Health inspection·December 5, 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 policies and procedures (P&P) for infection control for two of three sampled residents (Resident 1 and Resident 3) when Certified Nursing Assistant (CNA) 1 failed to change their gown after repositioning Resident 1 and before draining Resident 3's urinary catheter (also known as a Foley catheter, device that drains urine from the urinary bladder into a collection bag). This deficient practice had the potential for cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) between Resident 1 and Resident 3. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/22/2024, with a diagnosis of gastrostomy malfunction (the surgical creation of a new opening from the skin of the abdomen into the stomach, through which a tube can be inserted to provide food, liquids, and medication directly into the stomach, bypassing the mouth and esophagus) and epilepsy (a chronic brain disorder where the brain's normal electrical activity becomes abnormal, leading to recurrent seizures). During a review of Resident 1's Minimum Data Set (MDS - a Resident assessment tool), dated 8/20/2025, the MDS indicated Resident 1 was severely impaired with thought process and required dependent assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 1's Physician's Orders, dated 6/25/2025, the Physician's Order indicated every shift enteral (a way to provide liquid nutrition directly into a person's gastrointestinal (GI) tract through a feeding tube, bypassing the mouth and throat) continuous feed at 55 cubic centimeters (cc - total volume) per hour for 20 hours. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 7/3/2025 with a diagnosis of osteomyelitis (a bone infection caused by bacteria or other microorganisms) and acute kidney failure (the sudden, recent loss of kidney function over hours to days, which prevents the kidneys from properly filtering waste products and maintaining fluid and electrolyte balance). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 was moderately impaired with thought process and required substantial assistance from staff to complete activities of daily living. A review of Resident 3's Physician's Orders, dated 7/21/2025, the Physician's Order indicated to observe enhance barrier precaution (giving healthcare workers a targeted germ-shield (a gown and gloves) when they do specific care activities for nursing home residents who carry hard-to-treat germs (MDROs), like those with chronic wounds or certain medical devices) every shift. During a review of Resident 3's Physician's Orders, dated 7/22/2025, the Physician's Order indicated foley catheter to continuous drainage. During a concurrent observation and interview on 9/29/2025 at 12:40 p.m. with CNA 1 inside Resident 1 and Resident 3 room. Observe that CNA 1 reposition Resident 1 and CNA 1 went to the bathroom to wash her hand and change her gloves and did not change gown. Observe CNA 1 drain Resident 3's foley catheter without changing gown. CNA 1 stated that she did Residents Affected - Few Page 1 of 2 056084 056084 12/05/2025 Astoria Healthcare Center 14040 Astoria Street Sylmar, CA 91342

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not change her gown, and she was supposed to change her gown before she takes care of Resident 3 to prevent contamination. During an interview on 9/29/2025 at 1:09 p.m. with the Director of Nursing (DON), the DON stated that CNA 1 should change her gown before taking care of Resident 3 to prevent cross contamination infection. The DON stated that CNA 1 did not follow the infection control implemented for both residents for isolation. During a review of the facility policy and procedure titled, Infection Prevention and Control Program, last review date 6/19/2025, the policy and procedure indicated, The ensure the Facility establishes and maintains and Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements. 056084 Page 2 of 2