Health inspection·January 17, 2024

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 the facility ' s policy and procedure titled General Policies for IV (IV- is used to give medications and fluids directly to the vein) therapy, was implemented to infection control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) to prevent infection for one of two sampled residents (Resident 2). Residents Affected - Few This deficient practice placed the residents at risk for potential infection or cross contamination of infections (the physical movement or transfer of harmful bacteria from one person, object, or place to another. Findings: A review of an admission Records indicated resident 2 was admitted to the facility on [DATE] with diagnoses including cellulitis (bacterial skin infection) of left lower limb (leg) and Gastro-esophageal reflux disease (GERD-stomach acid flows into the food pipe and irritates the lining). A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 11/7/23, indicated Resident 2 was cognitively (a mental process of acquiring knowledge and understanding) intact. The MDS indicated Resident 2 was totally dependent on staff for toilet use, eating, bed mobility and dressing. A review of Resident 2 ' s Order Summary Report for January 2024, indicated Resident 2 has the following orders: 1. Ertapenem (medication to treat infection) 1 GM (gram- a unit of measurement of weight and mass) intravenously (medication delivered into a vein through a catheter) every 24 hours for UTI (Urinary Tract Infection – an infection in any part of the urinary system [kidney, bladder, or urethra]), 2. Change IV tubing every 24 hours for five days 3. Peripheral site (IV insertion site -a small, short plastic catheter that is placed through the skin into a vein, usually in the hand, elbow, or foot) care every 96 hours for site care. During an observation in Resident 2 ' s room on 1/17/24 at 10:20 a.m., Resident 2 was observed lying in bed with an IV line on resident ' s left hand. The tubing was observed without label of the name of the resident and the date the tubing was first used and when the tubing will be changed. (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: 055181 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 055181 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Gabriel Conv Center 8035 E Hill Drive Rosemead, CA 91770 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)