Health inspection·May 11, 2023

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement their Coronavirus 2019 (COVID-19, an illness caused by a virus that can spread from person to person) mitigation plan for two of three sampled residents (Resident 1 and 2) who tested positive for COVID-19 by failing to ensure: Residents Affected - Few Resident 1's and 2's vital signs (pulse rate, temperature, respiration rate, and blood pressure) and oxygen saturation (oxygen blood level) were monitored twice a shift or every four hours while Resident 1 and 2 were on COVID-19 isolation. These deficient practices had the potential for Resident 1 and 2 to receive delayed and inappropriate care. Findings: During a review of Resident 1's admission Record indicated the facility admitted Resident 1 on 4/29/2023 with diagnoses which included pneumonia (an infection that affects one or both lungs) due to COVID-19. During a review of Resident 2's admission Record indicated the facility originally admitted Resident 2 on 4/21/2023 with diagnoses which included COVID-19. During an interview, on 5/11/2023 at 12:24 pm, the Infection Prevention Nurse (IPN nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment) stated, Resident 1 went to the hospital on 4/22/2023 and tested positive for COVID-19 in the hospital. Resident 1 was readmitted by the facility and placed on COVID-19 isolation on 4/29/2023. The IPN stated, Resident 1 was taken off COVID-19 isolation on 5/3/2023. The IPN stated, Resident 2 was admitted by the facility with COVID-19 on 4/21/2023, and was placed on COVID-19 isolation on 4/21/2023 and was taken off COVID-19 isolation on 4/29/2023. During a review of Resident 1's Medication Administration Records (MARs), dated 4/1/2023--4/30/2023 and dated 5/1/2023--5/31/2023, indicated Resident 1's oxygen saturation was monitored only once a shift while Resident 1 was on COVID-19 isolation from 4/29/2023--5/3/2023. Resident 1's vital signs were not documented on the MARs. During a review of Resident 1's Weights and Vitals Summary indicated Resident 1's blood pressure was monitored on 4/30/2023 at 10:01 am, on 5/2/2023 at 5:38 pm, on 5/3/2023 at 3:18 am, and on 5/3/2023 at 6:35 pm. The Weights and Vitals Summary indicated Resident 1's temperature was monitored on 4/30/2023 at 10:01 am, on 5/2/2023 at 5:39 pm, on 5/3/2023 at 3:19 am, and on 5/3/2023 at 6:36 pm. The Weights and Vitals Summary indicated Resident 1's pulse was monitored on 4/30/2023 at 8:41 am, on Page 1 of 2 055187 055187 05/11/2023 Garden View Post Acute Rehabilitation 14475 Garden View Lane Baldwin Park, CA 91706

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 5/1/2023 at 8:35 am, on 5/2/2023 at 10:41 am, on 5/2/2023 at 5:39 pm, on 5/3/2023 at 3:18 am, on 5/3/2023 at 10:06 am, and on 5/3/2023 at 6:36 pm. The Weights and Vitals Summary indicated Resident 1's respiration was monitored on 4/30/2023 at 10:01 am, on 5/2/2023 at 5:39 pm, on 5/3/2023 at 3:18 am, and on 5/3/2023 at 6:36 pm. During a review of Resident 2's MAR, dated 4/1/2023--4/30/2023, indicated Resident 2's vital signs and oxygen saturation were monitored every shift. During an interview with Certified Nursing Assistant 1 (CNA 1) on 5/11/2023 at 1:47 pm, CNA 1 stated, residents who were under observation for possible COVID-19 should have their vital signs checked every four hours. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 5/11/2023 at 2:05 pm, LVN 1 stated, residents who tested positive for COVID-19 should be monitored for signs and symptoms of COVID-19 and have their vital signs checked every four hours. During a concurrent record review and interview, on 5/11/2023 at 3:35 pm the Director of Nursing (DON) reviewed Resident 1's and 2's clinical records. The DON stated, Resident 1's and 2's vital signs and oxygen saturation were not monitored every four hours or twice a shift when they were on COVID-19 isolation. The DON stated, vital signs and oxygen saturation must be monitored according to the facility's COVID-19 mitigation plan. During a review of the facility's, COVID-19 Facility Mitigation Plan, revised 4/20/2023, indicated, Residents with respiratory infectious illness (COVID test positive) are assessed (including documentation of vital signs and oxygen saturation) twice during the shift. Resident with suspected COVID positive or exposed to COVID positive individual are assessed (including documentation of vital signs and oxygen saturation) once every shift. 055187 Page 2 of 2