Health inspection·May 20, 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 observations, interviews, and record reviews, the facility failed to ensure infection prevention and practices were implemented for three of three sampled residents (Resident 1, 2, and 3) in accordance to the facility ' s Policy and Procedure (P&P) titled Infection Prevention and Control Program, by failing to: Residents Affected - Some 1. Ensure Resident 1 was immediately placed on isolation (the separation of a patient from others to prevent the spread of infections or to protect them from potential harm due to their own vulnerabilities) after the physician ordered Resident 1 to be transferred to the General Acute Care Hospital (GACH) for a diagnosis of impetigo (a contagious skin infection). 2. Ensure Resident 2 and Resident 3 were placed on isolation after being exposed to Resident 1. 3. Ensure signage was posted outside of Resident 1, Resident 2, and Resident 3 ' s room to alert facility staff and visitors on the specific personal protective equipment (PPEequipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) to utilize. These deficient practices had the potential to result in the transmission of disease and infection from resident to resident. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including pneumonia (an infection/inflammation in the lungs), Anemia (condition where the blood has a reduced ability to carry oxygen, can be caused by several factors), and hypertension (a condition of high blood pressure). During a review of Resident 1's History and Physical (H&P) dated 2/16/2025, the H&P indicated Resident 1 does not have the capacity to understand and make healthcare decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 4/17/2025, the MDS indicated the resident ' s cognition is severely impaired. During a review of Resident 2's AR, the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a brain dysfunction caused by a disruption in the body's chemical balance, often due to underlying medical conditions like diabetes, liver disease, or kidney failure), hearth failure (a condition when the heart can't pump enough blood to meet the body's needs), and hypertension (a condition of high blood pressure). Page 1 of 5 055899 055899 05/20/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0880 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 2's History and Physical (H&P) dated 4/23/2025,the H&P indicated Resident 2 does have the capacity to understand and make healthcare decisions. During a review of Resident 2's MDS dated [DATE],the MDS indicated the resident ' s cognition is moderately impaired. Residents Affected - Some During a review of Resident 3's AR, the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including type 2 diabetes (a condition of high blood sugar), Anemia (condition where the blood has a reduced ability to carry oxygen, can be caused by several factors), and hypertension (a condition of high blood pressure). During a review of Resident 3's H&P dated 2/3/2025, the H&P indicated Resident 3 mental status is competent to understand his/her medical condition. During a review of Resident 3's MDS dated [DATE], the MDS indicated the resident ' s cognition is intact. During a review of Facility Census dated 5/19/2025, the Census indicated Resident 1 was sharing the room with Resident 2 and Resident 3. During a review of Resident 1's physician telephone orders dated 5/19/2025 and timed at 11:42 AM indicated to transfer Resident 1 to the General Acute Care Hospital (GACH) 1 for further evaluation of impetigo involving the right side of the neck, ear and face . During a review of Resident 1's Change of Condition (COC), dated 5/19/2025 and timed at 9:58 AM, the COC indicated worsening of the right neck rashes with yellow and red crust and some blister and weeping, and right facial swelling. The COC indicated a Physician order was obtained to transfer Resident 1 to the GACH for further evaluation. The COC indicated a diagnosis of impetigo. During a review of Resident 1's nursing progress note dated 5/19/2025 and timed at 5:40 PM, the progress note indicated Resident was transported to GACH 1 at 5:25 PM via Ambulance due to the suspicion of impetigo affecting the right neck, ear and face for further evaluation. During a review of facility provided document titled Infectious Organism Transfer Form dated 5/19/2025 indicated, the form indicated Resident 1 was on contact precaution and required PPE, which included gown and gloves. The form indicated Resident 1 infectious organism was Impetigo involving Right side of the neck ,ear, and face . During a review of a facility provided phone text message sent by Infection Preventionist(IP) Nurse on 5/19/2025 at 9:58 AM, the text indicated We need to isolate Resident 1, shingles. During an interview on 5/20/2025 at 10:16 AM with Director of Nursing (DON), DON stated Resident 1 was transferred to the GACH on 5/19/25 for further evaluation of impetigo . DON stated she was not aware if Impetigo required contact isolation. DON stated Resident 1 ' s roommates (Resident 2 and Resident 3) were not placed on isolation. During an observation on 5/20/2025 at 10:23 AM, in Resident 1 ' s room, Resident 2 and Resident 3 were observed lying in bed. There was no isolation signage posted outside of Resident 2 and 3 ' s room. 055899 Page 2 of 5 055899 05/20/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 5/20/2025 at 10:24 AM with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s room was observed. Resident 2 and Resident 3 were lying on the bed and Resident 1 ' s bed empty. LVN 1 stated there were no isolation signage posted on the door. LVN 1 stated she was assigned to care for Resident 2 and Resident 3 on 5/20/2025 . LVN 1 stated Residents 2 and 3 were not on any kind of isolation. LVN 1 stated she did not receive any report to isolate them. LVN 1 stated Residents 2 and 3 were present yesterday, 5/19/2025 and shared the room with Resident 1. LVN 1 stated if she was aware that Resident 1 was transferred to the GACH for further evaluation for impetigo, Resident 2 and Resident 3 should be placed on isolation since the room was shared with Resident 1, to prevent the transmission of infection. LVN 1 stated she would post an isolation signage to alert staff and visitors to wear PPE to prevent the spread of infection. During an interview on 5/20/2025 at 10:47 AM with Certified Nursing Assistance (CNA) 1, CNA 1 stated she was assigned to care for Resident 1 on 5/19/25 from 7 AM to 3 PM, and also provide care for Resident 2 and Resident 3 (they were all roommate) . CNA 1 stated if a Resident was on isolation the facility should must post an isolation sign so staff and visitors would know what PPE to wear upon entering the room. CNA 1 stated Resident 1 was not on any isolation yesterday 5/19/2025 . CNA 1 stated Resident 2 and 3 were currently not on any isolation. CNA 1 stated not wearing PPE when caring for Resident 1 yesterday, or Resident 2 and 3. CNA 1 stated if she was aware that Resident 1 required isolation and required a gown and gloves when providing care, CNA 1 would have worn the PPE when caring for Resident 1. CNA 1 stated not using PPE for Resident 1, Resident 2 and Resident 3. During an interview on 5/20/2025 at 11:02 AM with Register Nurse (RN) 1,RN 1 stated she was assigned to Resident 1 on 5/19/25 and that Resident 1 was sharing a room with Resident 2 and Resident 3. RN 1 stated around 9:45 AM to 10:00 AM, RN 1 went to Resident 1 ' s room with IP nurse to assess Resident 1 skin. RN 1 stated Resident 1 had a rash, yellow crust and some blisters to the right side, around the neck area. RN 1 stated that the physician was informed, and an order to transfer Resident 1 to the GACH for further evaluation was obtained. RN 1 stated Resident 1 ' s diagnosis was impetigo. RN 1 stated Resident 1 was transferred to hospital around 5 PM on 5/19/2025 . RN1 stated Resident 1 was not place on contact isolation yesterday 5/19/2025 and no isolation signage were posted outside of Resident 1, 2 and 3 ' s room. RN 1 stated Resident 1 should have been placed on contact isolation to prevent the transition of infection. During an interview and record review on 5/20/2025 at 11:29 AM with DON, Resident 3 ' s physician telephone orders dated from 5/20/2025 at 10:54 AM reviewed. Resident 3 ' s physician telephone order indicated Enhanced Barrier Precaution (Staff to utilize gown and gloves for high-contact resident care activities). The DON stated Resident 1 should have been placed on isolation since Resident 3 shared a room with Resident 1. During an interview on 5/20/2025 at 11:35 AM with IP Nurse ,IP Nurse stated Resident 1 , Resident 2, and Resident 3 shared room on 5/19/2025 . IP nurse stated on 5/19/2025 around 9:50 AM, IP assessed Resident 1 ' s skin around the neck area with RN 1 and suspected shingles (a viral infection that causes a painful rash). The IP stated a text was sent to the physician on 5/19/2025 at 9:58 AM, and that Resident 1 required isolation. IP stated a physician order was received to transfer Resident 1 to the GACH around 11:30 AM for further evaluation of impetigo. IP stated Resident 1 remained in the room with Resident 2 and 3 from until Resident 1 was transferred to the GACH at approximately 5 PM ( approximately 8 hours after Resident 1 was ordered for isolation). IP nurse stated he did not place Resident 1 on contact isolation and did not post any sign on 5/19/2025. IP nurse stated Resident 2 and Resident 3 were not placed on isolation either until the next morning, 5/20/2025. IP nurse stated Resident 1, Resident 2 and Resident 3 should have been placed on isolation to prevent spread of 055899 Page 3 of 5 055899 05/20/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0880 infection. Level of Harm - Minimal harm or potential for actual harm During an interview and record review on 5/20/2025 at 12:52 PM with DON, DON stated the Resident 1 room was not placed on contact isolation on 4/19/2025 when physician order tranfer Residnet1 to GACH for further eval impetigo. DON stated staff should have place Resident 1, contact isolation and place Resident 1 ' s roommates (Resident 2 and Resident 3) on Enhanced Barrier precaution. DON stated the potential outcome was the transmission of infection. Residents Affected - Some During a concurrent interview and record review on 5/20/2025 at 1:02 PM with DON, Resident 1 ' s physician orders were reviewed. DON stated there was no order from the physician to place Resident 1 on isolation. During a concurrent interview and record review on 5/20/2025 at 1:10 PM with DON, Resident 1 ' s active care plans were reviewed. DON stated there was no care plan initiated for Resident 1 indicating a diagnosis of Impetigo, nor was there any care plans that indicated to place resident on contact precaution. DON stated care plans should have been initiated to address Resident 1 ' s specific need such as the type of isolation in place, and the type of PPE to use prior to entering Resident 1 ' s room. During a concurrent interview and record review on 5/20/2025 at 1:19 PM of a facility provided document by the IP nurse titled Centers for Disease Control and Prevention Group A Step Infection, and Clinical Guidance for Group A streptococcal Impetigo was reviewed. The IP nurse stated the facility was not following CDC guideline. IP nurse stated based on the CDC guidelines if the facility suspected a resident to have Impetigo the resident should be placed on contact isolation which means staff and visitors will wear gloves when entering he room, and remove before leaving the room, hand hygiene, and disposable trays. IP stated CDC guideline indicated contact with someone else with impetigo was the common risk for infection. A review of the facility ' s provided document titled CDC Group A Step Infection , Clinical Guidance for Group A streptococcal Impetigo, reference 2015 indicated: Impetigo (also called pyoderma) was a superficial bacterial skin infection caused by either S. pyogenes or S. aureus, Close Contact, contact with someone else with impetigo was the most common risk factor for infection. This includes contact with drainage from impetigo lesions. A review of the facility ' s policy and procedure titled Isolation-Categories of Transimission-Based Precautions, revised on October 2018 indicated: Transmission-Based Precautions was initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. The Centers for Disease Control and Prevention (CDC) maintains a list of diseases, modes of transmission and recommended precautions. Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The decision on whether contact precautions are necessary will be evaluated on a case by case basis. The individual on contact precautions will be placed in a private room if possible. If a private room is not available, the Infection Preventionist will assess various risks associated with other resident placement options (e.g., cohorting, placing with a low risk roommate). Staff and visitors will wear gloves (clean, non-sterile) when entering the room. While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage).b. Gloves will be removed and hand hygiene performed before 055899 Page 4 of 5 055899 05/20/2025 Royal Palms Post Acute 630 W. Broadway Glendale, CA 91204

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some leaving the room c.Staff will avoid touching potentia11y contaminated environmental surfaces or items in the resident's room after gloves are removed. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. When transporting individuals with skin lesions, excretions, secretions, or drainage that is difficult to contain, contact precautions will be taken during resident transport to minimize the risk of transmission. A review of the facility ' s policy and procedure titled Infection prevention and Control Program , revised on October 2018 indicated: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Prevention of Infection : a.Important facets of infection prevention include: (1) identifying possible infections or potential complications of existing infections; (2) instituting measures to avoid complications or dissemination; (3) educating staff and ensuring that they adhere to proper techniques and procedures; (4) communicating the importance of standard precautions and cough etiquette to visitors and family members; (5) enhancing screening for possible significant pathogens; (7) implementing appropriate isolation precautions when necessary; and (8) following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). A review of the facility ' s policy and procedure titled Care Plans, Comprehensive Person-Centered , revised on December 2016 indicated: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers. Care planning individual symptoms in isolation may have little, if any, benefit for the resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MOS). Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 055899 Page 5 of 5