Health inspection·February 11, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Enhanced Standard Precautions ([ESP] a framework for reducing multi drug-resistant organism [MDRO] transmission by using gowns and gloves while caring for residents at high risk for MDRO transmission, at the point of care during specific activities, by contmainating health care workers' hands, clothes and the environment), which indicated to don (put on) PPE within room, before engaging in activity (resident care), if splash is anticipated, for two of eight sampled residents (Residents 6 and 7), who had physician ' s orders for wound care. Residents Affected - Few This deficient practice had the potential to result in transmission of a disease-causing organisms, affecting the other residents in the facility, and the potential for the affected residents ' delay in wound healing process. Findings: 1). During a review of Resident 6 ' s admission Record, the admission Record indicated Resident 6 was originally admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses including muscle weakness (a lack of muscle strength or the inability to control voluntary muscle force) unspecified Dementia (a progressive state of decline in mental abilities) and quadriplegia (a condition characterized by the partial or complete loss of motor and sensory function in all four limbs) of the arms and legs. During a review of Resident 6 ' s History and Physical (H&P) dated 12/13/2024, the H&P indicated Resident 6 did not have the mental capacity to understand and make medical decisions. During a review of Resident 6 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 12/15/2024, the MDS indicated Resident 6 usually understand and be understood by others. The MDS indicated Resident 6 required substantial to maximum assistance for bed mobility, transfer, walking, eating, personal hygiene and toileting. During a review of Resident 6 ' s physician ' s order dated 1/27/2025, the physician ' s order indicated Resident 6 had a left heel Stage 3 pressure ulcer (deep and painful wounds in the skin). The physician ' s order indicated to cleanse the left heel with antiseptic spray, pat dry and apply santyl (an ointment used to remove damaged tissue from chronic skin ulcers), collagen alginate (type of dressing) then covers with bordered dressing, wrap with kerlix and secure with tape dressing daily, for 30 days. During a concurrent observation and interview on 2/11/2025 at 9:20 a.m. with Licensed Vocational Page 1 of 2 055072 055072 02/11/2025 Rosecrans Care Center 1140 West Rosecrans Avenue Gardena, CA 90247

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Nurse (LVN) 1, in Resident 6 ' s room, an ESP sign was observed outside Resident 6 ' s room. LVN 1 was observed performing wound care on Resident 6 ' s left heel without an isolation gown. LVN 1 stated, I did not used a gown while providing Resident 6 ' s left heel wound care, which was a precaution to minimize the transmission of bacteria to the wound. 2. During a review of Resident 7 ' s admission Record, the admission Record indicated Resident 7 was admitted to the facility on [DATE], with diagnoses including unstageable pressure ulcer (a pressure sore where the extent of tissue damage cannot be accurately assessed due to a thick layer of dead tissue) to left and right buttocks, unstageable pressure ulcer to right ankle and chronic kidney disease stage 3 (a mild to moderate loss of kidney function). During a review of Resident 7 ' s H&P dated 12/23/2024, the H&P indicated Resident 7 did not have the mental capacity to understand and make medical decisions. During a review of Resident 7 ' s MDS dated [DATE], the MDS indicated Resident 7 usually understand and be understood by others. The MDS indicated Resident 7 required substantial/ maximum assistance for bed mobility, transfer, walking, eating, personal hygiene and toileting. During a review of Resident 7 ' s Treatment Administration Record (TAR) for 2/2025, the TAR indicated Resident 7 had a sacro-coccyx stage 4 (full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bones) pressure injury. The TAR indicated to cleanse the sacrococcyx with normal saline ([NS] a sterile solution containing 0.9% sodium chloride in water), pat dry and apply santyl ointment, then cover with bordered dressing, daily for 21 days. The TAR indicated Resident 7 had a left lateral malleolus stage 4 pressure injury with order to cleanse with NS, pat dry and apply santyl ointment, then cover with bordered dressing, daily for 21 days. During a concurrent observation and interview on 2/11/2025 at 10:23 a.m. with LVN 2, in Resident 7 ' s room, an ESP sign was posted outside Resident 7 ' s room. LVN 2 was observed performing wound care on Resident 7 ' s sacrococcyx area and left lateral malleolus wounds, without an isolation gown. LVN 2 stated I should have worn an isolation gown before entering Resident 7 ' s room to perform the wound care. LVN 2 stated we used the ESP precautions to prevent any transmission of infection to another resident. During an interview on 2/11/2025 at 12:45 p.m. with Certified Nurse Assistant (CNA) 3, CNA 3 stated the ESP sign posted outside residents ' rooms meant, nurses should wear gown, mask and gloves before going inside the room to perform care, because these residents either had open wounds, gastric tube (tube surgically inserted into the stomach for feeding and medication administration) and these residents should be protected from any germs to get into open wounds. During an interview on 2/11/2025 at 2:30 p.m. with the Director of nursing (DON), the DON stated ESP precautions should be used when changing wound dressings. The DON stated ESP is also used on residents with history of Multiple Drug-Resistant Organisms (germs that are resistant to many antibiotics). The DON stated, the nurses must identify the isolation beds and use PPE when providing wound care or any activities involving close contact with the resident to prevent the transmission of any infection During a review of the facility ' s policy and procedure (P&P) titled, Enhance Standard Precautions, dated 2/20/2020, the P&P indicated to use PPE if splash is anticipated. The P&P indicated to don PPE within room before engaging in activity. 055072 Page 2 of 2