Health inspection·December 11, 2024

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 follow it's Policy and Procedure titled Isolation-Categories of Transmission- Based Precautions, when the facility failed to provide evidence of implementing isolation precautions (process of creating barriers between people and germs to help prevent the spread of infectious microbes) during an outbreak of infectious gastrointestinal related illnesses for four of six sampled residents (Resident 1, Resident 2, Resident 3 & Resident 4). This failure had the potential to spread infectious disease to other residents and staff at the facility. Residents Affected - Some Findings: During an interview on 12/2/24, at 9:35 a.m., with Infection Prevention Nurse (IP), IP stated, the care staff reported multiple residents with vomiting and diarrhea during the night shift in early October. IP stated, she became aware of the outbreak because it was documented in a change of condition report. IP stated, they began testing residents for C-diff (Clostridium difficile a bacterium that causes an infection of the colon, spread through physical contact) and Norovirus (viral infection causing vomiting and diarrhea spread through physical contact). IP stated, their procedure for isolation precautions are, once the staff identify symptoms of an infectious disease, they notify charge nurse who will place orders and notify the doctor, and put in orders for isolation precautions, in this case we would put the order for contact precautions (Use of personal protective equipment (PPE) appropriately, including gloves and gown). The IP stated, either herself or the charge nurse would put up isolation precaution signs outside the residents room to inform staff and visitors. During a review of the IP's outbreak documentation spreadsheet (an excel spreadsheet of all persons involved in the outbreak), undated, the spreadsheet indicated, 23 residents had GI related symptoms (ranging from nausea, vomiting, diarrhea, fever, or abdominal cramping) from the date range 10/18-10/30/24. The spreadsheet indicated, 11 staff members had GI related symptoms from the date range 10/22-10/27/24. The spreadsheet indicated, 6 residents were tested positive for norovirus in this date range, and one for c-diff. During a review of Resident 1's Change in Condition Evaluation(CIC) dated 10/22/24, CIC indicated, Nausea/Vomiting reported by staff during the night. During a concurrent interview and record review on 12/2/24, at 11:04 a.m., with IP, Resident 1's MD orders dated 10/22/24-10/28/24 was reviewed. MD orders indicated, no order for isolation precautions. IP stated Resident 1 should have been placed on isolation during the outbreak. During a review of Resident 1's MD orders dated 10/23/24, MD order indicated, collect stool culture for norovirus. Page 1 of 2 055517 055517 12/11/2024 Woodlands Healthcare Center 14966 Terreno DE Flores Lane Los Gatos, CA 95032

F 0880 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1's progress note dated 10/22/24, note indicated, resident began vomiting around 8p.m. During a review of Resident 1's progress note dated 11/4/24, note indicated, Resident 1 was positive for norovirus on 10/25/24. Residents Affected - Some During a review of Resident 2's Care Plan dated 10/22/24, Care plan indicated, Episodes of diarrhea due to unknown etiology. Interventions.Implement enhanced barrier precautions (Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) During a concurrent interview and record review on 12/2/24, at 11:06 a.m., with IP, Resident 2's MD orders dated 10/22/24-10/28/24 was reviewed. MD orders indicated, no order for isolation precautions. IP stated Resident 2 should have been placed on isolation during the outbreak. During a review of Resident 3's Care Plan dated 10/24/24, Care plan indicated, Episodes of diarrhea. Interventions. Implement enhanced barrier precautions. During a review of Resident 3's progress note dated 11/4/24, note indicated, Resident 3 was positive for norovirus on 10/25/24. During a concurrent interview and record review on 12/2/24, at 11:08 a.m., with IP, Resident 3's MD orders dated 10/22/24-10/28/24 was reviewed. MD orders indicated, no order for isolation precautions. IP stated Resident 3 should have been placed on isolation during the outbreak. During a review of Resident 4's Care Plan dated 10/24/24, Care plan indicated, Episodes of diarrhea due to unknown etiology. Interventions.Implement contact precaution. During a concurrent interview and record review on 12/2/24, at 11:10 a.m., with IP, Resident 4's MD orders dated 10/22/24-10/28/24 was reviewed. MD orders indicated, no order for isolation precautions. IP stated Resident 4 should have been placed on isolation during the outbreak. During a review of the facility's Policy & Procedure (P&P) titled, Infection Prevention and Control Program, dated 2021, the P&P indicated, 10. Outbreak management a. Outbreak management is a process that consists of: .(3) preventing the spread to other residents During a review of the facility's P&P titled, Isolation-Categories of Transmission- Based Precautions, the P&P indicated, Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection. 055517 Page 2 of 2