Health inspection·August 12, 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 ensure infection control practices were implemented when one of one Certified Nurse Assistant (CNA 1) did not wash or sanitize hands after exiting Resident 1's shower room and before touching Resident 2.This deficient practice had the potential to result in cross contamination (transfer of germs and harmful substance) and spread of infection.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility readmitted the resident to the facility on 7/31/25 with diagnoses that included type 2 diabetes mellitus (elevated blood sugar level) and acute kidney failure (kidneys can't filter waste).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 7/28/25, the MDS indicated Resident 1 had moderately impaired cognitive skills (ability to understand and process thoughts) for daily decision making.During a review of Resident 1's History & Physical (H&P) dated 8/1/25, the H&P indicated Resident 1 did not have the capacity to make medical decisions.During a review of Resident 2's AR, the AR indicated the facility readmitted the resident on 5/15/25 with diagnoses that included type 2 diabetes mellitus and urinary tract infection (UTI).During a review of Resident 2's H&P dated 5/16/25, the H&P indicated Resident 2 did not have the capacity to make medical decisions.During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was not able to complete the interview.During a review of Resident 3's AR, the AR indicated the facility readmitted the resident on 5/8/25 with diagnoses that included encephalopathy (problem with the brain that changes how it works) and subdural hemorrhage (a pool of blood between the brain and its outermost covering).During a review of Resident 3's H&P dated 5/9/25, the H&P indicated Resident 1 did not have the capacity to make medical decisions.During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had severely impaired cognitive skills.During a concurrent observation and interview on 8/8/25 at 3:40 p.m., CNA 1 was observed walking into Resident 1's shower room and turning the knobs that controlled the water. CNA 1 exited Resident 1's shower room. CNA 1 did not perform hand hygiene (cleaning hands to remove germs). CNA 1 proceeded by entering Resident 3's room and assisted Resident 2 out of Resident 3's room by touching Resident 3's arm. During an interview with CNA 1, CNA 1 stated handwashing or hand hygiene should be done after each contact with residents and upon exiting a room. CNA 1 stated hand hygiene was important to prevent contamination or spread of infection. CNA 1 stated CNA 1 did not perform hand hygiene and should have performed hand hygiene between Resident 1 and Resident 2's rooms.During an interview on 8/8/25 at 4:10 p.m., with the Infection Preventionist (IP), the IP stated hand hygiene was important between residents to prevent transmission and cross contamination, infection, prevent an outbreak, and mitigate the spread of any infection.During a subsequent interview on 8/8/25, at 4:15 p.m., the IP stated if staff were not following standard infection control precautions, staff would have the potential to spread infections. The IP stated all staff were required to perform hand hygiene between residents' contact and between resident rooms. The IP stated staff should be following Residents Affected - Few Page 1 of 2 055126 055126 08/12/2025 Chino Valley Health Care Cente 2351 S Towne Avenue Pomona, CA 91766

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few standard precautions regardless of whether residents were on isolation precaution or not.During an interview, on 8/12/25 at 5:20 p.m., with the Director of Nursing (DON), the DON stated hand hygiene was very important to prevent the spread of infection and to protect the residents from transmission of any infections. The DON stated staff (in general) should be performing hand hygiene between rooms. The DON stated hand sanitizers were available on the walls. The DON stated handwashing was recommended, but hand hygiene with sanitizer was acceptable.During a review of the facility's Policy and Procedure (P&P), titled, Policy: Infection Control, revised January 2016, the P&P indicated the facility has established and will maintain an infection control program designed to provide safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The spread of infection will be prevented by requiring staff to clean their hands after each direct resident contact using the most appropriate hand hygiene. All staff members will wash their hands before and after direct resident care and after contact with potentially contaminated substances to prevent, to the extent possible, the spread of infections. This facility may use alcohol-based hand hygiene dispensers.During a review of the facility's undated P&P titled, Hand Hygiene, the P&P indicated all staff members will wash their hands before and after direct resident care and after contact with potentially contaminated substances to prevent, to the extent possible, the spread of infections. The P&P indicated this facility may use alcohol-based hand hygiene dispensers.During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated 2001, the P&P indicated the facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. 055126 Page 2 of 2