Health inspection·August 1, 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 implement policies and procures to prevent and control the transmission of COVID-19 (coronavirus disease 2019 is an infectious disease caused by virus that can result in different symptoms from mild to severe respiratory illnesses and it spread during close contact and through the air from person to person) infection. By failing to ensure Licensed Vocational Nurse 3 (LVN 3) immediately left the facility upon testing positive for COVID-19. LVN 3 tested positive on 7/27/2024 at 7 PM and continued to work until 8 PM, charting and preparing medications for approximately 20 residents. Residents Affected - Few This deficient practices had the potential to transmit infectious disease microorganisms and increase the risk of infection to all 43 residents and staff. Findings: A review of the facility ' s Nursing Staffing Assignment and Sign-In Sheet dated 7/27/2024, indicated LVN 3 was assigned to work on 7/27/2024 from 4pm to 12am and was assigned medication administration. During an interview on 7/31/2024 at 9:34 AM, the Infection Preventionist (IP) stated on 7/27/2024, LVN 3 tested positive while at work in the facility. The IP stated LVN 3 stayed for a period in the facility to assist the registered nurse supervisor, who was to take over for LVN 3, by preparing medications for LVN 3 ' s assigned residents (approximately 20). The IP stated the current guidelines in place were for positive staff to go home, isolate for 5 days and return to work once symptoms were improving and had a negative test. The IP stated the guidelines were in place to ensure the safety of the facility ' s residents. The IP stated the spread of COVID in the facility could have been stopped if positive staff was removed from the facility. During an interview on 7/31/2024 at 12:14 PM, Resident 2 stated he has COVID-19. Resident 2 stated he had COVID-19 and was moved to this room when he tested positive. During a phone interview on 8/1/2024 at 9:32 AM, Licensed Vocational Nurse 3 (LVN 3) stated around 7 PM on 7/27/2024 while working the 3-11 PM shift at the facility she started feeling symptoms of COVID-19 that included headache and a runny nose. LVN 3 stated she tested positive at the facility then stayed at the nurse ' s station for about an hour to complete her charting and prepared the resident ' s medications (approximately 20) for the registered nurse supervisor to give. LVN 3 stated it was the facility ' s policy for staff to go home once testing positive. LVN 3 also stated staff had leave the facility due to residents being at high risk for becoming infected with COVID-19 and it was a very serious condition. (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: 055704 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 055704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Angels Nursing Health Center 415 S Union Avenue Los Angeles, CA 90017 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)