Health inspection·April 3, 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: Residents Affected - Some 1. Ensure two of two clean linen carts did not have unnecessary items such as a box of gloves, trash bags, assignment sheets, and container of perfumed body fragrance noted inside of the clean linen carts. 2. Ensure a box of clean gloves did not have soiled gloves inside for one of three resident rooms. These deficient practices had the potential to result in cross contamination (process by which germs are unintentionally transferred from one object to another) and the spread of infections in the facility. Findings: During a concurrent observation and interview, on 4/2/2024, at 9:20 a.m., with Certified Nurse Assistant 2 (CNA 2), in the hallway, CNA 2 was observed to have trash bags, and an assignment sheet laying on top of clean linens inside of the clean linen cart. CNA 2 stated the gloves, trash bags, and assignment sheet were inside of the linen cart because there was no other place to put them. CNA 2 stated leaving the box of gloves, trash bags, and the assignment sheets inside of the linen cart can contaminate clean linen and spread infection to other residents. During a concurrent observation and interview on 4/2/2024, at 9:30 a.m., with CNA 1, in the hallway, CNA 1 was observed to have a pink bottle of body spray lying in between three (3) clean bath towels and four (4) clean sheets in the clean linen cart. CNA 1 stated the pink container of body spray should not be lying inside of the linen cart because of cross contamination that could spread infection to other residents. During a concurrent observation and interview on 4/2/2024, at 4:20 p.m., with CNA 3, in Resident 2's room, CNA 3 was observed grabbing two gloves from a box of gloves that had soiled gloves with brown substance. CNA 3 stated the soiled gloves should not be in the box of clean gloves because it can cause infection to another resident. During an interview on 4/3/2024, at 11:56 a.m., with the Infection Preventionist ([IP] a healthcare worker who specializes in preventing infection and to keep infection from spreading), the IP stated, staff were not allowed to have any personal items like body spray, trash bags, or any items in the clean linen cart. The IP stated soiled gloves should not be in the clean box of gloves because of cross contamination and risk of spreading infection to residents in the facility. Page 1 of 2 056308 056308 04/03/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility's policy and procedure titled, Standard Precautions, dated, 10/2018, the policy stated, linen carts should be free from unnecessary items that might contaminate the clean linen inside the cart. The policy indicated gloves were removed promptly after use, before touching non contaminated items and environmental surfaces, and before going to another resident. The policy indicated Resident - care equipment soiled with blood, body fluids, secretions, and excretions were handled in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms (germs) to other residents and environments. 056308 Page 2 of 2