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 (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 2 Event ID: 555184 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 555184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heartwood Avenue Healthcare 1044 Heartwood Ave. Vallejo, CA 94591 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)