Health inspection·January 31, 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 and record review, the facility failed to investigate and monitor for signs and symptoms of Respiratory Syncytial Virus (RSV - is a common respiratory virus that usually causes mild, cold-like symptoms that affects infants and older adults who are more likely to develop severe RSV and need hospitalization) among healthcare personnel/healthcare workers after these healthcare workers exposed to two of two sampled residents (Residents 1 and 2) who tested positive for RSV. Residents Affected - Some These deficient practices had the potential to spread RSV to other residents and staff. Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted the resident on 6/12/2023, with diagnoses that included hypertensive heart disease (a condition that develops when prolonged high blood pressure damages the heart muscle), chronic kidney disease (a condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood. This can lead to a buildup of harmful substances in the body and various health problems). During a review of Resident 1's Laboratory Results Report, dated 1/24/2025, the report indicated Resident 1 was tested for RSV and other respiratory pathogens on 1/22/2025 and confirmed positive for RSV on 1/24/2025. b. During a review of Resident 2's AR, the AR indicated the facility admitted the resident on 1/9/2025, with diagnoses that included dependence on supplemental oxygen, muscle weakness. During a review of Resident 2's Laboratory Results Report, dated 1/28/2025, the report indicated Resident 2 was tested for RSV on 1/27/2025 and conformed positive on 1/28/2025. During an interview on 1/31/2025 at 2:01 PM, the Infection Prevention Nurse (IPN) stated Resident 1 and Resident 2 were diagnosed with RSV. During an interview on 1/31/2025 at 2:27 PM, the IPN stated Resident 1 would leave the room and stay by the nurse's station and continued to go to the nurse's station. The IPN stated Resident 1 was tested for RSV because Resident 1 was exhibiting cough symptoms. The IPN stated Resident 1 and Resident 2 were placed on isolation when both residents were tested positive for RSV. During an interview on 1/31/2025 at 2:29 PM, the IPN stated Resident 2 would not go to communal dining and activities but Resident 2 would go for rehabilitation. The IPN stated the IPN did not have a (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056083 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056083 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woods Health Services 2600 A Street LA Verne, CA 91750 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)