Health inspection·September 11, 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 observation, interview, and record review the facility failed to implement and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to Ensure Certified Nurse Assistant (CNA) 1 implemented proper use of personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) for two of four sampled residents (Resident 2 and 4) who are on Coronavirus disease isolation precautions ( infection control intervention designed to reduce transmission of Coronavirus disease [COVID-19-a newly identified respiratory infectious disease] that uses disposable gown, eye protection, mask, and gloves use while in the resident's room and providing resident care). This deficient practice had the potential to result in the spread of COVID-19 among residents and staff. Findings:a. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 11/19/2024 with diagnoses including generalized muscle weakness, adjustment disorder with mixed anxiety and depressed mood (an extreme emotional or behavioral reaction to a specific stressful event, causing symptoms of both sadness and worry), and hypothyroidism (a condition in which the thyroid gland [a hormone producing gland located in the front of the neck] does not produce enough hormones). During a review of Resident 2's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 11/21/2024, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 8/21/2025, the MDS indicated Resident 2 had functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 2 required moderate assistance (helper does less than half the effort) from the facility staff with personal hygiene, showers, upper and lower body dressing.During a review of Resident 2's Care Plan, initiated on 9/10/2025, the Care Plan indicated that Resident 2 had altered respiratory status, difficulty breathing related to sore throat, nonproductive cough, and congestion related to COVID-19. The Care Plan interventions indicated for facility staff to maintain Novel/respiratory precautions for COVID-19. During a review of Resident 2's Physician's Order dated 9/10/2025, the Physician's Order indicated to place Resident 2 on precautions for COVID-19 during every shift for ten days. b. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 6/25/2025 with diagnoses including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), unspecified dementia (a progressive state of decline in mental abilities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 4's H&P, dated 6/27/2025, the H&P indicated Resident 4 had the capacity to understand and make decisions.During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 2 had functioning (mental processes that Residents Affected - Few Page 1 of 3 056084 056084 09/11/2025 Astoria Healthcare Center 14040 Astoria Street Sylmar, CA 91342

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 4 was dependent on facility staff for toileting hygiene, showers, and lower body dressing. During a review of Resident 4's Physician's Order dated 9/4/2025, the Physician's Order indicated to place Resident 4 on precautions for COVID-19 during every shift for ten days. During a review of Resident 4's Care Plan, initiated on 9/14/2025, the Care Plan indicated that Resident 4 had a sore throat and cough related to COVID-19. The Care Plan interventions indicated for facility staff to strictly observe isolation precaution procedures. During an observation on 9/11/2025 at 10:55 a.m. in Room A (Resident 2 and Resident 4's shared room), CNA 1 was observed wearing a gown, gloves, mask, and face shield while changing Resident 2's gown and bed linens. CNA 1 was observed to remove gloves and gown, wash hands, take a new gown from the isolation cart (a storage cart used to hold PPE for caring for a resident with an infectious disease) located outside of Room A near the door, and put on the new gown while wearing mask and face shield. CNA 1's face shield was observed to slide down under the gown while CNA 1 was donning the new gown. During an observation on 9/11/2025 at 11:05 a.m. in Room A, CNA 1 was observed wearing a gown, gloves, mask, and face shield. While assisting Resident 4 with changing hospital gown and bed linens, CNA 1 was observed to remove gloves, clean hands with hand sanitizer, and remove clean linens and gown from the clean linen cart in front of Room A entrance. CNA 1 was observed wearing a gown, mask and face shield when removing clean linens from the cart. During an interview on 9/11/2025 at 11:18 a.m. with CNA 1, CNA 1 stated she (CNA 1) should have removed her (CNA 1) gown before taking clean linens from the linen cart. CNA 1 further stated she (CNA 1) should have put on a new gown after removing all PPE including the face shield and washing hands to prevent the spread of infection to other residents. During an interview on 9/11/2025 at 2:30 p.m. with the Infection Preventionist (IP), the IP stated that CNA 1 did not follow facility's policy and procedure of infection control and use of PPE. The IP stated CNA 1 should have removed gloves, gown, mask and face shield, and washed her hands before CNA 1 put on a new gown. The IP further stated CNA 1 should have removed gloves, gown, mask and face shield, and washed her hands before CNA 1 removed clean linens from the cart. The IP stated CNA 1 could have caused cross-contamination from used face shield and gown and spread infection to other residents. During an interview on 9/11/2025 at 4:32 p.m. with the Director of Nursing (DON), the DON stated the purpose of following infection control procedures and guidelines was to prevent cross contamination and spread of infection to residents. The DON stated CNA 1 should have removed the face shield prior to putting on a new gown. The DON further stated CNA 1 should have removed all PPE prior to obtaining clean linens from the linen cart. The DON stated these failures had the potential to cause cross-contamination and spread of infection to other residents. During a review of the facility-provided Policy and Procedure (P&P) titled, Resident Isolation-Categories of Transmission -Based Precautions last reviewed on 6/19/2025, the P&P indicated, To ensure that transmission-based precautions are used when caring for residents with communicable diseases or transmittable infections.Transmission-based precautions are used accordingly when caring for residents who are documented or are suspected of having communicable diseases or infections that can be transmitted to others.Contact precautions are implemented for residents known or suspected to be infected or colonized with microorganisms that are transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. i. Examples of infections requiring Contact Precautions include but are not limited to:.p. COVID-19.D. Gown.ii. The gown is removed, and hand hygiene is performed before leaving the resident's environment. iii. After removing the gown, clothing is not allowed to contact potentially contaminated environmental surfaces.IV. Droplet Precautions. A. Droplet precautions are implemented for a 056084 Page 2 of 3 056084 09/11/2025 Astoria Healthcare Center 14040 Astoria Street Sylmar, CA 91342

F 0880 Level of Harm - Minimal harm or potential for actual harm resident who is documented or is suspected of being infected with microorganisms transmitted by droplets.Examples of infections requiring droplet precautions include, but are not limited to: COVID-19. D. Gown.ii. The gown is removed, and hand hygiene is performed before leaving the resident's environment. iii. After removing the gown, clothing is not allowed to contact potentially contaminated environmental surfaces. Residents Affected - Few 056084 Page 3 of 3