Health inspection·June 17, 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, Licensed Vocational Nurse (LVN 2) failed to rinse G-tube (gastrostomy tube, a feeding tube inserted through the abdominal wall directly into the stomach) syringe after medication administration on one of two sampled residents (Resident 1). Residents Affected - Few This deficient practice had the potential to spread infection. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1's was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including gastroesophageal reflux disease (digestive disorder where stomach acid frequently flows back into the esophagus, causing irritation and symptoms like heartburn). hemiplegia (complete paralysis on one side of the body) and hemiparesis (hemiparesis refers to partial or weakness on one side of the body), dysphagia (difficulty swallowing) and gastrostomy tube (GT- a soft tube surgically inserted directly into the stomach to administer medication, fluids and nutrition) During a review of Resident 1's Minimum Data Set ( MDS- a resident assessment tool) dated 04/30/2025 indicated Resident 1's is cognitively (ability to think, understand, and remember) intact. The MDS indicated Resident 1's was dependent (helper does all the effort) with toileting, oral hygiene, shower and dressing. During a concurrent observation and interview on 06/17/2025 at 1:46 p.m. with LVN 2, LVN 2 was observed administer medication via G-tube, after medication administration LVN 2 failed to rinse the syringe that was used for medication administration, LVN 2 placed used syringe on the syringe bag without washing or rinsing and hang it on the G-tube pole by Resident 1's bed side. LVN 2 stated she was supposed to wash after medication administration before leaving the room. LVN 2 stated this can cause residuals to sit on the syringe for hours and will cause cross contamination. LVN 2 stated she forgot to rinse the syringe and knew this was an infection control issue, because the next nurse would consider the syringe clean and used it. During an interview on 06/17/2025 at 1:15 p.m. with LVN 1, LVN 1 stated that license staff should always rinse out the syringe after medication use and syringe should be changed after 24 hours or if contaminated for safety and avoid infections. During an interview on 6/17/2025 at 4:28 p.m., with the Director of Nursing (DON), the DON stated license staff supposed to follow protocol for medication administration all the time, check placement, wash hands, flush tube before and after, perform hand hygiene, identify resident before med given. (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: 055457 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 055457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Intercommunity Healthcare & Rehabilitation Center 12627 Studebaker Road Norwalk, CA 90650 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)