Health inspection·March 11, 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 ensure infection control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for two (2) of 2 sampled residents (Resident 1 and 3) in accordance with the facility ' s policy and procedure when: Residents Affected - Some 1. Resident 1 ' s oxygen humidifier (a device used to make supplemental oxygen moist) was not dated to indicate it was changed every 7 days. 2. 2. Resident 3 ' s oxygen humidifier was found sitting on the floor instead of on top of the oxygen concentrator (a medical device that gives extra oxygen by taking and filtering air from the surroundings). These deficient practices had the potential for residents ' medical devices to be contaminated and placing residents at risk for infection. Findings: 1. A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included interstitial pulmonary disease (disease that causes scarring of the lung making it difficult to breath and get oxygen to the bloodstream). A review of Resident 1 ' s History and Physical (H&P), dated 1/1/23, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 12/13/2023, indicated the resident had severely impaired cognitive skills (ability to understand and make decision) for daily decision making. The MDS also indicated Resident 1 required substantial assistance (helper does more than half the effort) with shower, upper body, and lower body dressing, putting on/taking off footwear and personal hygiene. The MDS further indicated that Resident 1 required partial assistance (helper does less than half the effort) with toileting hygiene and required supervision (helper provides verbal cues) with oral hygiene. During an observation in Resident 1 ' s room on 3/11/24 at 11:15 AM, Resident 1 was observed sleeping in bed with oxygen via nasal cannula ( NC, a device that delivers extra oxygen through a tube and into your nose) set at 2 liter per minute (L/min). The oxygen humidifier (a refillable plastic bottle that infuses the normal flow of oxygen with water droplets) which was attached to Resident 1 ' s NC was observed undated. Page 1 of 4 055548 055548 03/11/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 3/11/24 at 11:25 AM, the Licensed Vocational Nurse 1 (LVN 1) stated the oxygen humidifier should be changed every seven (7) days and as needed. LVN1 stated the oxygen humidifier should be labeled and dated once the humidifier was changed so staff were aware and know when to change the humidifier next. LVN 1 also stated that the oxygen humidifier should be placed on top of the oxygen concentrator (a medical device that gives extra oxygen by taking and filtering air from the surroundings). During an interview on 3/11/24 at 1:45 PM, the Director of Nursing (DON) stated the oxygen humidifier should be changed every Wednesday and labeled with the date changed so the staff were aware when the last time the humidifier was changed. The DON also stated the humidifier could build up molds and could be a carrier for infection. 2. A review of Resident 3 ' s admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included pleural effusion (a buildup of fluid between the layers of tissue that line the lungs and chest cavity). A review of Resident 3 ' s History and Physical (H&P), dated 4/8/22, indicated Resident 3 did not have the capacity to understand and make decisions. A review of Resident 3's MDS, dated [DATE], indicated the resident had severely impaired cognitive skills for daily decision making. The MDS also indicated Resident 3 required substantial assistance with upper body dressing and was dependent (helper does all the effort) with oral and personal hygiene, shower, lower body dressing, putting on/taking off footwear. During a concurrent observation and interview in Resident 3 ' s room on 3/11/24 at 2 PM, LVN 2 stated Resident 3 ' s oxygen humidifier was on the floor while Resident 3 received oxygen via NC at 1.5 L/min. LVN 2 stated the humidifier should not be on the floor since the floor had germs and Resident 3 could potentially get an infection from having the humidifier placed on the floor. During an interview on 3/11/24 at 2:20 PM, the DON stated the oxygen humidifier should not be left on the floor because the floor was a breeding ground for bacteria to grow on. A review of the undated facility ' s policy and procedure (P&P) titled, Nasal Cannula, indicated as one of the procedures was to attach pre-filled bubble humidifier to the oxygen concentrator. A review of the facility ' s P&P titled, Oxygen Therapy, revised November 2017, indicated that oxygen was administered under safe and sanitary conditions to meet resident ' s needs. The policy also indicated that the humidifier equipment will be maintained and/or changed per manufacturer ' s guidelines for no more than every 7 days and dated each time they are changed. 055548 Page 2 of 4 055548 03/11/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer pneumococcal vaccine (prevents infection by Streptococcus (bacterium that causes one of the most common and severe forms of pneumonia) to one (1) of six (6) sampled residents (Resident 2) in accordance with the facility ' s policy and procedure. Residents Affected - Few This deficient practice placed Resident 2 at a higher risk of acquiring and experiencing complications from pneumococcal pneumonia disease (bacterial lung disease) including transmitting pneumonia to other residents in the facility. Findings: A review of Resident 2 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included pulmonary hypertension pulmonary hypertension (increase of blood pressure in the lungs) and chronic bronchitis (a lung condition that develops over time in which the large air passages that lead to the lungs become inflamed and scarred). A review of Resident 2 ' s History and Physical (H&P), dated 11/23/23, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 1/4/24, indicated the resident had an intact cognitive skill (ability to understand and make decision) for daily decision making. The MDS also indicated Resident 2 was dependent (helper does all the effort) with toileting hygiene, shower, lower body dressing, putting on/taking off footwear and required substantial assistance (helper does more than half the effort) with eating, oral hygiene, and upper body dressing. During an interview on 3/11/24 at 12:32 PM, Resident 2 stated she was not offered the pneumococcal vaccine by any staff while she was in the facility. During a concurrent interview and record review on 3/11/24 at 2:40 PM, the Infection Prevention Nurse (IPN) stated Resident 2 was not offered the pneumococcal vaccine since admission to the facility. The IPN stated the vaccine should have been offered to Resident 2 upon admission to the facility to protect the resident against pneumonia and complications such as meningitis (swelling of the protective membranes covering the brain and spinal cord). The IPN also stated Resident 2 ' s records indicated she was recommended to get the pneumococcal vaccine and the California Immunization Registry (CARE) indicated Resident 2 did not have any documented evidence indicating Resident 2 receiving the pneumococcal vaccine. During an interview on 3/11/24 at 2:50 PM, the Director of Nursing (DON) stated the pneumococcal vaccine should be offered during admissions and readmissions. The DON also stated that pneumococcal vaccines was necessary to provide protection to Resident 2 from pneumonia and meningitis complications. The DON further stated that Resident 2 had the right to be offered and receive and/or refuse the pneumococcal vaccine. A review of the facility ' s policy and procedure titled, Pneumococcal Disease Prevention, revised 2/18/21 indicated that to minimize the risk of residents acquiring, transmitting or experiencing complications from pneumococcal disease, the facility will offer pneumococcal immunization to each 055548 Page 3 of 4 055548 03/11/2024 Pasadena Park Healthcare and Wellness Center 2585 E. Washington Blvd. Pasadena, CA 91107

F 0883 resident, according to Centers for Disease Control and Prevention (CDC) recommendation, unless it is medically contraindicated, or the resident has already been immunized. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055548 Page 4 of 4