Health inspection·May 30, 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 Enhanced Barrier Precautions ([EBP] involve gown and glove use during high contact resident care activities for residents at risk for Multidrug-Resistant Organisms ([MDRO, bacteria that have become resistant to certain antibiotics]) for one of three sampled residents (Resident 1), who had a left thigh wound and required daily dressing (sterile pad or material placed directly on a wound to protect it from infection and to promote healing ) changes. The facility failed to: Residents Affected - Few 1. Ensure the Treatment Nurse (TN) had the proper understanding of EBP and put on the appropriate personal protective equipment ([PPE] clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) prior to conducting Resident 1 ' s dressing change. 2. Ensure proper signage was placed outside Resident 1 ' s room indicating Resident 1 was on EBP. These deficient practices resulted in the TN not applying a gown prior to starting Resident 1 ' s dressing change. These deficient practices had the potential for all other staff not wearing the appropriate PPE when providing high contact resident care activities due to not having a sign indicating Resident 1 was on EBP. These deficient practices also had the potential to increase the risk of transmitting disease-causing organisms to Resident 1 and all other residents, staff, and/or visitors in the facility which could potentially lead to illness. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including left femur (thigh) fracture (broken bone), multiple pelvic (bowl shaped structure formed by bones on the top of legs) fractures, and muscle weakness. During a review of Resident 1 ' s Minimum Data Set ([MDS] a resident assessment tool) dated 5/2/2025, the MDS indicated Resident 1 ' s cognition (ability to register and recall information) was intact and had the ability to understand and be understood by others. During a review of Resident 1 ' s Order Summary Report (Physician ' s Orders), dated 5/30/2025, indicated an order was written to cleanse Resident 1 ' s left medial (towards the middle) thigh extending to the left medial knee ruptured blood blister daily and as needed, with normal saline (mixture of water and salt), gently pat dry, apply Santyl (prescription medication used to remove dead tissue from wounds to promote healing) ointment to wound bed, then cover with non-woven gauze. Page 1 of 2 056164 056164 05/30/2025 Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 5/30/2025 at 10 a.m., outside Resident 1 ' s room, there were no EBP signs posted outside Resident 1 ' s room indicating Resident 1 was on EBP. During an observation on 5/30/2025, at 10:10 a.m., in Resident 1 room, Resident 1 was observed lying in bed and the TN was observed setting up supplies to perform Resident 1 ' s left thigh dressing change then walked to the side of Resident 1 ' s bed and stated she was going to start Resident 1 ' s dressing change. The TN was observed not wearing a gown when she was going to start Resident 1 ' s dressing change. During an interview on 5/30/2025 at 10:15 a.m., the TN stated Resident 1 did not require EBP because Resident 1 did not have an indwelling device (medical device that is inserted into the body and left in place for an extended period). The TN stated she did not think Resident 1 ' s wound dictated the need for implementing EBP. The TN stated there was no EBP signage on or around Resident 1 ' s door indicating the need for EBP. The TN stated there should be a sign outside Resident 1 ' s room upon entrance so it could remind staff to implement EBP prior to entering Resident 1 ' s room. During a concurrent observation and interview on 5/30/2025 at 11:15 a.m., with the Infection Preventionist (IP) Nurse, the IP was observed placing an EBP sign outside of Resident 1 ' s room. The EPB sign indicated providers, and staff must also wear gloves, and a gown for high-contact activities which included dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use, and wound care. The IP stated she just placed a sign outside Resident 1 ' s room indicating the need for EBP. The IP nurse stated she overlooked Resident 1 ' s need for EBP because she thought Resident 1 ' s wound was already healed. The IP nurse stated EBP must be implemented to prevent the spread of disease to Resident 1 whom has a wound that is currently being treated. During an interview on 5/30/2025 at 4 p.m., with the Director of Nursing (DON), the DON stated she was aware of facility ' s policy on EBP but did not realize Resident 1 ' s wound was open and being treated. The DON stated residents with open wounds and who require dressing changes must have an EBP sign on or around entrance to the room indicating what precautions and/or PPE are required prior to entering the resident ' s room. The DON stated staff should also be properly educated on the understanding the rationale for EBP and when it is required. The DON stated staff must don (apply) the proper PPE when providing care to prevent the spread of any disease-causing microorganisms. The DON stated failure to ensure staff understood and implemented EBP put Resident 1 and all other residents, staff, and/or visitors in the facility for infections that could lead to unnecessary hospitalizations and/or death. During a review of the facility ' s undated policy and procedure (P&P) titled, Enhanced Barrier Precautions, the P&P indicated it is the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of MDROs. The P&P indicated EBP are recommended for residents with indwelling medical devices or wounds because wounds are risk factors that place these residents at higher risk for carrying or acquiring a MDRO. The P&P indicated the facility will have discretion on how to communicate with staff which residents require the use of EBP. CMS supports facilities in using creative (e.g. subtle) ways to alert staff when EBP use is necessary to help maintain a homelike environment as long as staff are aware which resident require the use of EBP prior to providing high-contact care activities. 056164 Page 2 of 2