement or missing How to locate or search the resident Reporting to governing agencies within 2 hours and CDPH within 24 hours. Measures that will be put in place to ensure that a deficiency will not occur A. The Director of Nursing/ Designee and Director of Staff Development conducted in-service to License Nurses and Certified Nursing Assistants on 04/18/2025 pertaining to the following: 1. Revised Policy and Procedure for Out on Pass Physician order for out on pass Duration and companion Protocol if the resident did not return after Specific duration Resident's decision against medical advice 2. Policy and Procedure for Elopement B. During daily angel rounds the Department Managers will check the out on pass log and discuss in the daily stand-up meeting. Monitoring A. The Director of Nursing Services/Registered Nurse Supervisor is responsible for monitoring the residents on a daily basis to ensure that the deficient practice will not be impacted. Results of the findings will be submitted and discussed to QAPI Committee during the monthly/quarterly QAPI meeting of its effectiveness. Findings: During a review of Resident 1's admission record, the admission record indicated the facility admitted Resident 1 on 3/11/2025. Resident 1's diagnoses of psychoactive substance abuse(drug addiction, is a disease that affects a person's brain and behavior and leads to an inability to control the use of a legal or illegal drug or medicine), unspecified alcohol- induced disorder (a medical condition characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences), generalized muscle weakness (a decrease in muscle strength), and unsteadiness on feet (the person is walking in an abnormal, uncoordinated, or unsteady manner). During a record review of Resident 1's Elopement Risk Assessment, dated 3/11/2025, the elopement risk indicated Resident 1 was at risk for elopement. During a review of Resident 1's Order Summary Report, dated 3/18/2025, the Order Summary Report indicated Resident 1 may go out on pass two times a week. During a review of Resident 1's Minimum Data Set (MDS, standardized care and screening tool), dated 3/24/2025, the MDS indicated Resident 1 had an intact cognitive (process of thinking and reasoning) skills for daily decision making. The MDS also indicated Resident 1 required partial moderate assistance (Helper does less than half the effort. Helper lifts, holds or support trunk or limbs, but provides less than half the effort) with walking 10 feet (ft., a unit to measure the length or distance) once standing and walking 50 ft. with two turns (once standing, the ability to walk at least 50 ft. and make 2 turns). During a concurrent review of Resident 1's Out on Pass (OOP)/ Leave of Absence log and interview with Registered Nurse 1 (RN1) on 4/17/2025 at 2:04 PM, RN1 stated Resident 1 left the facility by himself to go to the store and did not return at the expected time on 4/15/2025 at 9PM. During a review of Resident 1's nurses progress notes, dated 4/15/2025 at 11:08 PM, the progress notes indicated resident has not returned from OOP. The progress notes also indicated Licensed Vocational Nurse 1 (LVN1) called Resident 1 on his cellular phone, but the resident did not answer. During a review of Resident 1's nurses progress notes, dated 4/16/2025 at 5:58 AM, the progress notes indicated Resident 1 had not returned to the facility. During a review of Resident 1's nurses progress notes on 4/16/2025 from 10:33 AM to 1:27 PM, the nurses progress notes indicated Resident 1 was OOP. During a review of Resident 1's nurses progress notes from 4/16/2025 at 1:28 PM to 4/17/2025 at 7:59 AM, the nurses progress notes did not have any further documentation on the resident's whereabouts. During a review of Resident 1's nurses progress notes, dated 4/17/2025 at 8AM, the progress notes indicated, a late entry for 4/16/2025 at 8:30 AM that Resident 1 had not returned to the facility. Registered Nurse 1 (RN1) attempted to call Resident 1 but there was no response. RN 1 informed the medical doctor (MD1, primary physician), the Director of Nursing (DON), Administrator (ADM) and Social Service Director (SSD) that Resident 1 was not back from OOP. There were no new orders received from MD1. During a concurrent interview and record review on 4/17/2025 at 2:10 PM with RN1, Resident 1's Order Summary Report was reviewed. RN 1 stated order summary report dated 3/18/2025 indicated may go out on pass two times a week. RN1 stated Resident 1's OOP order was not specific because it did not indicate who will accompany the resident and for how long the resident may go OOP. During an interview on 4/17/2025 at 4:35 PM with LVN 1, LVN1 stated Resident 1 left the faciity on 4/15/2025 at 6PM for OOP and was expected to return at 9PM the same night (4/15/2025). LVN 1 stated Resident 1 was not back at 9PM (4 hours after Resident 1 left) so LVN 1 called Resident 1 on his cellular phone to verify the resident's whereabouts but did not get a reply. LVN1 stated he did not inform the DON, ADM or the police department. LVN 1 also stated he did not search for Resident 1 when he did not return as expected at 9PM or throughout his shift (3PM to 11PM on 4/15/2025). During an interview on 4/17/2025 at 4:40 PM with RN1, RN1 stated she notified MD1, DON, ADM and SSD on 4/16/2025 at 8:30 AM (11 hours and 30 minutes after) that Resident 1 has not been back at the facility since Resident 1 had gone OOP on 4/15/2025 at 6PM and was expected to return on 4/15/2025 at 9PM. RN1 also stated the facility did not search for the resident and neither did RN 1 report to the police nor to the department of public health about the Resident 1 not being back to the facility after OOP on 4/15/2025. During a review of Resident 1's Social Service Notes, dated 4/17/2025 at 5:42 PM, the Social Service notes indicated Resident 1 went OOP on 4/15/2025 at 4PM according to the signed OOP log. Resident 1 has not been back to the facility since 4/15/2025. During an interview on 4/17/2025 at 4:55 PM with the DON, the DON stated the facility did not search the facility and surrounding streets for Resident 1 on 4/15/2025 to 4/16/2025 because her understanding is that Resident 1 was not returning to the facility and did not consider it as an elopement. The DON confirmed that Resident 1 was in fact missing. The DON stated RN 2 reported to the police on 4/17/2025 at 3:15 PM (45 hours and 15 minutes from when resident left the facility) that Resident 1 has not been back to the facility since 4/15/2025 when resident went OOP. The DON stated she along with the IPN and SSD started calling hospitals and searched the facility surroundings on 4/17/2025 at 1:40 PM. During an interview on 4/17/2025 at 4:48 PM, the DON stated Resident 1 was at risk for elopement according to the elopement risk. The DON stated Resident 1 should have a care plan for elopement to ensure resident safety. During a concurrent interview and record review on 4/18/2025 at 12:45 PM with RN1, Resident 1's care plan was reviewed. RN1 stated Resident 1 does not have care plan for OOP and risk for elopement. RN 1 stated Resident 1 should have a care plan when going OOP and for risk for elopement. During an interview on 4/17/2025 at 6:48 PM with the DON, the DON stated any resident can go OOP even at nighttime if the resident is alert and oriented times four (4) and based on the resident's assessment such as if the resident is able to walk and can go by themselves. During a review of the facility's OOP policy, revised 7/2024, the policy indicated the resident may go out by him /herself if he/she is self-responsible depending upon physician's order. During a concurrent interview and record review on 4/17/2025 at 6:50 PM with the Administrator, Resident 1's Order Summary Report, dated 3/15/2025 was reviewed. The ADM stated Resident 1's order to may go out on pass two times a week was a blanket order because it is not specific. The ADM stated the order did not indicate how long was Resident 1 allowed to be OOP and did not indicate if Resident 1 can go OOP independently or be accompanied by a responsible person while OOP. During a concurrent interview and record review on 4/17/2025 at 6:55 PM with the Administrator, the Policy and Procedure titled, Out on Pass/ Against Medical Advice (AMA)/ Doctors Appointment, revised 7/20/2024 was reviewed. The ADM stated the policy did not have a timeframe indicating a duration of time for when the resident can be OOP. The ADM further stated facility staff should know procedures to follow when the resident does not return from OOP that include searching for residents if residents have not returned within a 4-hour timeframe, report to the responsible party, MD, ADM, DON, local police, and California Department of Public Health. During a concurrent interview and record review on 4/17/2025 at 7 PM with the Administrator, the Policy and Procedure titled, Elopement Risk Precautions and Procedures revised 7/2024 was reviewed. The ADM stated according to the policy, if the resident is not found within 2 hours, notify the local police, administrator, and resident representative and to notify California Department of Public Health (CDPH) within 24 hours from when Resident 1 eloped. The ADM confirmed that IPN reported Resident 1 missing to the local law enforcement on 4/17/2025 at 3:15 PM. During a review of the facility's Policies and Procedure (P&P) titled, Out on Pass/ Against Medical Advice/ Doctors Appointment, revised 7/2024, the P&P indicated to provide opportunity for the resident to participate in family and community life to maintain optimal functioning, the facility will respect resident's rights to be OOP unless otherwise contraindicated to the resident's medical needs. The P&P indicated the resident may go out by him /herself if he/she is self-responsible depending upon physician's order. During a review of the facility's P&P titled, Care Plan, revised 4/2024, the P&P indicated a care plan is a summation of the residents' concerns, goals, approaches and interventions in order to meet the goals and help minimize if not totally eradicate residents' problem. The P&P also indicated the resident care plan is developed within 7 days upon resident's admission, reviewed quarterly, annually or as often as needed as there is a change in condition. The evidence of a care plan that has been reviewed should include but not limited to the new interventions that have been added in addition to the current ones. These interventions should be in chronological order as implemented and carried out. During a review of the facility's P&P titled, Elopement Risk Precautions and Procedures, revised 7/2024, indicated the facility to identify residents who are wanderers or who are a threat to leaving the facility unattended without the knowledge of the facility staff. The P&P indicated to ensure the resident's safety utilizing the least restrictive means available. It also indicated when a resident believed to be missing, the following steps will be implemented: 1. The charge nurse shall be alerted that the resident is missing 2. The charge nurse of designee shall alert staff about the resident elopement or missing. All employees are to report to the nurse station. The charge nurse/ supervisor will explain the situation and designate where each staff person is to search. 3. Search the building: closet, shower, bathrooms and ground thoroughly. 4. If the facility search is unsuccessful, the surrounding streets and yards will be searched. 5. If the resident was not found within 2 hours, notify local police, administrator and responsible party. 6. Give the police a description and current photo of the missing resident. 8. If resident is not found within 24 hours even with the assistance of the police department of if found and resident sustains injury, department of public services will be notified in 24 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a concurrent observation in the kitchen and interview with KS 3 on 4/6/2023 at 10:10 AM, a large container of cottage cheese with a best by date of 4/5/2023 and a large container of sour cream with concealed expiration date were stored inside the kitchen refrigerator. KS 3 stated cottage cheese was supposed to be discarded after the best by date and the sour cream should show the expiration date, so kitchen staff know when to discard it. During an interview on 4/6/23 at 10:20 AM, the DSS stated expired and past the used by dates in the refrigerator should be discarded to prevent the items from being used and residents from getting sick. During an interview on 4/8/23 at 2 PM, KS 4 stated it is important to check expiration and use by dates on the ingredients used for cooking and discard them if labels are unclear and past the used by dates, so they do not give out food to residents that's expired and get them sick. A review of the facility's Policy and Procedure titled, Refrigerated Storage Practice, revised December 2014, indicated to check expiration dates of milk and other dated foods. Based on observation, interview and record review, the facility failed to follow safe food handling practices for two of two sampled residents (Resident 1 and 2) to prevent an unknown gastrointestinal (GI) outbreak (a sudden rise in the number of cases of an infectious disease) by: 1. Failed to ensure Kitchen Staff 1 (KS 1) did not work in the facility kitchen and prepare food for the residents on 3/27/2023 and from 3/30/2023 to 4/3/2023 while KS 1 was experiencing diarrhea (the passage of three or more loose or liquid stools per day) abdominal pain, vomiting, nausea, fever, and loss of appetite. 2. Failed to store refrigerated food items in accordance with professional standards for food service. Facility kept food items with unclear expiration dates and past used by dates in the refrigerator on 4/6/2023. These deficient practices placed the residents, facility staff and visitors at risk for contracting gastrointestinal (GI) infection and resulted to 21 residents (Residents 1,2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 and 21) and 5 facility staff (KS 2, Certified Nurse Assistant (CNA) 1, CNA 2, CNA 3, and CNA 4) to experience diarrhea, abdominal pain, vomiting, nausea, fever, and/ or loss of appetite. Resident 3, who experienced nausea, vomiting and diarrhea, was sent to the general acute care hospital (GACH) on 4/7/2023. Resident 4, who also experienced nausea, vomiting and diarrhea, was sent to the GACH on 4/5/2023. On 4/14/23 timed at 6:55 PM an Immediate Jeopardy (IJ: a situation in which the facility's' noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (ADM), Administrator In Training (AIT), and the Director of Nursing (DON) regarding the facility's failure to ensure KS 1 was not working in the facility kitchen and prepare food for the residents on 3/27/2023 and 3/30/2023 to 4/3/2023. On 4/16/2023 at 5:36 PM, the IJ was removed after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The surveyor verified and confirmed the implementation of the Plan of Action (POA) while onsite by observation, interview, and record review. The IJ was removed in the presence of the ADM and DON. The acceptable IJ Removal Plan included the following: 1. On 4/15/2023, ADM, provided counseling to KS 1 member that reported to work without informing her supervisor or any other department head that she was experiencing symptoms. 2. Facility has done in-service to dietary staff on 4/15/2023, given by back-up Infection Preventionist (IP) nurse, and DON, regarding the following topics: 2.a Employee screening: the importance of notifying the department heads when they are feeling sick and/or are experiencing any symptoms such as cough, fever, sore throat, chills, headache, diarrhea, muscle pain, fatigue (condition marked by extreme tiredness and inability to function due to lack of energy), nausea, vomiting, new loss of taste or smell, congestion, or runny nose 2.b Personal Hygiene, Safe Food Handling, Safe Food Handling/Handwashing, and the seriousness of food borne illness regarding how quickly it spreads, the potential and actual harm it can cause residents, and that it could lead to death. 3. The Supervisor of Dietary Services (DSS) and Manager of the Day (MOD) will monitor the new employee screening form which asks the staff member if they have experienced diarrhea, vomiting, nausea, stomach pain, cramping in the past 12-48 hours. as well as supervisors will randomly ask staff how they feel. Anyone who complains about sign or symptoms will immediately be asked to leave the premises until no longer experiencing signs and symptoms and a release letter has been issued from the physician. Department heads will inform the DON, ADM, and AIT if any of the above symptoms occur. 4. On 4/15/2023, the back-up Infection Preventionist nurse (IP) 2 and DON have in service to dietary staff on 4/15/2023 regarding the importance of notifying the department heads when they are feeling sick and/or are experiencing any symptoms such as cough, fever, sore throat, chills, headache, diarrhea, muscle pain, fatigue, nausea, vomiting, new loss of taste or smell, congestion, or runny nose. 5. The DSS and any other department heads will randomly ask dietary staff how they are feeling and if they are experiencing any symptoms every week. The Department heads will inform the DON, ADM, and the AIT if any of the above symptoms occur. 6. Counseling provided to Director of Dietary Services, on 4/15/2023, regarding requiring anyone who complains about signs or symptoms to immediately be asked to leave the premises until no longer experiencing signs and symptoms and a release letter has been issued from the physician. 7. Separate screening form, regarding GI symptoms, will be provided for the dietary department for them to complete on a daily basis to be monitored by the DSS or MOD and will report the findings to the ADM. All collected information will be taken to the Quality Assurance and Performance Improvement (QAPI) meeting and discussed for recommendations by the team to be implemented every month times 3 and then quarterly times 3. All in- services to be completed prior to the start of employee's next shift. Findings: 1. During an interview on 4/14/2023 at 2:45 PM, KS 1 stated, she first experienced symptoms of abdominal pain, diarrhea, vomiting, nausea, fever, and loss of appetite on 3/27/2023. KS 1 stated she worked at the facility as a dishwasher on 3/27/2023 and did not report her symptoms to DSS. KS 1 stated from 3/30/2023 to 4/3/2023 she was still having the same symptoms of abdominal pain, diarrhea, vomiting, nausea, fever, and loss of appetite. KS 1 stated she worked as a kitchen cook at the facility and prepared meals for the residents from 3/30/2023 to 4/3/2023 and she did not report to DSS or any of the facility staff that she was experiencing GI symptoms. A review of KS 1's Time and Attendance - Employee Punch History (timecard) dated 3/27/2023 to 4/14/2023, indicated KS 1 worked at the facility on 3/27/2023 from 9:38 AM to 6:14 PM. The timecard also indicated, KS 1 worked at the facility on 3/30/2023 to 4/3/2023 on different shifts (morning between 5 AM to 2:30 PM] or afternoon shift [between 2 PM to 7 PM]). During an interview on 4/14/2023 at 2:49 PM, Dietary Service Supervisor (DSS) stated that KS 1 did not report feeling sick on 3/27/2023 or on 3/30/2023 to 4/2/2023. The DSS stated, on 4/3/2023 after KS 1 finished working her entire shift KS 1 told DSS that she felt sick experiencing diarrhea. During an interview on 4/14/2023 at 3:50 PM, the DON stated, the staff identified to have first experienced the GI symptoms was KS 1. The DON stated, KS 1 had GI symptoms of abdominal pain, diarrhea, vomiting, nausea, fever, and loss of appetite which started on 3/27/2023 but KS 1 did not report being sick until 4/3/2023 at the end of her shift. The DON stated KS 1 was supposed to report her symptoms to DSS before coming to work on 3/27/2023. The DON stated it is important to report feeling sick if staff work in the kitchen to prevent the food from being contaminated, the residents from getting sick and from unknown GI outbreak to occur. A review of the facility's Acute Gastroenteritis (inflammation of the stomach and intestines resulting from bacterial toxins or viral infection and causing symptoms such as diarrhea, abdominal cramps, nausea, vomiting and fever) Surveillance Line List dated 4/5/2023 indicated on 3/28/2023, KS 1 experienced abdominal pain, diarrhea, nausea, vomiting, fever, and loss of appetite. A review of Resident 1's admission Record (AR) indicated the Resident 1 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes (a disease in which a person's blood glucose, or blood sugar, levels are too high). A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care-screening tool) dated 4/4/23, indicated Resident 1's cognition (mental processes, ability to understand and make decision) was intact. A review of Resident 1's Situation Background Assessment Recommendation (SBAR - written communication tool) dated 4/2/2023, indicated, Resident 1 had three (3) episodes of yellow- colored loose bowel movement (LBM). A review of Resident 2's AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included convulsions (a condition in which muscles contract and relax quickly and cause uncontrolled shaking of the body). A review of Resident 2's MDS dated [DATE], indicated Resident 2's cognition was severely impaired. A review of Resident 2's SBAR dated 4/4/2023, indicated, Resident 2 had episodes of nausea, vomiting and LBM. A review of Resident 3's AR indicated the resident was initially admitted to the facility on [DATE], with diagnoses that included type 2 diabetes (a disease in which a person's blood glucose, or blood sugar, levels are too high). A review of Resident 3's MDS dated [DATE], indicated Resident 3's cognition (ability to understand and make decision) was intact. A review of Resident 3's SBAR dated 4/4/2023 timed at 4:02 PM, indicated Resident 3 noted to have loose bowel movement (LBM/ diarrhea) with nausea and vomiting (not indicated how many times). A review of Resident 3's Nurses Progress Note (NPN) dated 4/4/2023 timed at 9:37 PM indicated Resident 3 had 1 episode of LBM (diarrhea) in moderate amount. A review of Resident 3's Acute Gastroenteritis Surveillance Line List dated 4/5/2023, indicated, on 4/3/2023 Resident 3 experienced diarrhea, nausea, and vomiting. A review of Resident 3's NPN dated 4/6/2023 times at 2:31 PM, indicated LBM (diarrhea) was noted at this time. A review of Resident 3's physician order dated 4/7/2023 indicated an order to transfer Resident 3 to GACH. A review of Resident 3's NPN dated 4/7/2023 times at 8:20 AM, indicated resident sent to GACH via 911 at 2:35 AM. A review of Resident 4's AR indicated the resident was initially admitted to the facility on [DATE], with diagnoses that included anemia (a condition in which the number of red blood cells within body is lower than normal). A review of Resident 4's MDS dated [DATE], indicated Resident 4's cognition was intact. A review of Resident 4's SBAR dated 4/4/2023, indicated, Resident 4 was experiencing nausea, vomiting and LBM (diarrhea). A review of Resident 4's SBAR dated 4/5/2023, indicated, Resident 4 was transferred to GACH. A review of the facility's Acute Gastroenteritis Surveillance Line List dated 4/5/23 indicated as follows for residents: a. On 4/2/2023, Resident1 and 2 experienced diarrhea, nausea, and vomiting. b. On 4/3/2023, Resident 3 and 13 experienced diarrhea, nausea, and vomiting. c. On 4/4/2023, Resident 4, 5, 6, 7, 8, 9, 10, 11, and 12 experienced diarrhea, nausea, and vomiting. d. On 4/5/2023, Resident 14 experienced diarrhea, nausea, and vomiting, and Resident 15 experienced diarrhea and nausea. e. On 4/6/2023, Resident 16 experienced vomiting and loss of appetite, Resident 17 experience diarrhea, nausea, and vomiting, and Resident 18 and 19 experienced nausea and vomiting. f. On 4/7/2023, Resident 20 experienced nausea, vomiting, and loss of appetite. g. On 4/8/2023, Resident 21 experienced diarrhea. A review of the facility's Acute Gastroenteritis Surveillance Line List dated 4/5/23 indicated as follows for staff: a. On 4/6/2023, KS 2 experienced diarrhea and vomiting. b. On 4/8/2023, CNA 1 experienced abdominal pain and nausea. c. On 4/9/2023, CNA 2 experienced abdominal pain, diarrhea, nausea and vomiting, CNA 3 experienced diarrhea and CNA 4 experienced nausea and vomiting. A review of the facility's P&P for Outbreak Investigation revised January 2023, indicated the facility will recognize and contain infectious disease outbreaks and outbreak measures will be instituted whenever there is evidence of an outbreak as outlined: - Goals of outbreak investigation and management are for prompt identification that an outbreak exits and to implement prompt resident placement, transmission- based precautions, and PPE in order to prevent the spread of outbreak. - The Infection Preventionist or designee will review details of signs or symptoms of infection for employee's call in sick and develop line listing of cases with signs or symptoms, onset date and details of illness for residents and employees. - To contain, control and prevent more cases facility will investigate potential cause of outbreak.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident 12's admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included paraplegia (paralysis affecting your legs, but not your arms) and stage 4 pressure ulcer (deep wound reaching the muscles, ligaments, or bones) of sacral (a large, flat, triangular shaped bone nested between the hip bones and positioned below the last lumbar vertebra) region. A review of Resident 12's MDS dated [DATE] indicated Resident 12 has no cognitive impairment. A review of Resident 8's admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest) and unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). A review of Resident 8's MDS dated [DATE] indicated Resident 8 has moderately impaired cognitive status. During a concurrent observation and interview on 4/6/2023 at 12:25 PM, CNA 6 entered Resident 12's room, set up the resident's lunch tray then touched the bed control at the foot of the bed without using gloves. CNA 6 proceeded to come out of Resident 12's room and puts his hands in his pockets performing hand hygiene. CNA 6 stated, he forgot to wear his gloves before he entered Resident 12's room who was on contact isolation and forgot to perform hand hygiene before exiting the resident's room. CNA 6 also stated gloves should be worn and hand hygiene should be done to prevent from contracting the infection. During an interview on 4/6/2023 at 12:40 PM, the LVN 1 stated staff are supposed to wear gloves when performing residents care to prevent the spread of the microorganism to other staffs and residents. During an observation on 4/6/2023 at 1 PM, the Treatment Nurse (TN) provided wound care and dressing change to Resident 1's wound on left foot with gloves on and TN was not wearing isolation gown. TN acknowledged she should have worn an isolation gown to protect herself from the infection that Resident 1 might have while performing wound care. During a concurrent observation and interview on 4/6/2023 at 1:40 PM, CNA 5 touched Resident 8 (who was observed with vomit all over the bed, clothes, and hands) and the call light system (device used by residents to call facility staff when they need help) without wearing gloves then immediately touched her (CNA 5) hair without performing hand hygiene. CNA 5 stated she should have used an isolation gown and gloves before touching the resident and performed hand hygiene to prevent getting the infection and spreading them to other residents and staffs. During an interview on 4/6/2023 at 4:45 PM, the DON stated staffs were advised to wear gowns and gloves before entering isolation rooms and touching the residents with suspected infections especially now with the unknown GI outbreak to prevent from spreading and getting the infections. During a concurrent observation and interview on 4/6/2023 at 5 PM, CNA 5 entered Resident 8's room without performing hand hygiene and without wearing isolation gown and gloves. CNA 5 stated she should have worn her PPE (isolation gown and gloves) and performed hand hygiene before and after going in and out of the room to prevent cross contamination to other residents and staff. 4. During an observation outside Resident 7's room on 4/6/2023 at 1:15 PM, there was no trash bin designated to discard used PPEs inside Resident 7's room. During an observation outside Resident 8's room on 4/6/2023 at 1:30 PM, Resident 8's room did not have a contact isolation sign posted outside the resident's room visible to facility staff and visitors to warn the residents, facility staff and/ or visitor on what PPE to use prior to entering the room. During an interview on 4/6/2023 at 4:45 PM, the DON stated contact isolation signs should be posted outside the isolation rooms to let the facility staff know what precautions to use before entering the room. The DON also stated trash bins to discard used PPEs inside isolation room is necessary for infection control so germs does not spread and will be confined in the trash can. The DON further stated if staff throws the PPEs they used in the resident's bathroom, other uninfected residents using the bathroom can possibly get exposed to whatever germs that is in the used PPEs. A review of the facility's policy and procedure titled, Infection Control, Standard Precautions, revised March 2001, indicated that standard precautions (set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin) will be used in the care of regardless of their diagnosis or presumed infection status. The policy indicated to perform hand washing after touching , body fluids, , and contaminated items, whether gloves are worn or not. The policy also stated to wear gloves when touching contaminated items and to wear a gown to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of , body fluids, secretions, or excretions. A review of the facility's policy and procedure titled, Categories of Infection Precautions, revised July 2012, indicated that along with the standard precautions, implement contact precautions for individuals assessed, known, or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environment surfaces or patient-care items in the resident's environment. The facility also stated Gastrointestinal infections as one of the infections requiring contact precautions. Based on observation, interview, and record review the facility failed to implement their policy and procedure for infection control to prevent infectious disease outbreak (a sudden rise in the number of cases of an infectious disease) for two of two residents (Resident 1 and 2) by: 1. Failed to ensure Kitchen Staff 1 (KS 1) did not work in the facility kitchen and prepare food for the residents on 3/27/2023 and from 3/30/2023 to 4/3/2023 while KS 1 was experiencing diarrhea (the passage of three or more loose or liquid stools per day) abdominal pain, vomiting, nausea, fever, and loss of appetite. 2. Facility failed to recognize an unknown gastrointestinal (GI, stomach and intestines) outbreak, identify organism/ source of infection, monitor, and control the spread of infectious disease when Resident 1 and Resident 2 had symptoms of diarrhea and vomiting on 4/2/2023 in accordance with the facility's policy and procedure. 3. Facility failed to ensure three (3) staff (Certified Nurse Assistant [CNA] 6, Treatment Nurse [TN, licensed nurse in charge of performing wound care] and CNA 5) were wearing Personal Protective Equipment (PPE) when working with residents on contact isolation (used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled) precautions. 4. Facility failed to ensure supplies (gloves) necessary for the care of residents on contact precautions are accessible and available for staff and visitors use. These deficient practices placed all the other 34 residents in the facility, facility staff and visitors at risk for contracting gastrointestinal (GI) infection and resulted in 21 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 and 21) and 5 facility staff (KS 2, Certified Nurse Assistant (CNA) 1, CNA 2, CNA 3, and CNA 4) experiencing vomiting and diarrhea. Resident 3, who developed symptoms of diarrhea, nausea, and vomiting, was sent to general acute care hospital (GACH) on 4/7/2023, and Resident 4 who also developed symptoms of diarrhea, nausea, and vomiting, was sent to GACH on 4/5/2023. On 4/14/23 timed at 6:55 PM an Immediate Jeopardy (IJ: a situation in which the facility's' noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (ADM), Administrator In Training (AIT) and the Director of Nursing (DON) regarding the facility's failure to ensure KS 1 was not working in the facility kitchen and preparing food for the residents from 3/27/2023 and 3/30/2023 to 4/3/2023, failure to recognize an unknown GI outbreak, identify organism or source of infection, monitor, and control the spread of infectious disease when Resident 1 and 2 experienced diarrhea and vomiting on 4/2/2023 and facility failed to report the unknown GI outbreak to the local public health (PHN) and district office / California Department of Public Health (CDPH) when Resident 1 and Resident 2 had diarrhea and vomiting on 4/2/2023. On 4/16/2023 at 5:36 PM the IJ was removed after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The surveyor verified and confirmed the implementation of the Plan of Action (POA) while onsite by observation, interview, and record review. The IJ was removed in the presence of the ADM and DON. The acceptable IJ Removal Plan included the following: 1. On 4/15/2023, ADM, provided counseling to KS 1 member that reported to work without informing her supervisor or any other department head that she was experiencing symptoms. 2. Facility has done in-service to dietary staff on 4/15/2023, given by back-up Infection Preventionist nurse (IP) 1, and DON, regarding the following topics: 2.a Employee screening: the importance of notifying the department heads when they are feeling sick and/or are experiencing any symptoms such as cough, fever, sore throat, chills, headache, diarrhea, muscle pain, fatigue (a condition marked by extreme tiredness and inability to function due to lack of energy), nausea, vomiting, new loss of taste or smell, congestion, or runny nose 2.b Personal Hygiene, Safe Food Handling, Safe Food Handling/Handwashing, and the seriousness of food borne illness in regarding how quickly it spreads, the potential and actual harm it can cause residents, and that it could lead to death. 3. Separate screening form, regarding GI symptoms, will be provided for the dietary department for them to complete daily. Dietetic Service Supervisor (DSS)/weekend Manager of the Day (MOD) will monitor and will report the findings to the ADM. 4. The facility's consultant, Registered Dietician provided an in-service on 4/18/2023 to the dietary department, for safe food handling, coming to work sick, and the seriousness of food borne illness, pertaining to seriousness and negative impact on resident's wellbeing. 5. On 4/15/2023, the ADM re-educated the DON on the policy and procedure of infection prevention and control. On 4/15/2023, IP 1 was in-serviced via telephone by ADM, on our in-house Outbreak Policy and Procedure, with specific emphasis on monitoring and recognizing signs of infection and the requirement to report two or more incidents of GI symptoms to the Department of Health completed using information from interviews of affected residents and staff, in order to find a root cause. 6. In-service was given by IP 1, on 4/15/2023, to licensed staff regarding change of condition (COC), recognizing symptoms of a potential viral outbreak, according to our in-house Outbreak Policy and Procedure, and how to report timely to the DON, ADM, and AIT. In-services will be completed prior to licensed staff next shift. 7. PHN was contacted 4/17/2023 to request reinforcement in-service on GI symptoms, Outbreak Management, and recognizing all symptoms that can lead to outbreak. 8. PHN requested the facility to add polymerase chain reaction (PCR) Biofire (a test used to identify pathogens [microorganisms that cause disease] associated with gastroenteritis [inflammation of the stomach and intestines, typically resulting from bacterial toxins or viral infection and causing vomiting and diarrhea]) laboratory test for Resident 21 (the last resident affected), who is 27th on the Line List since the resident was the last resident to come down with symptoms (diarrhea and vomiting), PHN felt that the sample would be most viable. The facility's laboratory cannot do the test, the facility is waiting for the laboratory to inform the facility whether the laboratory's out of -state- branch can assist with the test request. If the laboratory out- of- state branch is unable to provide the test facility will contact PHN department for further instructions and guidance. On 4/17/2023, facility will contact Laboratory 1 to see if they are able to do the PCR Biofire test. 9. IP 2 will compile data gathered during the outbreak and examine for improvement opportunities in identification and management of the disease. IP will develop a written report of the outbreak detail which will identify strategies that could be implemented to prevent future outbreaks or improve the process. Facility will implement the following strategies: - Re-educate staff on proper handwashing techniques, PPE (equipment worn to protect against infections) usage, initiate enhanced barrier protection (an approach of targeted gown and glove use during high contact resident care activities), contact isolation precautions (methods used for individuals with suspected infections to prevent the spread of it), disinfection, encourage fluid intake for residents, notifying facility/ supervisor when symptoms occur. - Interview all staff, from all departments, including department heads if any have GI signs or symptoms. - The physician of all symptomatic residents will be notified and requested to order stool culture (a test on a stool sample to find germs such as bacteria or a fungus [yeasts or molds] that can cause an infection). - Will be in close contact with the medical director - Utilize disinfectant cleaning solution as approved by the U.S. Environmental Protection Agency (EPA) - We will follow the recommendations from PHN in regards to activities and communal dining, and visitation. - Educate residents on handwashing and use of hand sanitizer - Residents with suspected symptoms of GI infection will be added to the line list to begin the tracking process. - Reinforce all departments on being observant when going into resident room, for COC. - Implement cleaning solutions in compliance with List G products (cleaning products used for Norovirus [very contagious virus that causes vomiting and diarrhea. You can get it from having direct contact with an infected person, consuming contaminated food or water and/ or touching contaminated surfaces and then putting your unwashed hands in your mouth. Outbreak can occur anytime but occur most often from November to April]). This information will be collected by medical records taken to the Quality Assurance and Performance Improvement (QAPI) meeting and discussed for recommendations by the team to be implemented every month x 3 and then quarterly x3. 10. Residents 1 and 2 had stool cultures done (Resident 1 on 4/2/2023 and Resident 2 on 4/5/2023) and Resident 1 also had complete blood count (CBC, a blood test that measures different parts of the blood) & complete metabolic panel (CMP, a test that measures several different substances in the blood) test on 4/2/2023. Findings: 1. During an interview on 4/14/2023 at 2:45 PM, KS 1 stated, she first experienced symptoms of abdominal pain, diarrhea, vomiting, nausea, fever, and loss of appetite on 3/27/2023. KS 1 stated she worked at the facility as a dishwasher on 3/27/2023 and did not report her symptoms to DSS. KS 1 stated from 3/30/2023 to 4/3/2023 she was still having the same symptoms of abdominal pain, diarrhea, vomiting, nausea, fever, and loss of appetite. KS 1 stated she worked as a kitchen cook at the facility and prepared meals for the residents from 3/30/2023 to 4/3/2023 and she did not report to DSS or any of the facility staff that she was experiencing GI symptoms. A review of KS 1's Time and Attendance - Employee Punch History (timecard) dated 3/27/2023 to 4/14/2023, indicated KS 1 worked at the facility on 3/27/2023 from 9:38 AM to 6:14 PM. The timecard also indicated, KS 1 worked at the facility on 3/30/2023 to 4/3/2023 on different shifts (morning between 5 AM to 2:30 PM] or afternoon shift [between 2 PM to 7 PM]). During an interview on 4/14/2023 at 2:49 PM, DSS stated that KS 1 did not report feeling sick on 3/27/2023 or on 3/30/2023 to 4/2/2023. The DSS stated, on 4/3/2023 after KS 1 finished working her entire shift KS 1 told DSS that she felt sick experiencing diarrhea. During an interview on 4/14/2023 at 3:50 PM, the DON stated, the staff identified to have first experienced the GI symptoms was KS 1. The DON stated, KS 1 had GI symptoms of abdominal pain, diarrhea, vomiting, nausea, fever, and loss of appetite which started on 3/27/2023 but KS 1 did not report being sick until 4/3/2023 at the end of her shift. The DON stated KS 1 was supposed to report her symptoms to DSS before coming to work on 3/27/2023. The DON stated it is important to report feeling sick if staff work in the kitchen to prevent the food from being contaminated, the residents from getting sick and the unknown GI outbreak that occurred. A review of the facility's Acute Gastroenteritis (inflammation of the stomach and intestines resulting from bacterial toxins or viral infection and causing symptoms such as diarrhea, abdominal cramps, nausea, vomiting and fever) Surveillance Line List dated 4/5/2023, indicated, on 3/28/2023 (as per KS 1 her GI symptoms started on 3/27/2023), KS 1 experienced abdominal pain, diarrhea, nausea, vomiting, fever, and loss of appetite. A review of the facility's Policy and Procedure (P&P) titled Norovirus Prevention and Control, revised August 2011, indicated the facility personnel who work with, prepare, or distribute food will be excluded from work if they develop symptoms of acute gastroenteritis and personnel will not return to work until 48 hours after the resolution of symptoms or longer as required by local health regulations. 2. A review of Resident 1's admission Record (AR) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes (a disease in which a person's blood glucose, or blood sugar, levels are too high) and atrial fibrillation (a serious abnormal heart rhythm). A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care-screening tool) dated 4/4/2023, indicated Resident 1's cognition (mental processes, ability to understand and make decision) was intact. A review of Resident 1's Situation Background Assessment Recommendation (SBAR - written communication tool) dated 4/2/2023, indicated that Resident 1 had three (3) episodes of yellow- colored diarrhea. A review of Resident 1's physician telephone order dated 4/3/2023 indicated an order for stool culture to rule out (R/O) Clostridium difficile (C. diff - a germ [bacteria] that causes life-threatening diarrhea). A review of Resident 1's Order Summary Report dated 4/6/2023, indicated, on 4/6/2023 (4 days from GI symptoms onset) resident was to be placed on contact isolation (the creation of barriers and other protection such as gloves, masks, or gowns to prevent the spread of an infection). A review of Resident 2's AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included convulsions (a condition in which muscles contract and relax quickly and cause uncontrolled shaking of the body). A review of Resident 2's MDS dated [DATE], indicated Resident 2 cognition was severely impaired. A review of Resident 2's SBAR dated 4/4/2023, indicated, Resident 2 was experiencing nausea, vomiting and loose bowel movement (LBM/ diarrhea). A review of Resident 2's physician telephone order dated 4/4/2023 indicated an order for stool culture. A review of Resident 3's AR indicated the resident was initially admitted to the facility on [DATE], with diagnoses that included type 2 diabetes. A review of Resident 3's MDS dated [DATE], indicated Resident 3's cognition was intact. A review of Resident 3's SBAR dated 4/4/2023 timed at 4:02 PM, indicated Resident 3 noted to have LBM (diarrhea) with nausea and vomiting (not indicated how many times). A review of Resident 3's Nurses Progress Note (NPN) dated 4/4/2023 timed at 4 PM indicated Resident 3 had LBM (diarrhea)) with nausea and vomiting. A review of Resident 3's NPN dated 4/4/2023 timed at 9:37 PM indicated Resident 3 had 1 episode of LBM in moderate amount. A review of Resident 3's Gastroenteritis Surveillance Line List dated 4/5/2023, indicated on 4/3/2023 (not consistent with Resident 3's SBAR dated 4/4/2023) Resident 3 experienced diarrhea, nausea, and vomiting. A review of Resident 3's NPN dated 4/6/2023 timed at 2:31 PM, indicated LBM was noted at this time. A review of Resident 3's physician order dated 4/7/2023 indicated an order to transfer Resident 3 to GACH. A review of Resident 3's NPN dated 4/7/2023 times at 8:20 AM, indicated resident sent to GACH via 911 at 2:35 AM. A review of Resident 3's physician's order dated from 4/4/2023 to 4/6/2023, did not indicate resident was to be placed on contact isolation. A review of Resident 4's AR indicated the resident was initially admitted to the facility on [DATE], with diagnoses that included anemia (a condition in which the number of red blood cells within body is lower than normal). A review of Resident 4's MDS dated [DATE], indicated Resident 4 cognition was intact. A review of Resident 4's SBAR dated 4/4/2023, indicated, Resident 4 was experiencing nausea, vomiting and LBM (diarrhea). A review of Resident 3's physician's order dated from 4/4/2023 to 4/6/2023, did not indicate resident was to be placed on contact isolation. A review of Resident 4's SBAR dated 4/5/2023, indicated Resident 4 was transferred to the GACH. A review of the facility's Acute Gastroenteritis Surveillance Line List dated 4/5/2023 indicated the following: a. On 4/2/2023, Resident 1 and 2 experienced diarrhea, nausea, and vomiting. b. On 4/3/202, Resident 3 (not consistent with SBAR when Resident 3 had GI symptoms onset on 4/4/2023) and Resident 13 experienced diarrhea, nausea, and vomiting. c. On 4/4/2023, Resident 4, 5, 6, 7, 8, 9, 10, 11, and 12 experienced diarrhea, nausea, and vomiting. d. On 4/5/2023, Resident 14 experienced diarrhea, nausea, and vomiting, and Resident 15 experienced diarrhea and nausea. e. On 4/6/2023, Resident 16 experienced vomiting and loss of appetite, Resident 17 experienced diarrhea, nausea, and vomiting, and Resident's 18 and 19 experienced nausea and vomiting. f. On 4/7/2023, Resident 20 experienced nausea, vomiting, and loss of appetite. g. On 4/8/2023, Resident 21 experienced diarrhea. A review of the facility's Acute Gastroenteritis Surveillance Line List dated 4/5/2023 indicated the following: a. On 4/6/2023, KS 2 experienced diarrhea and vomiting. b. On 4/8/2023, CNA 1 experienced abdominal pain and nausea. c. On 4/9/2023, CNA 2 experienced abdominal pain, diarrhea, nausea, and vomiting. It also indicated, CNA 3 experienced diarrhea and CNA 4 experienced nausea and vomiting. During an interview on 4/14/2023 at 4 PM, DON stated she cannot explain the reason as to why the contact isolation precautions were not done for Resident 1 and Resident 2 from 4/2/2023 to 4/5/2023. The DON stated the order should have been obtained from the resident's attending physician and implemented on 4/2/2023. The DON stated it was important to place residents (resident 1 and 2) on contact isolation to stop the spread of the infection. During a concurrent interview and record review on 4/14/2023 at 4:10 PM, ADM stated per facility's policy and procedure for outbreak investigation when two (2) or more residents are experiencing GI symptoms (diarrhea, vomiting, nausea, abdominal pain and/ or fever), outbreak control measures should be implemented. The ADM stated the facility's unknown GI outbreak which started on 4/2/2023 was reported to CDPH (via electronic notification) late on 4/5/2023. The electronic notification sent by the facility to CDPH, indicated the report of 14 cases (13 residents and 1 staff) with GI symptoms was sent on 4/5/2023. During an interview on 4/14/23 at 4:20 PM, DON stated the unknown GI outbreak was reported via electronic notification to CDPH on 4/5/2023 when a total of 14 cases: 1 Staff (KS 1) and 13 residents (Residents 1 to 13) were experiencing symptoms. The DON stated only a few symptomatic residents (Resident 1, 2, 3, 7, 10, 12, 13, 16,17, 20 and 21) were tested for stool culture that were experiencing GI symptoms (diarrhea and/ or nausea and vomiting). The DON stated she only got 4 stool culture test result from the 11 residents. The DON stated the 10 residents (Residents 4, 5, 6, 8, 9, 11, 14, 15, 18 and 19) have not been tested and the DON was unable to explain as to why the remaining 10 resident stool culture was not done. The DON stated, it was important to ensure correct laboratory test was done to ensure facility have recognized the source of infection and/ or type of bacteria or virus the facility need treat and prevent the spread. During the same interview on 4/14/2023 at 4:20 PM, DON stated outbreak was reported to PHN and CDPH (via electronic notification) on 4/5/2023 (3 days after the first 2 symptomatic residents). The DON stated, the IPN did not communicate with her why the GI outbreak was not reported until 4/5/2023 when it should have been reported on 4/2/2023. The DON stated it was important to ensure the facility report their outbreak to ensure they get guidance from PHN and to help control and manage the unknown GI outbreak. During an interview on 4/14/23 at 4:30 PM, DON stated she cannot explain the reason as to why there were inaccurate information in the facility's Acute Gastroenteritis Surveillance Line List dated 4/5/2023 such as the date when KS 1 first experienced symptoms of diarrhea, vomiting and fever. The DON stated, the line list indicated KS 1 symptoms started on 3/28/2023 wherein it should be 3/27/2023. The DON stated it was also inaccurate for Resident 3's onset of GI symptoms it should be 4/4/2023 instead of 4/3/2023. The DON stated, it is important to ensure the facility investigate, have an accurate monitoring and tracking of symptomatic residents and staff to be able to see trend and/ or possible source of infection in that way facility can provide the appropriate treatment and or control the spread of infection. A review of the facility's P&P for Outbreak Investigation revised January 2023, indicated the facility will recognize and contain infectious disease outbreaks and outbreak measures will be instituted whenever there is evidence of an outbreak as outlined: - Goals of outbreak investigation and management are for prompt identification that an outbreak exits and to implement prompt resident placement, transmission- based precautions, and PPE in order to prevent the spread of outbreak. - The Infection Preventionist or designee will review details of signs or symptoms of infection for employee's call in sick and develop line listing of cases with signs or symptoms, onset date and details of illness for residents and employees. - To contain, control and prevent more cases facility will investigate potential cause of outbreak. A review of the facility's P&P for Outbreak Investigation revised January 2023, indicated the facility will recognize and contain infectious disease outbreaks and outbreak measures will be instituted whenever there is evidence of an outbreak as outlined: Facility will notify State and local health officials as required by State Law, Public Health Codes or Ordinances, report reportable disease, illnesses, and new or unusual infections to public health agencies as soon as possible.