Health inspection·December 1, 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 its infection prevention and control measures for one of four sampled residents (Resident 1) by failing to change gloves (type of personal protective equipment [PPE] that is worn or used to provide protection against hazardous substances and/or environments) and perform hand hygiene (washing hands or using an alcohol-based hand sanitizer) before administering a wound treatment to Resident 1.This failure had the potential to increase the risk of infection, spread germs and bacteria and impede the healing process for Resident 1. Based on observation, interview and record review, the facility failed to implement its infection prevention and control measures for one of four sampled residents (Resident 1) by failing to change gloves (type of personal protective equipment [PPE] that is worn or used to provide protection against hazardous substances and/or environments) and perform hand hygiene (washing hands or using an alcohol-based hand sanitizer) before administering a wound treatment to Resident 1. This failure had the potential to increase the risk of infection, spread germs and bacteria and impede the healing process for Resident 1.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. The admission Record indicated Resident 1's diagnoses included acute respiratory failure with hypoxia (the inability of the respiratory system to maintain an adequate blood oxygen level to preserve normal organ function), acute pulmonary edema (a condition caused by too much fluid in the lungs) and pressure ulcer of sacral region, stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone).During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 08/26/2025, the MDS indicated Resident 1 had clear speech, difficulty communicating some words or finishing thoughts but was able if prompted or given time and usually understood others. The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for oral hygiene, toileting hygiene and showering/bathing self.During a review of Resident 1's Physician's Order dated 10/1/2025, the Order indicated to administer Ultramist Therapy (treatment using low-frequency ultrasound to deliver saline mist, debride dead tissue, reduce bacteria and control inflammation to promote healing of wounds) every day shift every Monday, Wednesday, Friday for management of stage 4 pressure injury. During a concurrent observation and interview on 12/01/2025 at 11:45 a.m. with the Occupational Therapist (OT) at Resident 1's bedside, the OT was observed wearing gloves, pulled the privacy curtain and proceeded to administer Ultramist wound treatment for Resident 1 without changing gloves and performing hand hygiene. The OT stated failure to change gloves and wash hands before administering the wound treatment could spread germs and increase the risk of infection for the resident. During a review of the OT Encounter Treatment Note dated 12/1/2025, the Note indicated the OT permed Mist Therapy treatment to Resident 1's Sacro coccyx pressure ulcer. During a review of the facility's policy and procedure (P/P) titled Hand Hygiene), revision dated 04/2025, indicated it is the policy of this facility to Residents Affected - Few (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: 056267 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 056267 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camino Healthcare 13922 Cerise Avenue Hawthorne, CA 90250 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)