Inspection·July 30, 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, medical record review, and facility document review, the facility failed to follow the infection control practices while cleaning the resident rooms for two of two sampled residents (Residents 1 and 2) and 10 nonsampled residents (Residents 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12.) Residents Affected - Some * Housekeepers 1 and 2 did not use a new cloth while cleaning the individually used equipment between Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9. * Housekeepers 1 and 2 did not wear a gown while cleaning the resident rooms with the EBP signage. * Housekeeper 1 scrubbed the toilet seats for Rooms A and B's shared restroom, and Room C's restroom with a toilet scrub brush for toilet bowl use only. * Housekeeper 1 failed to clean the restroom grab bars for Rooms A and B's shared restroom, and Room C's restroom. These failures had the potential to spread infection to the residents in the facility. Findings: Review of the facility's Infection Prevention Manual for Long Term Care revised 5/2024 showed EBP are an infection control intervention designed to reduce transmission of multidrug-resistant organisms by wearing a gown and gloves during high contact resident care activities, which may include environmental sanitation. 1.a. On 7/30/24 at 0919 hours, Housekeeper 1 was observed cleaning Resident Room C. The signage showed three residents (Residents 7, 8, and 9) resided in the room. An EBP sign was observed outside the room's doorway. The following observations were made: - Housekeeper 1 did not wear a gown while cleaning inside Room C. - Housekeeper 1 was observed using a damp washcloth with disinfectant and wiped down Residents 7, 8, and 9's tray tables with the same damp washcloth. - Housekeeper 1 got a new damp washcloth and cleaned Residents 7, 8, and 9's call light and call light cord with the same washcloth. - Housekeeper 1 got a new damp washcloth and cleaned Residents 7, 8, and 9's nightstand with the (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 3 Event ID: 555093 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 555093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Post-Acute 1929 N. Fairview Street Santa Ana, CA 92706 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)