Health inspection·August 27, 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 ensure proper infection control precautions were implemented for one of two residents (Resident 1), when a staff member was observed returning an unused dinner tray from a COVID (Corona virus - a contagious respiratory disease) positive residents isolation room (A room that separates residents from others, while receiving specialized medical treatment) to the meal cart which stored trays that were being served to other residents.This failure had the potential to cross contaminate clean resident dinner trays and spread COVID infection to uninfected residents. Findings:On August 26 and 27, 2025, unannounced visits were made to the facility to investigate infection control, safety, and quality of care issues.On August 26, 2025, at 2:10 p.m., an interview was conducted with the Infection Prevention (IP) Nurse, who stated the facility had two COVID positive residents sharing an isolation room. The IP stated an in-service was recently provided to staff on COVID which reviewed the topics of proper hand washing, Personal Protective Equipment (PPE-equipment worn by staff to protect against exposure to COVID positive residents), and the proper use of isolation/airborne precautions (specific infection control measures implemented to help prevent the spread of airborne diseases, such as COVID). The IP stated before staff enter a COVID isolation room they are to don (put on) PPE, including a mask, gown, gloves, and eye shields. When staff have completed caring for a COVID resident, they are to doff (take off) the PPE and dispose of the equipment in the rooms trash. A review of the facility in-service titled, COVID-19 & Droplet Isolation Precautions Management, dated, August 17, 2025, indicated, . At the conclusion of the presentation, (staff) will be able to .Demonstrate correct donning and doffing of PPE including gown, gloves, mask/N95, and face shield .Apply proper hand hygiene techniques according to facility policy .Safely manage meal tray removal for residents on droplet/COVID isolation using . reusable trays .On August 26, 2025, at 2:55 p.m., an observation of Resident 1's COVID isolation room was conducted. The room had a sign outside of the resident's door indicating airborne/droplet precautions, instructing staff to don the PPE of a mask, gown, gloves and eye shield before entering the room. A cart containing PPE equipment for staff to use was also outside of the room.On August 26, 2025, at 5:10 p.m., an observation of dinner service was conducted. Dinner trays from the kitchen on a main cart were rolled onto the unit. Two staff members were observed taking the unused dinner trays to assigned resident rooms.On August 26, 2025, at 5:20 p.m., an observation of Certified Nursing Assistant (CNA) 1 delivering Resident 1's dinner tray to resident's COVID isolation room was conducted. CNA 1 was observed wearing an N95 mask (respiratory protective mask that filters out bacteria and viruses), cleaning his hands with alcohol-based hand rub, then donning PPE of a gown, eye shield and gloves, prior to entering Resident 1's room. After donning PPE, an additional staff member was observed handing Resident 1's plastic dinner tray to CNA 1. CNA 1 then entered the resident's room with the dinner tray and partially closed the room door.On August 26, 2025, at 5:38 p.m., an observation of the Activity Director (AD) at Resident 1's bedroom Residents Affected - Few Page 1 of 2 056428 056428 08/27/2025 California Nursing & Rehabilitation Center 2299 North Indian Canyon Drive Palm Springs, CA 92262

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few door was conducted. The AD was wearing an N95 mask, approached Resident 1's room door, knocked on it, then opened it. The AD stood outside of the door, while asking CNA 1 a question. CNA 1 then approached the AD with Resident 1's plastic dinner tray in hand, and handed the tray to the AD, asking the AD if she could return the tray to the dinner cart. The AD took the tray from CNA 1 with ungloved hands and began walking the used tray to the main dinner cart. Unused dinner trays were observed still being served by staff from the cart. The surveyor intervened and asked the AD not to return Resident 1's tray to the cart.On August 26, 2025, at 5:42 p.m., an interview was conducted with CNA 1 who stated the correct process to return a used plastic meal tray from a COVID isolation room to the main service cart, includes placing the tray in a plastic bag when the resident is finished eating, and returning the tray to the main cart with other used trays, while wearing PPE (gloves). CNA 1 verified Resident 1 did eat from his dinner tray. CNA verified he did not follow the proper procedure of returning Resident 1's used dinner tray to the main cart, as he did not place the tray in a plastic bag, before handing the tray to the AD who was not wearing the proper PPE.On August 26, 2025, at 5:51 p.m., an interview was conducted with the IP who stated the correct process to return a used meal tray to the kitchen from a COVID isolation room is to place the used tray in a plastic bag after the resident is done eating, then leave the tray in the resident's room until all used trays are returned, then return the tray to the kitchen. The IP stated, after returning all used meal trays, staff are to go back to the COVID room, take the bagged tray to the kitchen, and notify kitchen staff that the tray came from a COVID isolation room. The IP verified CNA 1 did not follow the proper procedure of returning Resident 1's meal tray to the kitchen, as CNA 1 should have placed the resident's tray in a plastic bag, left the tray in resident's room, and returned the tray to the kitchen once all residents were done eating. The IP also verified CNA 1 should not have handed Resident 1's used dinner tray to the AD if she was not wearing gloves.On August 26, 2025, at 6:04 p.m., an interview was conducted with the AD who stated she should not have taken Resident 1's tray from CNA 1, when he handed her the tray, as she did not have gloves on. The AD stated she should have stopped CNA 1 and took the time to find out the facilities procedure on taking meal trays out of COVID isolation rooms.On August 27, 2025, at 3:00 p.m., an interview was conducted with the Director of Nursing (DON), who stated meal trays for residents with COVID will come in the main service cart with all the other trays, and served last to COVID residents. When the resident is done eating, the trays are to be placed in a plastic bag inside the room, returned to the main cart once all other trays are collected and returned to the kitchen. The DON verified CNA 1 did not follow the proper procedure of returning Resident 1's used dinner tray when he asked the AD to return Resident 1's tray to the main service cart prior to all other used resident trays being returned to the cart. A review of Resident 1's, Resident Information, dated, August 27, 2025, indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis of Kidney Failure, and a Brief Interview for Mental Status (BIMS-a cognitive assessment) score of 12 (Moderate cognitive impairment). A review of Resident 1's, Progress Notes, dated, August 16, 2025, at 9:24 p.m., indicated . Covid test was done on (Resident 1) (August 16, 2025). Results were positive . 056428 Page 2 of 2