Health inspection·November 26, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed, to maintain and implement its Infection Control Program to prevent the transmission of disease and infection for one of two sampled residents (Resident 1), by placing another resident's (unidentified) dentures in Residents Affected - Few Resident 1's mouth. This failure had the potential to result in the spread of infection to Resident 1. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/5/2024 with diagnoses that included urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra), dementia (a group of thinking and social symptoms that interferes with daily functioning), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/28/2024, the MDS indicated Resident 1 was severely impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) from staff for bathing and toileting hygiene. The MDS indicated Resident 1 required Partial/moderate (helper does less than half the effort) from staff for eating, oral and personal hygiene, and dressing. During a telephone interview on 11/21/2024 at 2:15 p.m. with Resident 1's Niece (FM 1), FM 1 stated Resident 1 had intellectual disability (person who has limitations in mental functioning and skills). FM 1 stated Resident 1's sister (FM 2) was Resident 1's conservator (a court appointed person to act or make decisions for the resident). FM 1 stated Resident 1 was recently hospitalized , at a General Acute Care Hospital (GACH) before being transferred to the facility. FM 1 stated during Resident 1's stay at the facility, Resident 1's dentures were lost. FM 1 stated on 11/23/2024, FM 2 called FM 1 and informed FM 1 that someone (unidentified) had found the dentures at the facility. FM 1 stated FM 2 informed FM 1 the Dentist (DD) put the dentures in Resident 1's mouth and discovered the dentures did not belong to Resident 1. During a telephone interview on 11/21/2024 at 3:03 p.m. with FM 2, FM 2 stated on one occasion (FM 2 cannot remember exact date), FM 2 was visiting Resident 1 at the facility when the DD put some dentures in Resident 1's mouth. FM 2 stated the dentures were inside a denture cup and had been sitting in Resident 1's drawer next to Resident 1's bed. FM 2 stated the dentures and cup were not labeled with any one's name. FM 2 stated the dentures did not belong to Resident 1. Page 1 of 2 056291 056291 11/26/2024 Casa Bonita Convalescent Hospital 535 E Bonita Avenue San Dimas, CA 91773

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a telephone interview on 11/26/2024 at 8:50 a.m. with the DD, the DD stated the Social Services Director (SSD) informed DD the facility found Resident 1's missing dentures. The DD stated the missing dentures were stored at Resident 1's bedside. The DD stated the dentures at Resident 1's bedside was not labeled with an identifier. The DD stated based on the DD's experience, the DD did not think the dentures belonged to Resident 1. The DD stated the DD informed the SSD the dentures did not belong to Resident 1. During an interview on 11/26/2024 at 8:55 a.m. with the SSD, the SSD stated the unidentified dentures the DD tried in Resident 1's mouth had been left at Resident 1's bedside before the DD put them in Resident 1's mouth.The SSD stated no one came forward and informed the SSD they had found Resident 1's missing dentures. The SSD stated the unidentified dentures were in a denture box. The SSD stated the unidentified dentures and box were not labeled. The SSD stated the SSD threw the unidentified dentures away. During an interview on 11/26/2024 at 10:12 a.m. with the Infection Preventionist (IP), the IP stated residents' dentures (in general) needed to be stored in a denture container when not in use. The IP stated the denture contains must be labeled to identify whose dentures they were and to ensure the dentures did not end up in the wrong residents' (in general) mouth. The IP stated there was a risk of infection for residents (in general) if the residents (in general) use the wrong dentures. During a review of the facility's policy and procedure (P&P) titled, Dentures, Cleaning and Storing, revised March 2023, the P&P indicated, The purposes of this procedure are to cleanse and freshen the resident's mouth, to clean the resident's dentures, to prevent infections of the mouth . The P&P indicated, .Be sure the denture cup is properly labeled with the resident's name and room number . During a review of the facility's P&P titled, Policies and Practices - Infection Control, revised April 2023, the P&P indicated, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. the P&P indicated, This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, nursing students, registry and the general public alike. 056291 Page 2 of 2