Health inspection·July 9, 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 implement its infection control policy by failing to: Residents Affected - Some 1. Implement its Enhanced Barrier Precautions (EBP- refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities, residents with wounds or indwelling medical devices) for three of seven sampled residents (Resident 4, Resident 6, and Resident 7). 2. Implement personal protective equipment (PPE- protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) during a coronavirus disease 2019 (COVID-19, a highly contagious viral illness that can lead to mild respiratory issues to severe pneumonia [a lung infection causing symptoms like cough, fever, and difficulty breathing]) outbreak (an increase, often sudden, in the number of cases of a disease above what is normally expected in that population in that area) when four Certified Nursing Assistants (CNA 1, CNA 2, CNA 3, and CNA 4) were observed without wearing eye protection (e.g. safety glasses or face shield) coming in and out of two out of seven sampled residents (Resident 2 and Resident 3) rooms who tested positive for COVID-19. These deficient practiices had the potential to result in an increased transmission of COVID-19 infections among residents and staff. Findings: a. A review of Resident 4 ' s admission Record indicated the facility admitted the resident on 4/27/2024 with diagnoses including pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of other site, urinary tract infection (a condition in which bacteria invade and grows in the urinary tract [the kidneys, ureters, bladder, and urethra]), and acute cholecystitis (is a redness and swelling [inflammation] of the gallbladder [a small, pear-shaped organ that stores and releases bile]). A review of the Order Summary Report for Resident 4 dated 4/27/2024 indicated: - cleanse biliary drain (a thin, flexible tube, allows bile to flow out from a blocked bile duct into a collection bag outside the body) insertion site with normal saline (NS- is a mixture of sodium chloride [salt] and water, that is used in medicine including cleaning wounds, removal, and storage of contact lenses, and help with dry eye), cover with dry dressing every day. (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 9 Event ID: 056382 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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)