Health inspection·September 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 implement its infection prevention and control measures by failing to ensure clear signage was posted for two of five sampled residents (Resident 4 and Resident 5) who were on Enhanced Barrier Precautions ([EBP] use of gown and gloves during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms ([MDROs] bacteria or other microorganism resistant to multiple classes of antibiotics)). Residents Affected - Some This deficient practice had the potential to result in staff and visitors entering the room without the proper personal protective equipment ([PPE] specialized clothing or equipment such as gloves and gown, worn to minimize exposure to serious illness) and increasing the risk of transmitting disease-causing organisms leading to illness. Findings: During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of enterostomy (a surgical procedure to create an opening [called a stoma] through the stomach wall into the small or large intestine to allow for intestines to drain) malfunction (failure to work properly). During a review of Resident 4 ' s History and Physical (H&P) dated 8/5/2024, the H&P indicated that Resident 4 did not have the capacity to understand and make decisions. During a review of Resident 4 ' s Minimum Data Set ( [MDS] a standardized assessment and care screening tool), dated 8/25/2024, the MDS indicated Resident 4 was dependent (staff does all the effort, resident does none of the effort to complete the activity or, the assistance of two or more helps is required for the resident to complete the activity) with Activities of Daily Living (ADLs) such as showering/bathing, upper and lower body dressing, and lying to sitting on side of bed. During a review of Resident 4 ' s physician ' s order dated 9/3/2024, the order indicated to place Resident 4 on EPB d/t (due to) the presence of J-tube ([jejunostomy tube] a soft plastic tube placed through the skin of the abdomen to deliver food and medicine). During a concurrent observation and interview on 9/3/2024 at 9:37 a.m. with the Infection Prevention Nurse (IPN) outside of Resident 4 ' s room, IPN stated Resident 4 required EBP and the resident ' s entrance to the room did not have signage to indicate Resident 4 was on EBP. During a review of Resident 5 ' s admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] with a diagnoses of hyperosmolality (a condition in which the body Page 1 of 2 555128 555128 09/03/2024 Downey Community Health Center 8425 Iowa Street Downey, CA 90241

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some has an abnormally high concentration of substances such as salt (sodium) or glucose, which causes water to be drawn out of other organs including the brain) and hypernatremia (a condition where there is too much sodium in the blood, or not enough water). During a review of Resident 5 ' s physician ' s order dated 9/3/2024, the order indicated to place Resident 5 on EBP d/t presence of a foley catheter (thin, flexible tube that drains urine from the bladder into a collection bag outside of the body). During a review of Resident 5 ' s MDS, dated [DATE], the MDS indicated Resident 5 had severe cognitive (ability to think, learn, remember, use judgement, and make decisions) impairment. The MDS also indicated Resident 5 was dependent on staff for ADLs such as eating, showering/bathing self, and changing positions from sitting to lying (the ability to move from sitting on side of bed to lying flat on the bed). During a concurrent observation and interview on 9/3/2024 at 9:38 a.m. with IPN outside of Resident 5 ' s room, IPN stated Resident 5 required EBP and the resident ' s entrance to the room did not have signage to indicate Resident 5 was on EBP. During an interview with IP Nurse on 9/3/2024 at 2:31 p.m., IPN stated EBP were precautions implemented to protect residents who were more prone to MRDOs, and staff were to wear a gown and gloves when providing care to the resident. IPN also stated, signage should always be on the door to inform those entering the room, the resident was on EBP. During a concurrent interview and record review on 9/3/2024 at 4:24 p.m. with the Director of Nursing (DON), a picture of the entrance of Resident 4 and 5 ' s rooms and the facility ' s P&P titled, Enhanced Barrier Precaution, were reviewed. The DON stated there should be signage to alert the staff before they entered the resident ' s room who was on EBP. The DON stated, signage served as communication for staff, visitors, and vendors to inform what equipment was needed before entering the room. The DON stated the signage was vital to mitigate (make less severe) and help prevent the spread of infection. The DON also stated, not having signage visible placed residents and staff at risk of catching infection. During a review of the facility ' s undated Policy and Procedure (P&P) titled, Infection Prevention Program Overview, the P&P indicated, the goals of the Infection Prevention Program was to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases by decreasing the risk of infection to residents and personnel and implementing appropriate control measures. The P&P indicated prevention of spread of infections was accomplished by hand hygiene, standard precautions, transmission-based precautions, as indicated and other barriers. During a review of the facility ' s P&P titled, Enhanced Barrier Precautions, dated 3/2024, the P&P indicated EBP refer to the use of gown and gloves for those during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased of MDRO acquisition (residents with wounds or indwelling medical devices). The P&P indicated clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required PPE, and the high-contact resident care activities that required the use of gown and gloves. 555128 Page 2 of 2