Health inspection·October 25, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and interview the facility failed to adequately store medications behind a locked door. Residents Affected - Few This failure had the potential to result in resident harm, for approximately 20 residents in Hallway 1, through accidental ingestion of unprescribed medications without staff awareness or supervision. On 10/25/23 at 11:40 A.M. and at 12: 21 P.M. an observation was made of an unlabeled door noted to be ajar and not completely closed. Upon opening the door, the room was noted to have over the counter, non-prespricption medications stored on open shelves, as well as a locked refrigerator and three tackle boxes sealed with zip-tie closures. The door did not self-close. An interview was held with LN 1, on 10/25/23 at 12:23 P.M., regarding the unlocked door. LN 1 demonstrated opening the door and letting it close, and stated that the door did not close all the way. LN 1 stated when a person left the room the door needed to be pushed shut behind them. LN 1 stated the door should have been fixed because it would allow everyone access to the medications. The medication room should also be locked, and only facility employees with a key should access the room. On 10/25/23, at 12:40 P.M., the DON was interviewed and stated that the medication room door should have been fixed to assure only authorized personnel accessed the medications, for the safety of the residents. Page 1 of 2 555158 555158 10/25/2023 El Centro Post-Acute Care 1700 S. Imperial Ave El Centro, CA 92243

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to ensure that staff followed proper hand washing technique during a meal service for 7 residents. This failure had the potential to spread germs and cause infections among the residents. On 10/25/23 at 12:09 P.M., the following observations were made during meal service on Hallway 1. CNA 1 was seen leaving a resident room and walking to the meal delivery cart in the hallway. CNA 1 selected and held resident ' s meal tray and delivered to resident room [ROOM NUMBER]. CNA 1 then returned from resident room [ROOM NUMBER] to the meal tray cart and selected and held another tray. No hand hygiene was observed. CNA 2 was seen leaving resident room [ROOM NUMBER]. CNA 2 selected and held a tray from the meal delivery cart, and delivered to another resident room. No hand hygiene was observed. CNA 3 was seen leaving a resident room, then selected and held a tray and delivered to room [ROOM NUMBER]. CNA 3 was next seen walking from the other end of the hallway and walked up to the the meal cart. CNA 3 selected and held a tray from the meal cart and then entered room [ROOM NUMBER]. No hand hygiene was observed. CNA 4 was observed walking down the hallway and then selected and held a meal tray and delivered to room [ROOM NUMBER]. No hand hygiene was observed. A joint interview was held on 10/25/23 at 12:25 P.M., with CNA 1, CNA 2, and CNA 3. CNA 2 stated hand washing or using an Alcohol Based Hand Rub (ABHR) should have been done between the delivery of each tray. CNA 3 stated that not performing hand washing or using an ABHR sanitizer was a problem because cross contamination of germs between residents could occur. A review of the policy, Hand Washing/Hand Hygiene, dated August, 2019, stated: All personnel are to follow hand hygiene procedures to help prevent the spread of infection to other residents, visitors, and staff. Use an Alcohol based hand rub.before and after direct contact with residents.handling food.assisting residents with meals. 555158 Page 2 of 2