Health inspection·December 12, 2023

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, interviews and record review, the facility failed to: Residents Affected - Some 1. Ensure staff refrained from washing their hands utilizing the sink meant for obtaining resident's drinking water. 2. Ensure sink area utilized to obtain resident's drinking water was cleaned and free of rust and dirt. These deficient practices had the potential for cross contamination (transfer of harmful bacteria from object or place to another) and cause residents to be ill. Findings: During an interview with Certified Nurse Assistant (CNA 1) on 12/12/2023 at 2:11 p.m., CNA 1 stated one source of the resident's drinking water was from a sink in the employee lounge. CNA 1 stated that sink had a filter for the resident's drinking water. During an observation on 12/12/2023 at 2:59 p.m. in the employee lounge, CNA 2 was observed filling water pitchers to be dispensed for residents from from the sink in the employee lounge. CNA 1 was also observed washing her hands with soap and water after she finished filling the water pitchers utilizing the same sink. During an observation of the sink on 12/12/2023 at 3:02 p.m., the sink had a water filter dated 8/19/2023 and the drain underneath the sink was surround with soap suds and black and brown areas of discoloration around the drain and floor area by the drain. The basin underneath the sink was also observed with rust. During an interview on 12/12/2023 at 3:19 p.m. with the Maintenance assistant (MA), MA stated the outside of the sink was rusty and needed to be cleaned. During an interview on 12/12/2023 at 3:43 pm. with the Infection Preventionist Nurse (IPN), IPN stated staff were not supposed to use the sink in the employee lounge for handwashing. The IPN stated staff were supposed to use the sink in the bathroom in the employee lounge for handwashing and the sink in the employee lounge was solely for resident drinking water. IPN stated the residents could get sick from water borne illness such as Legionnaires (a type of lung infection caused by a bacteria found in [NAME] environments) if the sink was used for handwashing and drinking water. Page 1 of 2 056218 056218 12/12/2023 Bell Convalescent Hospital 4900 E. Florence Ave Bell, CA 90201

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 12/12/2023 at 4:42 p.m. with the Director of Nursing (DON) on 12/12/2023 at 4:42 p.m., DON stated the sink in the employee lounge was just for drinking water and there were handwashing sinks in the bathrooms and in the nursing station for handwashing. The DON stated it was cross contamination if employees use the drinking water sink for handwashing and residents could get sick. During a review of the facility's undated policy and procedure (P&P) titled Water Management Policy and Procedure , the P&P indicated the facility was committed to providing a safe and healthy environment for residents and staff by implementing effective water management practices to ensure the delivery of safe and potable water to residents and staff. The P&P indicated the infection prevention and control team was responsible for educating staff on water safety and hygiene practices and the facility maintenance team was responsible for conducting regular inspections and maintenance of water systems. The P&P also indicated facility staff would be responsible for monitoring and maintaining the cleanliness of water dispensers, coolers, and drinking fountains. During a review of the facility's undated P&P titled, Waterborne Pathogen Risk Assessment, the P&P indicated drinking fountains had a risk of contamination of water dispensers and one of the control measures were to regularly clean and disinfect drinking fountains and ensure proper filtration and maintenance of water fountains. The P&P indicated nursing station sinks had the potential for cross-contamination due to frequent use and one of the control measures were to provide hand hygiene training for staff and reinforce proper practices. 056218 Page 2 of 2