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. (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: 056168 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 056168 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Granada Hills Convalescent 16123 Chatsworth Ave Granada Hills, CA 91344 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)