Health inspection·November 25, 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 implement its infection control measures for three of three sampled residents (Residents 1, 2, and 3) during a respiratory virus season (a specific period, typically during the fall and winter months, when common respiratory illnesses like influenza [flu-a contagious {spread from one person to another by direct or indirect contact}-respiratory illness caused by influenza viruses], Coronavirus Disease 2019 [COVID-19-a highly contagious respiratory disease thought to spread from person to person through droplets], and Respiratory Syncytial Virus [RSV-common respiratory virus that primarily affects infants and young children, but can also cause illness in older adults and people with underlying health conditions] become more prevalent [widespread] and circulate widely in the population) by failing to wear a mask while inside the facility. These failures had the potential for the spread of respiratory diseases (flu, COVID-19 and RSV) to other residents, staff, and visitors.Findings:a. During a review of Resident 1‘s admission Record, the admission Record indicated the facility admitted Resident 1 on 9/15/2025, with diagnoses that included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), generalized muscle weakness and aphasia (a disorder that affects how you communicate). During a review of Resident 1's Care Plan, dated 9/15/2025, regarding risk for COVID-19, the Care Plan indicated an intervention to wear designated face covering (mask) as source control during family visits. During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 9/21/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 9/23/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. During a review of facility's Inservice (educational training), dated 9/29/2025, about flu/ COVID 19 and respiratory season, the Inservice indicated, Respiratory seasons starts 11/1/2025, to 3/31/2026 and surgical mask are to be worn regardless of vaccination status starting 11/1/2025. During a review of facility's Inservice, dated 11/19/2025, about surgical mask requirement, the Inservice indicated surgical mask must be worn at all times while in the building. During an observation on 11/25/2025, at 8:28 a.m., in the facility's main lobby, observed a signage posted on the desk of the Receptionist (RCP) that indicated a reminder for all staff and visitor to wear a mask regardless of vaccination status. During an observation on 11/25/2025, at 8:29 a.m., in the facility's hallway, observed Activity Director (AD) wearing a mask covering her mouth with her nose exposed and gave Resident 1 a high five in the hallway. During an interview on 11/25/2025, at 8:53 a.m., with the AD, the AD stated she (AD) was walking in the hallway and adjusted her (AD) mask and forgot to cover her (AD) nose back before interacting with Resident 1. The AD stated it is mandatory for staff and visitors to wear a mask when inside the facility to prevent the spread of respiratory Residents Affected - Some Page 1 of 3 055307 055307 11/25/2025 Desert Canyon Post Acute, LLC 1642 West Avenue J Lancaster, CA 93534

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some diseases. The AD stated the proper way of wearing a mask was to cover both mouth and nose. The AD stated Resident 1 could get infected with influenza since her (AD) mask was not worn properly. b. During a review of Resident 2‘s admission Record, the admission Record indicated the facility admitted Resident 2 on 7/27/2023, with diagnoses that included other specified diseases of respiratory tract (symptoms of these conditions can vary widely based on the specific disease, ranging from nasal congestion and runny nose, to coughing and difficulty swallowing), generalized muscle weakness and essential hypertension (high blood pressure that is not due to another medical condition). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decisions were severely impaired. During a review of Resident 2's Care Plan, dated 9/12/2025, regarding refusal of RSV vaccine (a simple, safe, and effective way of protecting you against harmful diseases), the Care Plan indicated Resident 2 was at risk for RSV and its complication (a medical problem that occurs during a disease, or after a procedure or treatment). c. During a review of Resident 3‘s admission Record, the admission Record indicated the facility admitted Resident 3 on 2/5/2024, with diagnoses that included urinary tract infection (UTI- an infection in the bladder/urinary tract), generalized muscle weakness and essential HTN. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decisions were severely impaired. During an observation on 11/25/2025, at 8:30 a.m., in the facility's hallway, observed Housekeeping 1 (HSK 1) walking in the hallway in front of Resident 2 and 3's room without mask. During an observation on 11/25/2025, at 8:31 a.m., in the facility's hallway, observed Certified Nursing Assistant 1 (CNA 1) walking in the hallway and went inside Resident 2's and Resident 3's room without a mask. During an interview on 11/25/2025, at 8:56 a.m., with CNA 1, CNA 1 stated he (CNA 1) was walking in the hallway earlier and forgot to wear his (CNA 1) mask. CNA 1 stated it was his (CNA 1) fault as he (CNA 1) was informed that wearing mask is mandatory inside the facility to prevent spread of infection. During an interview on 11/25/2025, at 9:36 a.m., with the infection Preventionist (IP), the IP stated beginning 11/1/2025, to 3/31/2026, the staff had to wear a mask while inside the facility to prevent the spread of respiratory illness. The IP stated the proper way to wear a mask was to both cover the nose and mouth and check that mask was closely fit. During an interview on 11/25/2025, at 10:23 a.m., with the Director of Nursing (DON), the DON stated wearing a mask is mandatory inside the facility to prevent spread of respiratory illnesses. The DON stated because HSK 1 and CNA 1 did not wear a mask and the AD did not wear a mask properly, Residents 1, 2 and 3 could have been exposed to respiratory illness. During an interview on 11/25/2025, at 10:31 a.m., with HSK 1, HSK 1 stated he (HSK 1) was going for his (HSK 1) break when he (HSK 1) was walking in the hallway with no mask on. HSK 1 stated he (HSK 1) was informed to wear a mask while inside the facility to prevent spread of infection. During an interview on 11/25/2025, at 10:43 a.m., with the Assistant Director of Nursing (ADON), the ADON stated staff needs to wear a mask even in the hallways. During a review of facility's policy and procedure (P&P), titled, Respiratory Syncytial Virus (RSV) Vaccine, dated 3/24/2025, the P&P indicated, During periods of increased community transmission (the passing of a disease from an infected individual or group to a previously uninfected individual or group) of respiratory viruses, the Facility will conduct active monitoring to identify signs or symptoms of respiratory Illness. During a review of facility's P&P, titled, Infection Prevention and Control Program, dated 10/24/2022, the P&P indicated, The ensure the Facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements. During a review of facility provided document titled, Order of the Los Angeles County Health Officer (HOO) dated 055307 Page 2 of 3 055307 11/25/2025 Desert Canyon Post Acute, LLC 1642 West Avenue J Lancaster, CA 93534

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 10/16/2025, was reviewed. The HOO indicated, masking requirements for healthcare personnel during respiratory virus season. This Health Officer Order (Order) requires that each year, Healthcare Personnel (HCP) in all Licensed Healthcare Facilities, except Skilled Nursing Facilities (SNF), must either: a) be immunized with an annual influenza vaccine authorized for use in the United States for the current respiratory virus season, or b) wear a Respiratory Mask while in contact with patients or working in Patient-Care Areas during the Respiratory Virus Season (November 1 through March 31 ). Due to the nature of care provided to highly vulnerable populations, the high risk of rapid respiratory virus transmission in SNFs, and low influenza vaccination rates among SNF HCP, all HCP working in Skilled Nursing Facilities must wear a Respiratory Mask while in contact with patients or working in Patient-Care Areas throughout the Respiratory Virus Season. 4) Definitions. For purposes of this Order, the following terms are defined as follows: a. Respiratory Virus Season. The term Respiratory Virus Season refers to November 1 of one year through March 31 of the following year. If surveillance data in a particular year demonstrate that the respiratory virus season is different than November 1 to March 31, this period may be amended in an updated order. d. Patient-Care Areas. The term Patient-Care Areas refers to areas in facilities that include, but are not limited to, patient or resident rooms and areas where patients receive diagnostic or treatment services, can be taken for procedures or tests, and are allowed to be present (example given elevators, hallways, and nurses' stations). During a review of Centers for Disease Control and Prevention (CDC) titled, Mask and Respiratory Virus Prevention, dated 8/18/2025, the CDC indicated Wearing a mask can help lower the risk of respiratory virus transmission. When worn by a person with an infection, masks reduce the spread of the virus to others. Masks can also protect wearers from breathing infectious particles from people around them. Different masks offer different levels of protection. Wearing the most protective one you can comfortably wear for extended periods of time that fits well (completely covering the nose and mouth) is the most effective option. 055307 Page 3 of 3