Health inspection·June 12, 2023

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to follow their policy and procedure by failing to: Residents Affected - Some 1. Sanitize and disinfect spaces in between visitors, after Coronavirus (COVID-19, a severe infection mainly respiratory disease that could spread from person to person) testing. 2. Properly manage biohazard (a risk to human health or the environment arising from biological work, especially with microorganisms) waste by discarding the used covid testing supply/kits which included a swab, sealed solutions, empty tube and covid 19 test in a regular trash. This deficient practice had the potential for a spread of infection including COVID-19. Findings: During an observation at the facility lobby, in front of the receptionist ' s desk on 6/12/2023 at 10:30 AM, three(3) visitors were observed taking a COVID - 19 test on a table designated by the facility for Covid testing. The 3 visitors were observed disposing the used covid testing suppliesin a regular trash bin, which was in front of the receptionist desk. The facility staff did not disinfect the table used for the Covid 19 testing. There was no biohazard bin and no disinfecting wipes observed on the Covid testing table. During a concurrent observation at the facility lobby, in front of the receptionist ' s desk and interview with Infection Preventionist (IP) Nurse on 6/12/2023 at 11 AM, observed Janitor taking trash from the regular trash bin, which was filled with used COVID testing supplies. The Janitor was observed putting the trash in a housekeeping cart.The IP Nurse stated the used covid testing supplies were considered biohazard and should be in a biohazard bag and not be in a regular trash bin. The IP Nurse stated the Janitors should be treating the waste as a biohazard waste because it can spread COVID. The IP Nurse stated the biohazard waste should be in the locked biohazard room which was only accessible to housekeeping/ janitor and Director of Nursing (DON). During a concurrent observation at the facility lobby, in front of the receptionist ' s desk and interview with IP Nurse on 6/12/2023 at 11:22 AM, two (2) groups of visitors were observed taking the COVID test. The IP Nurse stated that it was not right that the table was not being sanitized before and after every different group of visitors that take the COVID test. IP Nurse stated it is to prevent the spread of infection/COVID. During an interview on 6/12/2023 at 12:10 PM, a visitor for Resident 4 stated they would do the Covid testing on their own and no one would watch them. The visitor stated this was the second time Page 1 of 2 055760 055760 06/12/2023 Alhambra Healthcare & Wellness Centre, LP 415 South Garfield Alhambra, CA 91801

F 0880 that they came to the faiclity. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/12/2023 at 12:18 PM, a visitor for Resident 5 stated he would do the Covid test on his own and no one was helping him. Visitor also stated no one was wiping the table. Residents Affected - Some During an interview with on 6/12/2023 at 12:28pm, the Janitor stated he was busy so he threw the bag with used covid testing supplies in a housekeeping cart. Janitor stated it should not have been thrown in a housekeeping cart and should be treated as a biohazard. Janitor stated it should have been thrown in the biohazard room. During an interview on 6/12/2023 at 12:35pm, IP Nurse stated that used covid testing supplies should be treated as biohazard. IP Nurse stated it was not but it should have been included in the policy and procedure. A review of the facility ' s policy and procedure titled,Waste Management, revised April 21, 2022, indicated to maintain appropriate regulated waste containers. Container must be labeled with biohazard symbol or color coded in red. Policy also indicated to dispose bag in regulated container in the holding area (soiled utility room). A review of the facility ' s policy and procedure titled,Medical Waste – Containers and Storage, revised 1/1/2012, indicated designated individuals will be responsible for ensuring that containers are placed in locations where needed. Policy also indicated containers of medical waste are stored in the biohazard room. A review of the facility ' s policy and procedure titled, Visitation, revised 4/10/2023, indicated all communal, high touch surfaces are disinfected frequently with an U.S. Environmental Protection Agency (EPA; regulates disinfectants, sanitizers, and related cleaning products) approved hospital grade disinfectant form the EPA List N. A review of the Centers for Disease Control (CDC) and Prevention titled, Performing Broad-Based Testing for SARS-CoV-2 in Congregate Settings, updated 3/29/2021, indicated to clean space between tests, clean and disinfect participant side of table following each interview, and clean and disinfect clipboards and pens between participants. https://www.cdc.gov/coronavirus/2019-ncov/hcp/broad-based-testing.html 055760 Page 2 of 2