Health inspection·February 10, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews and record reviews, the facility failed to ensure proper infection control was practiced when: Residents Affected - Few 1. Dietary Staff (DS) was observed to touch the part of a fork that goes into the mouth with bare hands, and 2. DS did not perform hand hygiene (HH, hand washing) prior to putting on new gloves. These failures had the potential to increase the transmission of illness and infection among the 56 vulnerable residents of the facility. Findings: 1. During a concurrent observation and interview on 2/10/25 at 12:10 p.m., while arranging silverware for a resident ' s lunch tray, the DS acknowledged he touched the part of the fork that goes into the resident ' s mouth with his bare hands and he should not have. The Dietary Manager (DM), who was also present, verified seeing DS touching the part of the fork that goes into the mouth of the resident with his bare hands and stated it was not acceptable for infection control purposes. 2. During a concurrent observation and interview on 2/10/25 at 12:13 p.m., DS was observed to put a glove on his right hand without performing HH prior. DS verified he did not perform HH prior to putting on the new glove. The DM who was also present, verified DS did not performed HH prior to putting on a new glove. During an interview on 2/10/25 at 12:49 p.m., the DM stated staff should always perform HH prior to putting on new gloves for infection control purposes. The DM stated the facility cared for residents who are immunocompromised (weakened immune system, making residents more susceptible to infection) and could easily get an infection. The DM added, not practicing infection control, such as HH, could result in transfer of bacteria from hands to food which could result to gastrointestinal (GI, related to stomach and intestines) illness and put the residents' safety at risk. During an interview on 2/10/25 at 12:58 p.m., the Director of Nursing (DON) stated staff should not touch the part of the utensil that goes into the residents ' mouths with their bare hands and should perform HH prior to putting on new gloves for infection control. The DON stated not performing HH could transfer bacteria from hands to the resident or their food, which could make them sick from GI illness. A review of the facility ' s policy and procedure titled, Handwashing/Hand Hygiene, revised in Page 1 of 2 555184 555184 02/10/2025 Heartwood Avenue Healthcare 1044 Heartwood Ave. Vallejo, CA 94591

F 0880 Level of Harm - Minimal harm or potential for actual harm 2019, indicated, .This facility considers hand hygiene the primary means to prevent the spread of infections . All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . Use . soap (antimicrobial or non-antimicrobial) and water for the following situations: . Before and after handling an invasive device . Before and after eating or handling food . Perform hand hygiene before applying non-sterile gloves . Residents Affected - Few 555184 Page 2 of 2