Health inspection·January 21, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to implement its policy and procedures (P&P) titled, Hand Hygiene, and Management of C. Difficile (a type of bacteria that can cause diarrhea) Infection, by failing to ensure staff washed their hands with soap and water after providing care for one of five sampled residents (Resident 2), who had C. Diff. Residents Affected - Few This deficient practice had the potential to result in cross-contamination (the transfer of harmful bacteria from one person, object, or place to another) and the spread of infection throughout the facility. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility originally admitted Resident 2 on 10/3/2024 and recently readmitted Resident 2 on 12/28/24 with diagnoses of dysphagia following cerebral infarction (a swallowing disorder that may occur after a stroke), respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide in the body), and pleural effusion (a condition in which fluid builds up in the space between the lung and the chest wall). During a review of Resident 2's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/1/2025, the MDS indicated Resident 2 was sometimes understood by others and had the ability to sometimes understand others. The MDS indicated Resident 2 was dependent (helper does all of the effort) in performing oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, and putting on and taking off footwear. During a review of Resident 2's Care Plan (CP), revised on 1/17/2025, the CP indicated Resident 2 had c. difficile. The CP included an intervention for C. difficile to encourage good handwashing technique. During an observation on 1/17/2025 at 12:02 pm, Licensed Vocational Nurse 1 (LVN 1) was observed in Resident 2's room wearing a gown, mask, and gloves while taking Resident 2's vital signs (measurements of the body's most basic functions). After LVN 1 was finished with Resident 2, LVN 1 wiped down the vital signs machine with bleach wipes then doffed (to remove) the gown and gloves. LVN 1 then used the hand sanitizer (alcohol-based substance used to reduce or eliminate some disease-causing agents on the skin) on the wall by the doorway. LVN 1 then plugged the vital signs machine into an electrical outlet across the hallway from Resident 2's room. During an interview on 1/17/2025 at 12:10 pm, and at 12:21 pm, with LVN 1, LVN 1 stated after taking Resident 2's vital signs, LVN 1 used the hand sanitizer. LVN 1 stated LVN 1 did not wash LVN 1's Page 1 of 2 055104 055104 01/21/2025 Sunset Manor Conv Hosp 2720 Nevada Avenue El Monte, CA 91733

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hands because Resident 2's roommate was using the restroom. LVN 1 stated using the hand sanitizer alone was not effective for C. difficile. LVN 1 stated it was important for staff to wash their hands to not spread the organism. During an interview on 1/17/2025 at 2:36 pm, with the Director of Nursing (DON), the DON stated if Resident 2's roommate was using the restroom, LVN 1 should have waited in Resident 2's room and washed LVN 1's hands after Resident 2's roommate finished using the restroom. The DON stated it was important for Staff to wash their hands to prevent infection transmission. During an interview on 1/21/2025 at 2:35 pm, with the Infection Preventionist (IP), the IP stated if Resident 2's roommate was using the restroom, it was not recommended for staff to go to another resident's room to wash their hands. IP stated staff would have to wait for Resident 2's roommate to finish using the restroom and then they could wash their hands. IP stated it was important to wash hands to kill the c. difficile spores on the hands if ever the hands came into contact with the contaminated part of the gloves. During a review of the facility's P&P titled, Hand Hygiene, revised on 12/19/2022, the P&P indicated, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility For conditions involving a resident, or the resident's environment, who is isolated for clostridioides difficile or other infectious diarrhea, handwashing with soap and water is required. During a review of the facility's P&P titled, Management of C. Difficile Infection, revised on 12/16/2024, the P&P indicated, The facility implements facility-wide strategies for the prevention and spread of clostridioides difficile (c. difficile) infections. 'Clostridioides difficile', formerly known as Clostridium difficile and often-called C. difficile or C. diff, is a bacterium that causes diarrhea and colitis (an inflammation of the colon). It is shed in feces and is spread by direct contact with contaminated objects or the hands of persons who have touched a contaminated object . Hand hygiene shall be performed by handwashing with soap and water in accordance with facility policy for hand hygiene. 055104 Page 2 of 2