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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055104 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055104 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Manor Conv Hosp 2720 Nevada Avenue El Monte, CA 91733 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)