Health inspection·March 6, 2025

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, medical record review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections for three of five sampled residents (Residents 1, 2, and 3). Residents Affected - Few * The facility staff failed to don PPE prior to entering the residents ' rooms (Rooms A and B) which were on contact isolation. This failure posed the risk for transmission of disease-causing microorganisms. Findings: Review of the facility's P&P titled Isolation-Categories of Transmission-Based Precautions revised 9/2022 showed the staff and visitors will wear gloves (clean, non-sterile) when entering the room. Gloves will be removed, and hand hygiene performed before leaving the room. 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. a. On 3/3/25 at 1218 hours, during an observation, Room A had a sign showing contact precautions. The sign showed everyone must clean their hands, including before entering and when leaving the room. The sign also showed the providers and staff must put on gloves and gowns before entering the room and discard the gloves and gowns before exiting the room. CNA 3 entered Room A without performing hand hygiene and donning gloves or an isolation gown. CNA 3 then put the linen on the resident ' s bed with her bare hands. On 3/3/25 at 1219 hours, an observation and concurrent interview was conducted with CNA 3. CNA 3 verified Room A was on contact precautions. CNA 3 confirmed she entered Room A without performing hand hygiene, using gloves, or wearing a gown and should have followed the precautions. On 3/3/25 at 1546 hours, an observation and concurrent interview was conducted with CNA 4. CNA 4 entered Room A, which was on contact precautions, with gloves and a surgical mask. CNA 4 did not perform hand hygiene prior to entering Room A. CNA 4 was observed removing the resident's water pitcher. CNA 4 did not perform hand hygiene prior to exiting Room A. CNA 4 stated he was not aware Room A was placed on contact precautions. When asked how CNA 4 would know a room was placed on isolation precautions, CNA 4 pointed at the contact precautions sign located outside Room A. CNA 4 verified he did not wear a gown and perform hand hygiene prior to entering Room A. b. On 3/4/25 at 0926 hours, an observation of Room B and concurrent interview was conducted with LVN 3. Room B had a sign showing contact precautions. The sign showed everyone must clean their hands, including before entering and when leaving the room. The sign also showed providers and staff must Page 1 of 2 056010 056010 03/06/2025 Seal Beach Health and Rehabilitation Center 3000 N Gate Road Seal Beach, CA 90740

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few put on gloves and gowns before entering the room,and discard gloves and gowns before exiting the room. LVN 3 entered Room B without donning an isolation gown. LVN 3 then informed the resident she would be doing the treatment. LVN 3 stated she was not aware Room B was placed on contact isolation. LVN 3 verified she did not wear a gown. c. On 3/4/25 at 1003 hours, an observation of Room A and concurrent interview was conducted with LVN 6. Room A was on contact precautions, with gloves and a surgical mask. LVN 6 entered Room A without performing hand hygiene and donning gloves or an isolation gown. LVN 6 gave the resident a boost drink with her bare hands. LVN 6 stated she was not aware Room A was placed on contact precautions. LVN 6 confirmed she entered Room A without performing hand hygiene, using gloves, or wearing a gown and should have followed the precautions. On 3/4/25 at 1220 hours, an interview was conducted with the IP. When asked how the staff were notified of the residents on isolation precautions, the IP stated the staff were notified via in-service, huddles, and isolation postings indicating PPE use. The IP stated the expectation was for the staff to follow the precaution signages posted outside the residents' rooms. 056010 Page 2 of 2