Health inspection·March 11, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to implement the infection control program and practices designed to help prevent the development and transmission of diseases and infections in the facility. Residents Affected - Some * The facility failed to ensure the licensed staff practiced the EBP during high contact care for one of four sampled residents (Resident 3). This failure posed the risk for the transmission of diseases and infections in the facility. Findings: According to the CDC, the EBP promotes the use of PPE to include donning of gown and gloves during high contact resident care activities that can provide the opportunities for transmission of MDROs to others. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include the following: - Dressing; - Bathing/showering; - Transferring; - Providing hygiene; - Changing linens; - Changing briefs or assisting with toileting; - Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator; and - Wound care: any skin opening requiring a dressing. Review of the facility's EBP signage showed everyone must clean their hands, including before entering and when leaving the room. Providers and staff must wear gloves and for the following high contact resident care activities: - Dressing; Page 1 of 3 055984 055984 03/11/2025 Anaheim Healthcare Center, LLC 501 South Beach Blvd. Anaheim, CA 92804

F 0880 - Bathing/showering; Level of Harm - Potential for minimal harm - Transferring; - Changing linens; Residents Affected - Some - Providing hygiene; - Changing briefs or assisting with toileting ; - Device care or use: central line, urinary catheter, feeding tube, tracheostomy; and - Wound care: any skin opening requiring a dressing. Medical record review for Resident 3 was initiated on 3/11/25. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Order Summary Report dated 3/11/25, showed a physician's order dated 2/28/25, for EBPrelated to GT use to apply the EBP to prevent the spread of infections for specific care activities such as morning and evening care, toileting and changing incontinence briefs, caring for the devices and giving medical treatments, wound care, mobility assistance, and preparing to leave the room and cleaning and disinfecting the environment every shift. Further review of Resident 3's Order Summary Report dated 3/11/25, showed a physician's order dated 2/26/25, to provide the trachea stoma wound care treatments every day shift. On 3/11/25 at 0910 hours, Resident 3's room was observed with an EBP standard precautions signage posted on Resident 3's door. The signage showed for the EBP, everyone must clean their hands, including before entering and when leaving the room and wear gloves during the following high contact resident care activities: - Dressing; - Bathing/showering; - Transferring; - Changing linens; - Providing hygiene; - Changing briefs or assisting with toileting ; - Device care or use: central line, urinary catheter, feeding tube, tracheostomy; and - Wound care: any skin opening requiring a dressing. On 3/11/25 at 0945 hours, an observation and concurrent interview was conducted with Treatment Nurse 1 for Resident 3. Treatment Nurse 1 was observed wearing gloves and providing the dressing change 055984 Page 2 of 3 055984 03/11/2025 Anaheim Healthcare Center, LLC 501 South Beach Blvd. Anaheim, CA 92804

F 0880 Level of Harm - Potential for minimal harm Residents Affected - Some to Resident 3's trachea stoma. Treatment Nurse 1 was not observed wearing a gown during the wound care treatment. When asked, Treatment Nurse 1 verified he should have donned the proper PPE which included a gown to prevent the spread of infections. On 3/11/25 at 1410 hours, an interview was conducted with the IP. The IP was informed of the above findings and stated the facility staff were expected to perform hand hygiene, don gloves and gown when providing high-contact resident care activities, including wound care treatment to prevent the transmission of diseases and infection for the residents on the EBP. 055984 Page 3 of 3