Health inspection·March 26, 2024

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for two of three sampled residents (Resident 2 and 3) were complete and accurate. * The facility failed to ensure the complete documentation for Residents 2 and 3's turning and repositioning monitoring. This failure had the potential for the resident care needs not being met as the medical information was incomplete and inaccurate. Findings: Review of the facility's P&P titled Positioning and Repositioning Policy (undated) showed to assist the residents in positioning/repositioning every two hours and as needed, and the CNA will sign the Turn and Reposition every two hours or as needed in the CNA tasks to ensure that the positioning/repositioning task is performed on shift. a. Medical record review for Resident 2 was initiated on 3/25/24. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Follow Up Question Report for March 2024 showed Resident 2 was turned and repositioned every two hours or as needed. The document further showed the missing documentation for turning and repositioning from the CNAs on the following shifts and dates: - afternoon shift on 3/4/24 - morning shift on 3/21/24 Review of Resident 2's Weekly Licensed Nurses Notes dated 3/25/24, failed to show the documentation if the repositioning every two hours or as indicated was provided to Resident 2. b. Medical record review for Resident 3 was initiated on 3/25/24. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 3's Follow Up Question Report for March 2024 showed Resident 3 was turned and repositioned every two hours or as needed. The document further showed no documented evidence of turning and repositioning from the CNA on the afternoon shift on 3/3/24. On 3/25/24 at 1532 hours, an interview and concurrent medical record review was conducted with the Page 1 of 3 555035 555035 03/26/2024 Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some ADON. The ADON verified the nurse did not document the repositioning every two hours or as indicated under the Skin Management Protocols section in Resident 2's Weekly Licensed Nurses Notes. On 3/26/24 at 1145 hours, an interview and concurrent medical record review was conducted with the Medical Record Staff. The Medical Record Staff acknowledged the missing CNAs documentations in the Follow Up Question Report for turning and repositioning every two hours or as needed for Residents 2 and 3. The Medical Record Staff stated if it was not documented, it did not happen. On 3/26/24 at 1210 hours, a follow-up interview and concurrent facility document review was conducted with the Medical Record Staff. The Medical Record Staff verified the CNA Chart Audit dated 3/4, 3/5, and 3/25/24, included the CNAsmissing documentation in Residents 2 and 3's Follow Up Question Report for turning and repositioning every two hours or as needed. 555035 Page 2 of 3 555035 03/26/2024 Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804

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, medical record review, and facility P&P review, the facility failed to maintain the infection prevention and control program designed to provide thesafe, sanitary comfortable environment to help prevent the transmission of communicable diseasesand infection. Residents Affected - Few * CNA 5 failed to properly perform the proper hand hygiene after removing and disposing the PPE. * The facility failed to ensure the proper disposal of used gowns and gloves in the trash in Room A. These failures had the potential risk to spread and control the infection to the residents, staff personnel, and visitors. Findings: 1. Review of the facility's P&P titled Handwashing/ Hand Hygiene revised April 2023 showed the facility considers hand hygiene the primary means to prevent the spread of infections, all personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents and visitors, and the hand hygiene is the final step after removing and disposing or personal protective equipment. Medical record review for Resident 2 was initiated on 3/25/24. Resident 2 was admitted to the facility on [DATE]. On 3/26/24 at 0824 hours, an observation was conducted with CNA 5 while taking care of Resident 2. CNA 5 removed her gown and gloves and disposed the PPE she was wearing in the trash bin. CNA 5 touched the trash bin while disposing the PPE. CNA 5 proceeded back to Resident 2's bedside, touched Resident 2's shoulders, and assisted Resident 2 with repositioning. However, CNA 5 was not observed performing the proper hand hygiene after disposing the PPE. On 3/26/24 at 0901 hours, an interview was conducted with LVN 4. LVN 4 stated the proper hand hygiene was required after touching something dirty and should be performed before attending to the resident. 2. On 3/26/24 at 1034 hours, a wound care observation was conducted with Treatment Nurse 4 in Room A. The resident in Room A was also observed with tracheostomy and GT site. Furthermore, the trash bin in Room A was observed overflowing with disposable gowns and gloves. On 3/26/24 at 1055 hours, an interview was conducted with Treatment Nurse 2. Treatment Nurse 2 stated the trash bin should not be overflowing and it should have been collected. 555035 Page 3 of 3