Health inspection·July 22, 2025

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 observe infection control measures for two (2) of 2 sampled residents (Resident 1 and 2) as indicated on the facility policy by failing to ensure:1. Certified Nursing Assistant (CNA) 1 performed hand hygiene (the practice of cleaning and disinfecting hands to remove harmful microorganisms) when exiting Resident 1 and 2's room. 2. Resident 1 had clinical or laboratory results for Carbapenem-Resistant Acinetobactor baumannii (CRAB - a bacterial infection caused by a drug-resistant strain of bacteria) when resident was readmitted to the facility on [DATE].This deficient practice has the potential to spread infection to staff and other residents in the facility.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of resistance to multiple antibiotics (a microorganism has developed the ability to withstand the effects of several different antibiotics), pneumonitis (swelling and irritation, also called inflammation, of lung tissue), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and malnutrition (lack of proper nutrition). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/15/2025, the MDS indicated the resident was moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 1 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with upper body dressing and personal hygiene but requires substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, lower body dressing and putting on/taking off footwear. During a review of Resident 1's Change of Condition (COC - a significant alteration in the residents physical or mental status), dated 6/12/2025 at 11:46 PM, the COC indicated the resident was transferred via 911 (emergency services) to GACH (General Acute Care Hospital) 1. During a review of Resident 1's laboratory results from GACH (General Acute Care Hospital) 1, dated 6/14/2025, the laboratory results indicated Resident 1 was admitted to GACH 1 on 6/13/2025 and was positive for CRAB. During a review of the facility's electronic mail (email) from Public Health Nurse (PHN) to the facility, dated 7/7/2025, the email thread indicated a report of Resident 1 was positive for CRAB. The email thread also indicated PHN instructions was staff should always conduct hand hygiene and ensure to implement Enhanced Barrier Precautions (EBP - infection control measures implemented in nursing homes to reduce the spread of multidrug-resistant organisms [MDROs]). During a review of Resident 1's Nurses Notes, dated 7/16/2025 at 6:28 PM, the Nurses Notes indicated the resident was on monitoring for new admission (not indicated from where). During a review of Resident 1's Care Plan with focus EBP, revised 7/16/2025, the care plan indicated the resident had a history of CRAB. The care plan also indicated hand hygiene before and after resident contact and standard precautions (a set of infection Residents Affected - Some Page 1 of 3 055818 055818 07/22/2025 Royal Gardens Healthcare 2339 W. Valley Blvd. Alhambra, CA 91803

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some control practices designed to prevent the transmission of infectious diseases in healthcare settings, such as washing hands or using an alcohol-based hand rub when entering and exiting patient care areas) apply to the care of the resident. During a review of Resident 2's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of DM, urinary tract infection (UTI- an infection in the bladder/urinary tract), and sepsis (a life-threatening blood infection). During a review of Resident 2' s MDS, dated [DATE], the MDS indicated the resident was independent in cognitive skills for daily decision making. The MDS also indicated the resident required partial/moderate assistance with upper body dressing, substantial/maximal assistance with lower body dressing and was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene and shower/bathe self. During a concurrent observation and interview outside Room A (Resident 1 and 2's room) on 7/21/2025 at 11:15 AM, the Infection Preventionist Nurse (IPN) stated the EBP sign indicated the resident is currently and only on Carbapenem-resistant Enterobacterales (CRE - a family of bacteria that are resistant to many antibiotics) precautions. During an interview with Resident 2 on 7/21/2025 at 11:22 AM, Resident 2 stated the staff would just bring in his food without personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments), does not perform hand hygiene when the staff leaves the resident's room. During an observation on 7/21/2025 at 12:15 PM, during the passing of meal trays, Certified Nursing Assistant (CNA) 1 was observed delivering a meal tray to Room A for Resident 2. CNA 1 was also observed coming out of Room A without performing hand hygiene. During an interview on 7/21/2025 at 1:06 PM, the IPN stated Resident 1's diagnosis of CRAB is not but should be on the admission Record, so the staff and other facilities receiving the resident can take appropriate infection control measures. During an interview with GACH 1 IPN on 7/21/2025 at 1:20 PM with IPN present, GACH 1 IPN stated Resident 1 was positive for CRAB since 6/14/2025 and was discharged to GACH 2 on 6/22/2025. During an interview with GACH 2 Case Manager on 7/21/2025 at 1:32 PM with IPN present, GACH 2 stated Resident 1 was not tested for CRAB during stay of Resident in GACH 2 from 6/22/2025 to 7/15/2025. IPN stated, there was no diagnostic result that showed Resident 1 was cleared from CRAB and the facility should have tested Resident 1 when the resident was admitted back on 7/15/2025. During an interview on 7/21/2025 at 2:15 PM, the IPN stated she did not test Resident 1 and Resident 2 for CRAB since Resident 1 was admitted at the facility on 7/15/2025. During a concurrent interview and record review on 7/21/2025 at 2:40 PM, the facility's policy and procedure (P&P) titled Isolation Discontinuing, revised 10/2018, was reviewed. The P&P indicated precautions are evaluated daily and clinical, or laboratory results are needed to indicate that the infection is resolved. The IPN stated according to the P&P, the facility needs to complete clinical or laboratory results for Resident 1's CRAB when the resident was admitted to the facility. The IPN stated Resident 1 was not and should have been retested for CRAB upon readmission on [DATE] and diagnosis of CRAB or history of CRAB would need to be indicated on Resident 1's admission Record. During the same concurrent interview and record review on 7/21/2025 at 2:40 PM, the facility's undated P&P titled Enhanced Barrier Precautions, was reviewed. The P&P indicated, standards precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status. The IPN stated standard precautions are applied to all residents regardless of suspected or confirmed infection or colonization status. The IPN also stated the CNA should perform hand hygiene upon entering and exiting resident's room. During an interview on 7/21/2025 at 3:38 PM, the IPN stated the reason to test Resident 1 if the reisdent is still 055818 Page 2 of 3 055818 07/22/2025 Royal Gardens Healthcare 2339 W. Valley Blvd. Alhambra, CA 91803

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some positive for CRAB is to ensure infection control measures are followed. During a concurrent observation and interview of the facility's surveillance video dated 7/21/2025 with time stamp around 12:15PM on 7/21/2025 at 4 PM, the video showed CNA 1 did not perform hand hygiene upon exiting Room A. The Administrator (ADM) stated CNA 1 did not perform hand hygiene upon exiting Room A. During an interview on 7/22/2025 at 9:30 AM, CNA 1 stated she should have performed hand hygiene when she exited Room A on 7/21/2025 at 12:15 PM because that can spread infection to other residents in the facility. During a concurrent interview and record review of Resident 1's admission Record, printed on 7/21/2025 at 12:20 PM, on 7/22/2025 at 9:42 PM, the IPN stated the resident's admission Record should indicate diagnosis of CRAB because the diagnosis is not officially discontinued since we do not have evidence Resident 1 was negative from CRAB. The IPN also stated it is for staff and other facilities, who receive the resident, to take precautionary infection control measures. 055818 Page 3 of 3