Health inspection·February 3, 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 and interview the facility failed to implement its infection control policy by falling to ensure Certified Nursing Assistant (CNA) 1, Registered Nurse supervisor (RN) 1, and House Keeping (HK) performed hand hygiene (hand washing with soap and water and use alcohol-based hand sanitizer) while entering and exiting residents' rooms [ROOM NUMBERS], touching curtains, and bedside tables in the residents' rooms. Residents Affected - Some These deficient practices had the potential to result in the spread of infectious disease (disorders that are caused by organisms, usually microscopic in size, such as bacteria, viruses, fungi, or parasites that are passed, directly or indirectly, from one person to another). Findings: During an observation on 2/1/2025 at 8:45 AM CNA 1, observed carrying a clear trash bag with bare hands, threw the trash in a trash receptacle next room [ROOM NUMBER]. CNA 1 entered room [ROOM NUMBER], pulled a curtain at room [ROOM NUMBER] bed B and pushed a bed side table. During an observation on 2/1/2025 at 9:40 AM, observed RN 1 answering a call light in room [ROOM NUMBER]. RN 1 entered room [ROOM NUMBER] not applying hand hygiene, touched the bed side table in room [ROOM NUMBER] bed A, donned a glove to assist the resident. Observed removing the gloves and exited room not applying hand hygiene. During an observation on 2/1/2025 at 11:41 AM, observed HK in utility room, touching mop bucket with bare hands, exited utility room and entered room [ROOM NUMBER] not applying hand hygiene. During an interview on 2/1/2025 at 8:55 AM with CNA 1, CNA 1 stated I should apply hand hygiene after handling trash, before touching high touch areas, touching patients, and patient equipment. The potential outcome for not applying hand hygiene is spread of infections between residents and staff. During an interview on 2/1/2025 at 9:40 AM with RN 1, RN 1 stated, I should have applied hand hygiene before entering room [ROOM NUMBER], hand hygiene is important to protect the spread of infections. During an interview on 2/1/2025 at 2:13 PM with Director of Staffing Development (DSD), DSD stated, hand hygiene is a basic infection prevention practice that needs to be practiced by staff. DSD will conduct routine monitoring of staff hand hygiene practice and will conduct in-service to enforce hand hygiene practice. Page 1 of 2 055161 055161 02/03/2025 Garden Crest Rehabilitation Center 909 Lucile Ave. Los Angeles, CA 90026

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 2/3/2025 at 2:33 PM with the Director of Nursing (DON), DON stated, RN1 acknowledged the mistakes on 2/12025 on hand hygiene practice, RN will improve practicing hand hygiene. DON stated hand hygiene should be practiced by all staff. The outcome not practicing hand hygiene, residents will be at risk for infection outbreak. During a review of the facility's policy and procedure (P&P) titled Infection Prevention and Control Program reviewed January 2025, the P&P indicated, a. Important facets of infection prevention include: educating staff and ensuring that they adhere to proper techniques and procedures; implementing appropriate enhanced barrier and transmission-based precautions when necessary; and following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). 055161 Page 2 of 2