Health inspection·August 15, 2024

F 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) who had a colostomy (an opening that connects the digestive tract to the surface of the belly to allow for waste material and gas to leave the body) received care consistent with professional standards of practice when Resident 1's colostomy bag was removed, emptied, and placed back on by unlicensed staff. This failure had the potential to place Resident 1 at risk for complications such as infections or dislodgment of the colostomy bag. Findings: During a review of Resident 1's admission Record (AR), dated 7/12/24, the AR indicated, Resident 1 was admitted with diagnoses including, colostomy, artificial opening of urinary tract, hypertension (high blood pressure) and hyperlipidemia (build-up of fats in the blood). During a review of Resident 1's, MDS (Minimum Data Sheet - a federally mandated process of clinical assessment for nursing home patients) Assessment, dated 7/16/24 , the MDS indicated, Section C - Brief Interview of Mental Status (BIMS) assessment indicated, Resident 1 had a BIMS Score of 15 (The BIMS assessment uses a points system that ranges from 0 to 15 points: 0 to 7 points suggests severe cognitive impairment. 8 to 12 points suggests moderate cognitive impairment. 13 to 15 points suggests that cognition is intact.) During an interview on 8/15/24 at 12:15 p.m. with Resident 1, Resident 1 verbalized concerns that a staff was reusing a colostomy bag. During an interview on 8/16/24 at 2:30 p.m. with Certified Nurse Assistant (CNA 2), CNA 2 stated she was instructed by the licensed nurse to clean the bag. CNA 2 further stated they removed, rinsed, and then placed the colostomy bag on Resident 1. During an interview on 8/16/24 at 3:30 p.m. with the Licensed Nurse (LN 4), LN 4 stated that CNA 2 was instructed only to empty the colostomy bag, not remove it. During an interview on 8/16/24 at 4 p.m. with Director of Nursing (DON), DON verbalized that unlicensed staff are only permitted to empty the colostomy bag, not to remove it. DON verbalized the removal of a colostomy bag is a task for a licensed nurse. During a review of the facility's policy and procedure (P&P) titled, Colostomy Urostomy or Page 1 of 3 055342 055342 08/15/2024 Thousand Oaks Post Acute, LLC 93 West Avenida DE Los Arboles Thousand Oaks, CA 91360

F 0691 Ileostomy Care, (undated), the P&P indicated in part, resident receives the necessary care and treatment including medical and nursing care and services when they need colostomy . care. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055342 Page 2 of 3 055342 08/15/2024 Thousand Oaks Post Acute, LLC 93 West Avenida DE Los Arboles Thousand Oaks, CA 91360

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to perform hand washing while providing colostomy (an opening that connects the digestive tract to the surface of the belly to allow for waste material and gas to leave the body) care with one of three sampled resident (Resident 3). Residents Affected - Few This failure had the potential to cause infection to Resident 3's colostomy site. Findings: During an observation of Resident 3's colostomy care treatment on 8/9/24 at 12:45 p.m. with Licensed Nurse (LN 1), LN 1 with a new pair of gloves, removed the soiled colostomy bag, placed them in a garbage receptable. LN 1 removed the pair of dirty gloves, placed them in a garbage receptacle, and then put on clean gloves without washing her hands. LN 1 then proceeded to clean the stoma (any opening in the body) removed dirty gloves, grabbed a new pair of gloves, and again placing a new pair on without performing handwashing. During an interview on 8/9/24 at 12:50 p.m. with LN 1, LN 1 acknowledged not washing her hands during the treatment. LN 1 further stated that washing hands in between glove changes makes her hands sticky and harder to put the new gloves on. During a review of the facility's policy and procedure (P&P) titled, Colostomy Urostomy Or Ileostomy Care, dated 11/2017, the P&P indicated in part, Steps in the procedure: removed gloves, wash hands, put on clean gloves. 055342 Page 3 of 3