Health inspection·January 29, 2024

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 maintain an infection prevention and control program regarding Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for one of five sampled residents (Resident 1), by failing to ensure Registered Nurse 1 (RN 1) perform hand hygiene (hand washing with soap and water and use of alcohol-based hand sanitizer) before and after providing care to Resident 1 and after touching unclean surfaces. RN 1 also did not wear gloves during the blood pressure monitoring procedure on Resident 1. Residents Affected - Few These deficient practices placed other residents and staff at risk for exposure and contracting COVID-19. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 5/28/2018. Resident 1 ' s diagnoses included hemiplegia (paralysis that affected one side of the body) and hemiparesis (weakness or inability to move one side of the body) on the left side, heart failure (a condition that develops when the heart does not pump enough blood for the body ' s need), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). A review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 1/17/2024, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. The MDS indicated that Resident 1 had range of motion limitation on both upper (shoulder, elbow, wrist, or hand) and lower extremity (hip, knee, ankle, or foot). Resident 1 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) on toileting, bath, upper and lower body dressing, and personal hygiene. On 1/29/2024 at 9:30 a.m., during a concurrent observation and interview, observed RN 1 enter Resident 1 ' s room without performing hand hygiene. RN 1 placed the blood pressure (BP) machine on Resident 1 ' s right arm and touched the resident ' s bed linen without gloves on. RN 1 removed the BP machine from Resident 1 ' s right arm and placed it on the medication cart. RN 1 did not perform hand hygiene and proceeded to document on the medication cart computer. RN 1 opened the medication cart drawer and touched the medication packets without performing hand hygiene. RN 1 stated that he should wear gloves when providing care for residents. RN 1 stated that he should sanitize his hands before and after touching Resident 1, before and after gloves use, and after touching the resident ' s surroundings. RN 1 stated that not performing hand hygiene and not wearing gloves had the potential to spread infections to other residents. Page 1 of 2 056168 056168 01/29/2024 Granada Hills Convalescent 16123 Chatsworth Ave Granada Hills, CA 91344

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/29/2024 at 11:20 a.m., during an interview, the Infection Preventionist Nurse (IPN) stated that hand hygiene should be done before and after entering the resident ' s room and in between resident care. The IPN stated that gloves should be worn when providing care to the residents, changing linens going in the isolation rooms, or any contact with the residents. The IPN stated that not following the infection prevention and control practices had the potential to expose residents and staff to infection such as Covid-19, bacteria, and germs. A review of the facility ' s policy and procedure titled, Handwashing / Hand Hygiene, dated 2/3/2023, indicated that the facility considers hand hygiene the primary means to prevent the spread of infections. The policy indicated that all personnel shall; follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy indicated to use an alcohol-based rub at least 62% alcohol, or alternatively soap and water before and after direct contact with residents, after contact with resident ' s intact skin, after handling contaminated equipment, and after contact with objects in the immediate vicinity of the resident. A review of the facility ' s policy and procedure titled, Personal Protective Equipment – Gloves, dated 2/3/2023, indicated that gloves must be worn when handling blood, body fluids, secretions and excretions, mucous membranes and /or non-intact skin. The policy indicated that the use of disposable gloves was indicated when handling soiled linen or items that may be contaminated. 056168 Page 2 of 2