Health inspection·October 30, 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 implement their policy and procedure for norovirus (also often called food poisoning. It is the most common cause of diarrhea [watery stool] and vomiting [throwing up]) prevention and control for three of three sampled residents (Resident 1, 2 and 3) when facility did not cohort (a group of people with a shared characteristic) their staff assignment after they received a positive norovirus result for Resident 1 on 10/27/2024. Residents Affected - Some This deficient practice placed all the other residents in the facility, facility staff and visitors at risk for contacting (exposure to contagious disease) norovirus. Findings: 1. During a review of Resident 1's admission Record, indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for residents with swallowing problems), sepsis (a life-threatening blood infection). During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/6/2024, the MDS indicated Resident 1's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more the half the effort) with oral hygiene, toileting hygiene, and personal hygiene. The MDS also indicated Resident 1 was dependent (helper does all the effort. Resident does none of the effort to complete the activity) with eating, shower/bath, upper and lower body dressing, and putting on/taking off footwear. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers when there is a change of condition among the residents), dated 10/26/2024, entered at 5:08 AM, indicated the resident is exhibiting the following symptoms: Diarrhea: 3 or more liquid or watery stools above what is normal for the resident within a 24-hour period. Vomiting: 2 or more episodes in a 24-hour period. Abdominal pain Nausea (a feeling of discomfort or sickness in the stomach that can make you feel like you need to vomit) Page 1 of 11 055480 055480 10/30/2024 The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 1's SBAR, dated 10/27/2024, entered at 5:39 PM, indicated nurse received laboratory reports from General Acute Care Hospital (GACH) indicating Resident 1 was positive for Norwalk agent (norovirus). During a review of Resident 1's laboratory results from GACH, dated 10/27/2024, timed 3:08 PM, indicated a detected result for norovirus. 2. During a review of Resident 2's admission Record, indicated Resident 2 was originally admitted to the facility on [DATE]. Resident 2's diagnoses included acute gastritis (occurs when the lining of your stomach is damaged or weak), dysphagia (difficulty swallowing), and muscle weakness. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated Resident 2 required setup or clean up assistance (helper sets ups or cleans up, resident completes activity) with eating, oral hygiene, and upper body dressing. The MDS indicated Resident 2 required supervision (helper provides verbal cues and/or touching as resident completes activity) with lower body dressing and putting on/taking off footwear. The MDS also indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, shower/bath. During a review of Resident 2's SBAR, dated 10/26/2024, entered at 12:37 PM, indicated Resident 2 is exhibiting nausea and vomiting. 3. During a review of Resident 3's admission Record, indicated Resident 3 was originally admitted to the facility on [DATE]. Resident 3's diagnoses included muscle weakness, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and protein calorie malnutrition (PCM, is the state of inadequate intake of food.) During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 3 required supervision with eating. The MDS indicated Resident 3 required partial/moderate assistance with oral hygiene. The MDS indicated Resident 3 required substantial/maximal assistance with upper body dressing. The MDS indicated Resident 3 was dependent with toileting hygiene, shower/bath, lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 3's SBAR, dated 10/27/2024, entered at 3:11 AM, indicated Resident 3 is exhibiting 2 or more episodes of vomiting in a 24-hour period. During a review of Certified Nurse Assistant (CNA) assignment form, dated 10/27/2024 for evening shift (3 PM to 11 PM shift), indicated CNA 1 was assigned the following rooms: Room M (asymptomatic [no symptoms of norovirus]) Room N (suspected with norovirus) Room O (asymptomatic) Room P (asymptomatic) 055480 Page 2 of 11 055480 10/30/2024 The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105

F 0880 Room Q (asymptomatic) Level of Harm - Minimal harm or potential for actual harm The form indicated indicated CNA 2 was assigned the following rooms: Room D (asymptomatic) Residents Affected - Some Room E (asymptomatic) Room A (confirmed norovirus) Room F (suspected with norovirus) Room B (suspected with norovirus) Room G (asymptomatic) Room H (asymptomatic) The form indicated CNA 3 was assigned the following rooms: Room I (asymptomatic) Room J (asymptomatic) Room K (asymptomatic) Room C (suspected with norovirus) Room L (asymptomatic) During a review of CNA assignment form, dated 10/27/2024 for night shift (11 PM to 7 AM shift), indicated CNA 4 was assigned the following rooms: Room M (asymptomatic) Room N (suspected with norovirus) Room O (asymptomatic) Room P (asymptomatic) Room E (asymptomatic) The form indicated CNA 5 was assigned the following rooms: Room Q (asymptomatic) Room D (asymptomatic) 055480 Page 3 of 11 055480 10/30/2024 The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105

F 0880 Room A (confirmed norovirus) Level of Harm - Minimal harm or potential for actual harm Room F (suspected with norovirus) Room B (suspected with norovirus) Residents Affected - Some Room R (asymptomatic) The form indicated CNA 6 was assigned the following rooms: Room K (asymptomatic) Room S (asymptomatic) Room C (suspected with norovirus) Room T (asymptomatic) During a review of CNA assignment form, dated 10/28/2024 for morning shift (7 AM to 3 PM shift), indicated CNA 7 was assigned the following rooms: o Room M (asymptomatic) o Room N (suspected with norovirus) o Room O (asymptomatic) o Room P (asymptomatic) o Room Q (asymptomatic) The form indicated CNA 8 was assigned the following rooms: Room Q (asymptomatic) Room D (asymptomatic) Room E (asymptomatic) 055480 Page 4 of 11 055480 10/30/2024 The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105

F 0880 Room A (confirmed norovirus) Level of Harm - Minimal harm or potential for actual harm Room F (suspected with norovirus) Room R (asymptomatic) Residents Affected - Some Room B (suspected with norovirus) The form indicated CNA 9 was assigned the following rooms: Room K (asymptomatic) Room C (suspected with norovirus) Room L (asymptomatic) Room T (asymptomatic) Room U (asymptomatic) During a review of CNA assignment form, dated 10/28/2024 for evening shift, indicated CNA 1 was assigned the following rooms: o Room M (suspected with norovirus) o Room N (suspected with norovirus) o Room O (asymptomatic) o Room P (asymptomatic) o Room Q (asymptomatic) The form indicated CNA 10 was assigned the following rooms: Room D (asymptomatic) Room E (asymptomatic) 055480 Page 5 of 11 055480 10/30/2024 The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105

F 0880 Room A (confirmed norovirus) Level of Harm - Minimal harm or potential for actual harm Room F (suspected with norovirus) Room B (suspected with norovirus) Residents Affected - Some Room G (asymptomatic) Room H (asymptomatic) Room V (asymptomatic) The form indicated CNA 11 was assigned the following rooms: Room C (suspected with norovirus) Room L (asymptomatic) Room T (asymptomatic) Room U (asymptomatic) Room X (asymptomatic) Room Y (asymptomatic) Room Z (asymptomatic) During a review of CNA assignment form, dated 10/28/2024 for night shift, indicated CNA 12 was assigned the following rooms: o Room M (suspected with norovirus) o Room N (suspected with norovirus) o Room O (asymptomatic) o Room P (asymptomatic) o 055480 Page 6 of 11 055480 10/30/2024 The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105

F 0880 Room Q (asymptomatic) Level of Harm - Minimal harm or potential for actual harm The form indicated CNA 13 was assigned the following rooms: o Residents Affected - Some Room D (asymptomatic) o Room E (asymptomatic) o Room A (confirmed norovirus) o Room F (suspected with norovirus) o Room R (asymptomatic) o Room B (suspected with norovirus) o Room G (asymptomatic) o Room H (asymptomatic) o Room W (asymptomatic) The form indicated CNA 14 was assigned the following rooms: o Room C (suspected with norovirus) o Room L (asymptomatic) 055480 Page 7 of 11 055480 10/30/2024 The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105

F 0880 o Level of Harm - Minimal harm or potential for actual harm Room T (asymptomatic) o Residents Affected - Some Room U (asymptomatic) o Room X (asymptomatic) o Room Y (asymptomatic) o Room Z (asymptomatic) During a review of CNA assignment form, dated 10/29/2024 for morning shift, indicated CNA 7 was assigned the following rooms: o Room M (suspected with norovirus) o Room H (asymptomatic) o Room O (asymptomatic) o Room P (asymptomatic) o Room Q (asymptomatic) The form indicated CNA 8 was assigned the following rooms: o Room N (asymptomatic) 055480 Page 8 of 11 055480 10/30/2024 The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105

F 0880 o Level of Harm - Minimal harm or potential for actual harm Room D (asymptomatic) o Residents Affected - Some Room E (asymptomatic) o Room A (confirmed norovirus) o Room F (suspected with norovirus) o Room R (asymptomatic) o Room B (suspected with norovirus) o Room V (asymptomatic) The form indicated CNA 15 was assigned the following rooms: o Room C (suspected with norovirus) o Room ZZZ (asymptomatic) o Room J (asymptomatic) o Room K (asymptomatic) o Room L (asymptomatic) 055480 Page 9 of 11 055480 10/30/2024 The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent record review of Resident 1's medical records on 10/29/2024 at 10 AM and interview with Infection Preventionist (IP), the IP stated facility received the positive norovirus result from GACH on 10/27/2024 evening shift. IP stated Registered Nurse (RN ) who was working that day informed her through telephone and gave RN instructions to place Resident 1 on contact isolation (staff members wear gloves and aprons when they come into contact with you), notify Doctor and family. IP verified she did not give instructions to designate a separate staff to take care Resident 1 who was tested positive for norovirus and to other residents with the same symptoms of vomiting and diarrhea and to ensure they are not assigned to asymptomatic residents. During a concurrent record review of Facility's Policy and Procedure (P&P), titled Norovirus Prevention and Control, revised on 10/2011, and interview with IP on 10/29/2024 at 10:30 AM, indicated in the event of an outbreak of norovirus gastroenteritis, staff will care for one resident cohort on their unit and will not move between resident cohorts (resident cohorts may include symptomatic, asymptomatic, exposed, or asymptomatic unexposed resident groups). IP stated facility should have changed the CNA assignment on 10/27/2024 evening shift when facility received Resident 1's positive result of norovirus. IP stated there should have been one CNA assigned to Resident 1 who was tested positive for norovirus and other residents with the same symptoms of vomiting and diarrhea. IP stated that staff taking care of mix cohorts (both with norovirus, symptomatic residents, and asymptomatic residents) has high potential of spreading the virus through direct contact resident care. During a concurrent record review of CNA assignments dated from 10/27/2024 to 10/29/2024 with Director of Staff Development (DSD) on 10/30/2024 at 1:40 PM, DSD verified Resident 1 who is in Room A, did not have a designated staff assigned to the resident and to other residents with similar symptoms of vomiting and diarrhea. DSD stated residents who were not having symptoms had high risk of contacting the norovirus because CNA assigned to Resident 1 had mixed cohorts and was assigned to take care of asymptomatic residents at the same time. DSD added not cohorting CNA assignments is not a good thing to other asymptomatic residents because they are exposed to the virus. During an interview on 10/30/2024 at 3:25 PM with RN, she verified that she did not receive instructions to cohort licensed nurse and CNA assigned to Resident 1 and other residents with the same symptoms of norovirus on 10/27/2024 from IP. RN stated she should have changed the CNA assignment that shift, to assign one (1) CNA to Resident 1 and to other suspected residents (residents with the same signs and symptoms) to avoid contamination and spread of infection to other residents that are asymptomatic. During an interview on 10/30/2024 at 4:25 PM with Assistant Director of Nursing (ADON), the ADON stated cohort means residents with the same symptoms or diagnosis. The ADON added they should have cohort the staffing assignment to residents with same symptoms from the reisdent without symptoms, to prevent further spread of infection or virus. During a review of Facility's P&P titled Norovirus Prevention and Control, revised on 10/2011, P&P indicated facility will implement strict infection control measures to prevent the transmission of norovirus infection. It also indicated the following interpretation and implementation: o Avoid exposure to vomitus or diarrhea. Place resident on contact precaution in a single occupancy room, if possible, when symptoms are consistent with norovirus gastroenteritis. 055480 Page 10 of 11 055480 10/30/2024 The Californian Pasadena Healthcare 120 Bellefontaine Street Pasadena, CA 91105

F 0880 o Level of Harm - Minimal harm or potential for actual harm Approaches for Cohorting residents during outbreaks may include placing resident in multi-occupancy rooms or designating resident care areas within the facility for resident cohorts. Residents Affected - Some o In the event of an outbreak of norovirus gastroenteritis, staff will care for one resident cohort on their unit and will not move between resident cohorts. 055480 Page 11 of 11