Health inspection·August 26, 2024

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 ensure Certified Nursing Assistant 1 (CNA 1) followed proper hand hygiene for contact isolation (the use of personal protective equipment [PPE - gown, mask, and gloves] for patients with diseases [illness or sickness characterized by specific signs or symptoms] caused by bacteria [germs] and viruses [a type of germ which causes disease] that are spread through direct and indirect contact) for Clostridioides difficile ([C. diff] a bacteria that causes diarrhea [the passage of three or more loos or liquid stools in one day or more frequent passage than is normal for the individual] and inflammation [the body ' s immune system ' s (body ' s protection against germs) response to an irritant] in the large intestine) for one of three sampled residents (Resident 2) when CNA 1 did not wash her hands with soap and water after providing direct care to Resident 2. Residents Affected - Few This deficient practice has the potential to spread contagious bacteria and spores such as C.diff to other residents. Findings: During a review of Resident 2 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including enterocolitis (inflammation in the intestines) due to C.diff. During a review of Resident 2 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 7/1/2024, the MDS indicated Resident 2 ' s cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired and Resident 2 was dependent (helper does all the effort) on facility staff for completion of activities of daily living ([ADLs] eating, personal hygiene, and transfers). During a review of Resident 2 ' s Order Summary Report (Physician ' s Order), dated 8/13/2024, the Physician ' s Order indicated Resident 2 required contact isolation for C.diff. During a review of the Isolation Sign (a sign placed outside of a patient ' s room indicting what type of precaution they are on, and which PPE should be used upon entering the room) outside of Resident 2 ' s room, the Isolation Sign indicated Resident 2 was on Contact and Spore (a cell which certain bacteria produce to defend itself) Precautions. The Isolation Sign indicated facility staff and visitors should be cleaning hands with soap and water upon exiting the room. During an observation on 8/26/2024 at 12:29 p.m. outside of Resident 2 ' s room, CNA 1 was observed removing her gown and gloves, applied hand sanitizer to both of her hands, then proceeded to walk Page 1 of 2 056308 056308 08/26/2024 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few down the hallway to get Resident 2 some blankets. CNA 1 did not wash her hands with soap and water upon exiting Resident 2 ' s room. During an interview on 8/26/2024 at 12:29 p.m., CNA 1 stated she knew Resident 2 was on contact isolation for C.diff and only used hand sanitizer upon exiting Resident 2 ' s room but should have washed her hands with soap and water. CNA 2 stated all staff should wash their hands upon exiting Resident 2 ' s room to prevent the spread of germs to residents and staff. During an interview on 8/26/2024 at 2:43 p.m., the Director of Nursing (DON) stated C.diff cannot be killed by hand sanitizer alone, staff should be washing their hands with soap and water after providing care to residents in contact isolation for C.diff. The DON stated if staff do not preform the correct hand hygiene, there is a risk of transferring germs and bacteria to residents and staff. During a review of facility ' s policy and procedure (P/P) titled Handwashing/Hand Hygiene undated, the P/P indicated when there is likely exposure to spores (i.e., C-diff) all employees must wash their hands for 30-60 seconds with soap and water as alcohol-based hand rubs are inactive against the effective removal of spores. 056308 Page 2 of 2