Health inspection·December 27, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete the infection monitoring form during an influenza outbreak for one of four sampled residents (Resident 3). This deficient practice had the potential for Resident 3 to not have an accurate assessment, progression, or regression of the delivery of care services. Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 12/16/2024, with diagnoses including influenza (a contagious respiratory illness that affects the nose, throat, and sometimes the lungs) pneumonia (an infection/inflammation in the lungs) and respiratory failure. During a review of Resident 3's History and Physical (H&P), dated 12/18/2024, the H&P indicated Resident 3 had the capacity to understand and make decisions. During an interview and a concurrent record review on 12/27/2024 at 2:01 PM, with the Director of Nursing (DON), the Infection Monitoring Forms for the facility's influenza outbreak, dated 12/13/2024 and 12/14/2024 was reviewed with the DON. The Infection Monitoring Forms, dated 12/13/2024 and 12/14/2024, indicated Resident 3 was in the facility in room [ROOM NUMBER] and had signs and symptoms of a cough. The DON stated that the form was inaccurately completed as Resident 3 did not admit to the facility until 12/16/2024. The DON stated that the dates on the forms were inaccurate as the infection monitoring in the facility was not initiated until 12/17/2024 for all residents. The DON stated that she did not ensure the dates on the forms were completed accurately. The DON stated ensuring that forms are accurately completed in healthcare is crucial for multiple reasons, as they directly impact patient care, safety, compliance, and operational efficiency. During a review of the facility's P&P titled, Charting and Documentation, dated 7/2017, the P&P indicated that documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Page 1 of 3 056083 056083 12/27/2024 Woods Health Services 2600 A Street LA Verne, CA 91750

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 maintain its infection prevention and control program for 2 of 4 sampled residents (Residents 1 and 2) by failing to ensure hand hygiene was performed during meal pass at lunch between Resident 1 and Resident 2. Residents Affected - Some These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for Residents 1 and 2. Findings During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 11/27/2024, and re-admitted the resident on 12/12/2024, with diagnoses including left femur (thigh bone) fracture, gastrointestinal hemorrhage (any bleeding that occurs in the digestive tract, from the mouth to the anus), and muscle wasting and atrophy (loss of muscle tissue). During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 12/19/2024, the MDS indicated Resident 1's cognition (the ability to think and process information) was moderately impaired. The MDS indicated Resident 1 was dependent (helper does all the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and required partial/moderate assistance (helper does less than half the effort) with mobility. During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 8/6/2016, and re-admitted the resident on 12/20/2024, with diagnoses including myocardial infarction (a heart attack), urinary tract infection (UTI-a condition in which bacteria invade and grow in the urinary tract), and difficulty walking. During a review of Resident 2's History and Physical (H&P), dated 12/21/2024, indicated Resident 2 had decision-making capacity can depend on the situation/context. The H&P indicated resident was able to move all extremities and weight-bearing as tolerated (WBAT- how much weight or force is put through a specific limb). During an observation on 12/27/2024 at 12:19 PM, Certified Nursing Assistant (CNA) 1 did not perform hand hygiene before entering Resident 1's room and after providing and assisting Resident 1 with Resident 1's lunch tray. CNA 1 did not perform hand hygiene after exiting Resident 1's room. CNA 1 then walked over to the coffee cart located next to the nursing station, grabbed the coffee pot, and pour some into the coffee cup without performing hand hygiene. CNA 1 then entered Resident 2's room without performing hand hygiene and provided Resident 2 with the coffee cup. During an interview on 12/27/2024 at 12:44 PM, with CNA 1, CNA 1 stated that she forgot to perform hand hygiene before entering Resident 1's room to provide Resident 1's lunch tray and then forgot to perform hand hygiene after exiting room [ROOM NUMBER]. CNA 1 stated that she then walked over to the coffee station grabbed the coffee pot and poured the coffee in a cup without performing hand hygiene. CNA 1 stated that she forgot to perform hand hygiene before entering Resident 2's room to provide Resident 2 a coffee cup. CNA 1 stated that not performing proper hand hygiene increases the risk of cross-contamination and the potential spread of infectious diseases. CNA 1 stated she should have performed hand hygiene after exiting Resident 1's room and before touching the coffee pot as this 056083 Page 2 of 3 056083 12/27/2024 Woods Health Services 2600 A Street LA Verne, CA 91750

F 0880 could lead to contamination of shared equipment, potentially further spreading infectious diseases. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/27/2024 at 3:42 PM, with the Infection Preventionist Nurse (IPN), the IPN stated that staff often move between rooms and interact with multiple residents and hand hygiene prevents carrying germs from one resident or surface to another. The IPN stated that touching shared equipment like a coffee pot in between residents without proper hand hygiene can spread germs. Residents Affected - Some During a review of the facility's Policy and Procedure (P&P) titled, Handwashing, undated, the P&P indicated all staff members will wash their hands before and after direct resident care and after contact with potentially contaminated substances to prevent, to the extent possible, the spread of nosocomial infections. During a review of the facility's Policy and Procedure (P&P) titled, Infection Control Program, the P&P indicated that the facility shall establish an infection control program designed to provide a safe, sanitary, and comfortable environment for residents and staff to help prevent the development and transmission of disease and infection. 056083 Page 3 of 3