Health inspection·December 3, 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 maintain an infection prevention and control program designed to help prevent the development and transmission of Coronavirus - 19 (COVID-19, COVID, a virus that causes respiratory illness that can spread from person to person) as evidenced by: Residents Affected - Few 1. Failing to ensure that one of the three sampled residents (Residents 1) was wearing a mask while the facility was in an active Covid 19 outbreak (a sudden increase in the number of cases of a disease or medical condition in a specific location or population over a given time period). 2. Failing to ensure that staff were fit tested for N95 respirators/masks (is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) 3. Failing to ensure that staff were appropriately screened before starting their shifts. These deficient practices had the potential to place both residents and staff at a risk for infection to COVID-19. Findings: During a review of the admission record for Resident 1 indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including hypertension (HTN-high blood pressure), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and morbid obesity (a severe and dangerous level of obesity that's defined by a body mass index (BMI) of 40 or higher). During a review of a history and physical (a term used to describe a physician's examination of a patient. In an H&P, the physician obtains a thorough medical history from the patient, performs a physical examination, and then documents their findings) for Resident 1 dated 10/28/2024 indicated, Resident 1 had the capacity to understand and make decisions. During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/15/2024, indicated Resident 1 had moderate cognitive impairments (a stage of cognitive decline where a person experiences significant short-term memory loss, difficulty navigating new places, and challenges with complex tasks). The same MDS indicated Resident 1 required partial/moderate assistance for most of her Activities of Daily Living such as: (ADLs- routine tasks/activities such as bathing, dressing, toileting hygiene). Page 1 of 5 555019 555019 12/03/2024 Temple Park Convalescent Hospital 2411 W. Temple Street Los Angeles, CA 90026

F 0880 Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview with the Director of Nursing (DON) on 12/3/2024 at 10:15 am, Resident 1 was observed sitting in the front lobby of the facility and was not wearing a mask. The DON stated that the Resident 1 had refused to wear a mask but was unable to provide documented evidence that the mask was offered to the resident. The DON confirmed that the facility was in an active outbreak. The DON admitted that the potential of not wearing a mask could increase the risk of Covid 19 infection. Residents Affected - Few During an interview with the Receptionist (RCPT) on 12/3/2024 at 10:25 am, the RCPT stated that the facility had two entrances/exits which were the front lobby were the reception was located and another entrance located in the back. RCPT stated that the back entrance had a log were staff self-screened with a Covid 19 questionnaire and tested with the Covid 19 antigen tests available at the entry point but was not sure on who ensured that staff were complying for the requirements. RCPT stated that the facility did not require visitors to have their temperature checked when getting screened to enter the facility. During a concurrent observation and interview with Dietary Staff (DS) 1 on 12/3/2024 at 10:32 am, DS 1 was observed self-screening at the back entrance. DS 1 answered the Covid 19 questionnaire, checked and logged in her temperature and started leaving the area to begin her shift. DS 1 had not performed the Covid 19 test per facility protocol. DS 1 admitted that she had come in to work earlier and went straight to a meeting where other facility staff were present then went back to screen after the meeting was over. DS 1 admitted that she should have self-screened before entering the facility and interacting with other staff and/or residents in the facility. DS 1 confirmed that entering the facility without screening and testing could potentially increase the risk of spreading infection to both residents and staff. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 1 on 12/3/24 at 10:44 am, LVN 1 was observed wearing a white N95 mask. LVN 1 admitted that she had not been fit tested for the N95 mask she was wearing. LVN 1 stated that the importance of for testing is to ensure proper fitting for infection control. During a concurrent observation and interview with LVN 2 on 12/3/24 at 11:01 am, LVN 2 was observed wear a white N95 mask. LVN 2 admitted that she had not been fit tested since she was hired. LVN 2 stated that fit testing is impotence for proper fitting to prevent infection between staff and residents. During an interview with Infection Prevention Nurse (IPN) 2 on 12/3/2024, IPN 2 stated that all residents and staff must be masked to prevent further spread of the Covid 19 infection during the outbreak. IPN 2 admitted that there was no system in place to ensure that all staff entering through the back door were properly screened and tested before starting their shift. IPN 2 also admitted that the last time she had audited to ensure that facility staff were fit tested was five months prior while the facility was in another outbreak. There was no system in place to ensure that new staff were fit tested upon hire. IPN 2 stated that not fit testing staff could result in poor fitting masks which could potentially increase the risk of exposure. During an interview with the DON on 12/3/2024 at 12:26 pm, the DON stated that the importance of self-screen is to make sure that staff are checking to see if they are positive otherwise, they may risk spreading the infection to other staff and residents. The DON stated that fit testing is to be done annually. Importance is to prevent the spread the covid infection by making sure staff have a proper seal. If not fit tested, staff may have lost or gained weight which may make their current mask 555019 Page 2 of 5 555019 12/03/2024 Temple Park Convalescent Hospital 2411 W. Temple Street Los Angeles, CA 90026

F 0880 not properly fit. This may increase the spread of the infection. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's Policy and Procedures (P&P) titled Policy and Procedure for Conducting N95 Fit Testing at a Skilled Nursing Facility (SNF), revised 1/29/2024, indicated, To ensure that staff required to wear N95 respirators are properly fitted to minimize exposure to airborne contaminants, including infectious agents. The same P&P indicated that fit testing must be done annually, whenever there is a change in the employee's facial structure or when using a different model or size mask. Residents Affected - Few During a review of the facility's P&P titled COVID 19, Prevention and Control, revised 7/14/2023 indicated under healthcare personnel (HCP-staff) screening that HCP (including contract/registry staff) passive/self-screening for COVTD-I9 symptoms prior to shift starting or as per public health recommendations. Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of Coronavirus - 19 (COVID-19, COVID, a virus that causes respiratory illness that can spread from person to person) as evidenced by: 1. Failing to ensure that one of the three sampled residents (Residents 1) was wearing a mask while the facility was in an active Covid 19 outbreak (a sudden increase in the number of cases of a disease or medical condition in a specific location or population over a given time period). 2. Failing to ensure that staff were fit tested for N95 respirators/masks (is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) 3. Failing to ensure that staff were appropriately screened before starting their shifts. These deficient practices had the potential to place both residents and staff at a risk for infection to COVID-19. Findings: During a review of the admission record for Resident 1 indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including hypertension (HTN-high blood pressure), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and morbid obesity (a severe and dangerous level of obesity that's defined by a body mass index (BMI) of 40 or higher). During a review of a history and physical (a term used to describe a physician's examination of a patient. In an H&P, the physician obtains a thorough medical history from the patient, performs a physical examination, and then documents their findings) for Resident 1 dated 10/28/2024 indicated, Resident 1 had the capacity to understand and make decisions. During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/15/2024, indicated Resident 1 had moderate cognitive impairments (a stage of cognitive decline where a person experiences significant short-term memory loss, difficulty navigating new places, and challenges with complex tasks). The same MDS indicated Resident 1 required partial/moderate assistance for most of her 555019 Page 3 of 5 555019 12/03/2024 Temple Park Convalescent Hospital 2411 W. Temple Street Los Angeles, CA 90026

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Activities of Daily Living such as: (ADLs- routine tasks/activities such as bathing, dressing, toileting hygiene). During a concurrent observation and interview with the Director of Nursing (DON) on 12/3/2024 at 10:15 am, Resident 1 was observed sitting in the front lobby of the facility and was not wearing a mask. The DON stated that the Resident 1 had refused to wear a mask but was unable to provide documented evidence that the mask was offered to the resident. The DON confirmed that the facility was in an active outbreak. The DON admitted that the potential of not wearing a mask could increase the risk of Covid 19 infection. During an interview with the Receptionist (RCPT) on 12/3/2024 at 10:25 am, the RCPT stated that the facility had two entrances/exits which were the front lobby were the reception was located and another entrance located in the back. RCPT stated that the back entrance had a log were staff self-screened with a Covid 19 questionnaire and tested with the Covid 19 antigen tests available at the entry point but was not sure on who ensured that staff were complying for the requirements. RCPT stated that the facility did not require visitors to have their temperature checked when getting screened to enter the facility. During a concurrent observation and interview with Dietary Staff (DS) 1 on 12/3/2024 at 10:32 am, DS 1 was observed self-screening at the back entrance. DS 1 answered the Covid 19 questionnaire, checked and logged in her temperature and started leaving the area to begin her shift. DS 1 had not performed the Covid 19 test per facility protocol. DS 1 admitted that she had come in to work earlier and went straight to a meeting where other facility staff were present then went back to screen after the meeting was over. DS 1 admitted that she should have self-screened before entering the facility and interacting with other staff and/or residents in the facility. DS 1 confirmed that entering the facility without screening and testing could potentially increase the risk of spreading infection to both residents and staff. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 1 on 12/3/24 at 10:44 am, LVN 1 was observed wearing a white N95 mask. LVN 1 admitted that she had not been fit tested for the N95 mask she was wearing. LVN 1 stated that the importance of for testing is to ensure proper fitting for infection control. During a concurrent observation and interview with LVN 2 on 12/3/24 at 11:01 am, LVN 2 was observed wear a white N95 mask. LVN 2 admitted that she had not been fit tested since she was hired. LVN 2 stated that fit testing is impotence for proper fitting to prevent infection between staff and residents. During an interview with Infection Prevention Nurse (IPN) 2 on 12/3/2024, IPN 2 stated that all residents and staff must be masked to prevent further spread of the Covid 19 infection during the outbreak. IPN 2 admitted that there was no system in place to ensure that all staff entering through the back door were properly screened and tested before starting their shift. IPN 2 also admitted that the last time she had audited to ensure that facility staff were fit tested was five months prior while the facility was in another outbreak. There was no system in place to ensure that new staff were fit tested upon hire. IPN 2 stated that not fit testing staff could result in poor fitting masks which could potentially increase the risk of exposure. During an interview with the DON on 12/3/2024 at 12:26 pm, the DON stated that the importance of self-screen is to make sure that staff are checking to see if they are positive otherwise, they may 555019 Page 4 of 5 555019 12/03/2024 Temple Park Convalescent Hospital 2411 W. Temple Street Los Angeles, CA 90026

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few risk spreading the infection to other staff and residents. The DON stated that fit testing is to be done annually. Importance is to prevent the spread the covid infection by making sure staff have a proper seal. If not fit tested, staff may have lost or gained weight which may make their current mask not properly fit. This may increase the spread of the infection. During a review of the facility's Policy and Procedures (P&P) titled Policy and Procedure for Conducting N95 Fit Testing at a Skilled Nursing Facility (SNF), revised 1/29/2024, indicated, To ensure that staff required to wear N95 respirators are properly fitted to minimize exposure to airborne contaminants, including infectious agents. The same P&P indicated that fit testing must be done annually, whenever there is a change in the employee's facial structure or when using a different model or size mask. During a review of the facility's P&P titled COVID 19, Prevention and Control, revised 7/14/2023 indicated under healthcare personnel (HCP-staff) screening that HCP (including contract/registry staff) passive/self-screening for COVTD-I9 symptoms prior to shift starting or as per public health recommendations. 555019 Page 5 of 5