Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Immediate
jeopardy to resident health or
safety
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure an effective infection prevention and
control program to prevent infectious disease outbreak (a sudden rise in the number of cases of a disease)
for four (4) of 4 sampled residents (Residents 1, 2, 3 and 8) by failing to:
Residents Affected - Some
1. Control the spread of unknown gastrointestinal (GI, relating to, affecting, or including both stomach and
intestine) outbreak when Residents 1, 2, and 3 were not placed on contact isolation precautions (intended
to prevent transmission of infectious agents, which are spread by direct or indirect contact with the resident
or resident's environment) on the onset of GI symptoms. Resident 1 was not placed on contact isolation
until 4 days after onset of diarrhea (loose watery stool). Residents 2 and 3 were not placed on isolation until
two (2) days after onset of diarrhea and vomiting.
2. Ensure Certified Nurse Assistant 1 (CNA 1) wear gloves and isolation gown on 4/19/2023 while pushing
Resident 8's wheelchair inside the resident's room, who was on contact isolation precaution.
3. Ensure CNA 1 wear gloves and isolation gown in the resident's room while feeding Resident 8 who was
on contact isolation precaution on 4/19/2023.
These deficient practices placed 82 residents, facility staff and visitors at risk for contracting GI infection
and resulted to nine (9) residents (Residents 1,2, 3, 4, 5, 6, 7, 8, and 9) experiencing GI symptoms
(vomiting and/ or diarrhea).
On 4/19/2023 timed at 3:15 pm, an Immediate Jeopardy (IJ, a situation in which the facility's
noncompliance with one or more requirements of participation had caused, or is likely to cause, serious
injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Director of
Nursing (DON) regarding the facility's failure to recognize and report a GI outbreak of two (2) or more
residents within a 24-hour period, collect stool specimens as soon as the residents experienced GI
symptoms, obtain the orders from the Attending Physician to send the specimen to the lab for viruses and
bacterial infection testing, and failure to control the spread of unknown GI outbreak.
On 4/20/2023 at 4:59 pm, the IJ was removed after the facility submitted an acceptable IJ Removal Plan
(interventions to correct the deficient practices). The surveyor verified and confirmed the implementation of
the Plan of Action (POA) while onsite by observation, interview, and record review. The IJ was removed in
the presence of the AIT (Administrator in Training) and DON. The acceptable IJ Removal Plan included the
following:
1) [NAME] Baptist Homes will recognize a possible outbreak and will report the GI outbreak of 2 or
(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 5
Event ID:
555272
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
555272
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Atherton Baptist Home
214 South Atlantic Blvd.
Alhambra, CA 91801
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)
F 0880
Level of Harm - Immediate
jeopardy to resident health or
safety
more residents within a 24-hour period who are experiencing symptoms of GI infection according to CDPH
guidelines. [NAME] Baptist Home will report to Local Health Department and CDPH when this outbreak
occurs within 24 hours via phone or email. (Reference material: Recommendations for the prevention and
control of Viral Gastroenteritis outbreaks in California Long -Term Care Facilities [DATE] and Acute
Communicable Disease Control [ACDC] Manual revised June 2019 - Centers for Disease Control and
Prevention [CDC]).
Residents Affected - Some
a. Resident 1 had one episode of loose stool and vomiting on 4/13/2023. Attending Physician and family
were notified on 4/13/2023. Attending Physician ordered laboratory work. Charge Nurse started monitoring
and recording resident's condition every shift and documenting in medical progress note. Resident was
placed in contact isolation on 4/17/2023. Documentation continued for an additional 48 hrs.
b. Resident 2 had 3 episodes of vomiting on 4/15/2023. Attending Physician and family were notified on
4/15/2023. Charge Nurse started monitoring and recording resident's condition every shift and documenting
in medical progress note. Resident was placed on contact isolation on 4/17/2023. Documentation continued
for an additional 48 hrs.
c. Resident 3 had two episodes of vomiting on 4/15/2023. Attending Physician and family were notified on
4/15/2023. Charge Nurse started monitoring and recording resident's condition every shift and
documentation in medical progress note. Resident was placed on contact isolation on 4/17/2023.
Documentation continued for an additional 48 hrs. The DON and Director of Staff Development (DSD)
educated the licensed nurses and CNA staff on 4/17/2023 about the importance of knowing how to
recognize possible signs of GI infection and deciding when to place the residents in isolation with signs and
symptoms of GI infection immediately. At the same time, staff were educated on reporting to DON
immediately. (Training provided by using reference training material noted above). The DON will then report
to Local public health and CDPH within 24 hours of any suspected outbreak.
On 4/20/2023 DON and AIT reviewed and updated the phone numbers for reporting to the CDC. If in case
the ACDC was not answering by phone, the facility must report by email.
2) [NAME] Baptist Homes will collect stool specimens as soon as the residents experience GI symptoms
and obtain the orders from the Attending Physician to send the specimen to the lab for viruses and
bacterial infection testing, following the instruction from the public health nurse and CDC guidelines.
Findings:
1. During a concurrent review of the facility's undated Gastroenteritis (an inflammation of the lining of the
stomach and intestines) Illness Outbreak Line List (provides a template for data collection and active
monitoring of both residents and staff during a suspected gastroenteritis outbreak) and interview with the
DON on 4/19/2023 at 8:04 am, the DON verified the following:
a. Resident 1 experienced diarrhea and vomiting on 4/13/2023.
b. Resident 2 and 3 experienced vomiting on 4/15/2023
c. Resident 4 experienced diarrhea and Residents 5, 6 and 7 experienced vomiting on 4/16/2023
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555272
If continuation sheet
Page 2 of 5
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
555272
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Atherton Baptist Home
214 South Atlantic Blvd.
Alhambra, CA 91801
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)
F 0880
d. Resident 8 experienced diarrhea on 4/17/2023
Level of Harm - Immediate
jeopardy to resident health or
safety
e. Resident 9 experienced watery diarrhea on 4/18/2023
The DON stated the GI outbreak was reported to CDPH on 4/17/2023 and local public health on 4/18/2023.
The DON stated the GI outbreak should have been reported to CDPH and local public health sooner.
Residents Affected - Some
A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with
diagnoses that included unspecified atrial fibrillation (a serious abnormal heart rhythm characterized by
rapid and irregular beating), heart failure (a chronic condition in which the heart cannot pump blood as well
as it should) and essential hypertension (abnormal high blood pressure that is not the result of a medical
condition).
A review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment and care screening tool),
dated 1/11/2023, indicated Resident 1's cognitive (mental processes, ability to understand and make
decision) skills for daily decision making was severely impaired. Resident 1 required limited assistance for
transfers, dressing and eating. Resident 1 required extensive assistance for toilet use and personal
hygiene.
A review of Resident 1's Interdisciplinary (IDT, involving two or more disciplines or fields of study) notes,
dated 4/13/2023, timed at 10:52 am, indicated Resident 1 had greenish yellow emesis (vomiting) on his
shirt. Interdisciplinary notes further indicated according to Resident 1, he had vomited once in the morning,
A review of Resident 1's IDT notes, dated 4/17/2023, timed at 2:35 pm, indicated Resident 1 was placed on
contact isolation precaution (4 days from GI symptoms onset) due to episode of vomiting on 4/13/2023.
During an interview on 4/19/2023 at 8:01 am, the DON stated, Resident 1 had diarrhea and vomiting on
4/13/2023. The DON stated, an unnamed facility staff called the physician (MD) who ordered laboratory
work which included a comprehensive metabolic panel (CMP, blood tests that give an overall picture of your
body's metabolism and chemical balance) and complete blood count (CBC, a test that counts the cells that
make up your blood). The DON stated the MD did not order a stool culture (checks for presence of
abnormal bacteria in the digestive tract/gastrointestinal tract that may cause diarrhea and other problems).
The DON stated, Resident 1 was placed on isolation precaution on 4/17/2023, 4 days after resident
presented with vomiting and diarrhea. The DON stated isolation precaution was not and should have been
initiated for Resident 1 prior to 4/17/2023 but facility staff did not report Resident 1's GI symptoms to the
DON not until 4/17/2023. The DON stated, Resident 1 should have been placed on contact isolation
immediately on the onset of GI symptoms on 4/13/2023 to prevent spread of infection amongst other
residents residing in the facility.
A review of Resident 2's admission Record indicated the resident was initially admitted to the facility on
[DATE], with diagnoses that included essential hypertension, unspecified dementia (condition in which a
person loses the ability to think, remember, learn, make decisions, and solve problems) and hyperlipidemia
(have too many lipids [fats] in the blood).
A review of Resident 2's MDS, dated [DATE], indicated Resident 2's cognitive skills for daily decision
making were severely impaired. Resident 2 required limited assistance (resident highly involved in activity;
staff provide guided maneuvering of limbs or other non-weight-bearing assistance))for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555272
If continuation sheet
Page 3 of 5
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
555272
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Atherton Baptist Home
214 South Atlantic Blvd.
Alhambra, CA 91801
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)
F 0880
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Some
transfers, dressing and eating. Resident 2 required extensive assistance for toilet use and personal
hygiene.
A review of Resident 2's IDT notes, dated 4/15/2023, timed at 3:13 am, indicated Resident 2 was found
seated at the edge of bed and stated, I threw up in the bathroom.
A review of Resident 2's IDT notes, dated 4/15/2023, timed at 2:09 pm, indicated monitoring for episodes of
nausea and vomiting. The Interdisciplinary notes further indicated Resident 2 had two episodes of vomiting
during the shift.
A review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE],
with diagnoses that included unspecified dementia, essential hypertension, and chronic kidney disease (a
condition in which the kidneys are damaged and cannot filter blood as well as they should).
A review of Resident 3's MDS, dated [DATE], indicated Resident 3's cognitive skills for daily decision
making was severely impaired. Resident 3 required limited assistance for transfers, dressing, eating, toilet
use and personal hygiene.
A review of Resident 3's Interdisciplinary notes, dated 4/15/2023, timed at 10:06 pm, indicated Resident 3
was being monitored for an episode of vomiting after lunch.
A review of Resident 3's Interdisciplinary notes dated, 4/15/2023, timed at 10:19 pm, indicated that after
Resident 3 took two scoops of mashed potato during dinner, Resident 3 vomited medium amount of brown
colored emesis.
During an interview on 4/19/2023 at 1:07 pm, the DON stated on 4/15/2023 Residents 2 and 3 presented
with vomiting. The DON stated, MD did not order a stool culture for Residents 2 and 3. The DON stated,
Residents 2 and 3 were placed on contact isolation precautions on 4/17/2023, 2 days after both residents
presented with vomiting. The DON stated, Residents 2 and 3 should have been placed on contact isolation
immediately on the onset of GI symptoms on 4/15/2023.
2. A review of Resident 8's admission Record indicated the resident was initially admitted to the facility on
[DATE], with diagnoses of unspecified dementia, difficulty walking and hypertension.
A review of Resident 8's MDS, dated [DATE], indicated Resident 8 was severely impaired with cognitive
skills for daily decision making. Resident 8 required limited assistance for eating and extensive assistance
(resident involved in activity, staff provide weight-bearing support) for transfers, dressing toilet use and
personal hygiene.
During an observation outside of Resident 8's room on 4/19/2023 at 9:00 am, signage was posted on the
wall near the resident's door indicating Resident 8 was on contact precaution. There was an isolation cart
directly outside for personal protective equipment (PPE, used to prevent or minimize exposure to hazards).
CNA1 entered Resident 8's room only wearing a mask. CNA1 was not wearing a gown or gloves.
During an interview on 4/18/2023 at 9:01 am, CNA1 stated, Resident 8 was on contact precautions but was
allowed to leave the room and go to the beauty salon, which was in the facility's basement. CNA1 stated
she does not wear PPE when entering Resident 8's room but usually wears a gown or gloves
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555272
If continuation sheet
Page 4 of 5
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
555272
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Atherton Baptist Home
214 South Atlantic Blvd.
Alhambra, CA 91801
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)
F 0880
when assisting Resident 8 to the restroom and cleaning Resident 8 after use of the restroom.
Level of Harm - Immediate
jeopardy to resident health or
safety
During a concurrent observation and interview on 4/18/2023 at 9:04 am, CNA1 stated Resident 8's beauty
salon schedule was canceled and had to wheel Resident 8 back to her room. CNA1 did not put on gloves
or isolation gown once inside room. CNA1 stated she did not but was supposed to wear gloves because
she was touching the handle of Resident 8's wheelchair.
Residents Affected - Some
During an interview on 4/18/2023 at 9:14 am, License Vocational Nurse 1 (LVN 1) stated, she was not sure
if staff have to wear gloves and gowns when pushing a wheelchair for a resident that was on contact
precautions.
During a concurrent observation in Resident 8's room and interview on 4/19/2023 at 12:47 pm, CNA1 was
observed assisting Resident 8 with setting up the meal tray for the resident. CNA1 was observed not
wearing an isolation gown or gloves while in the resident's room. CNA1 stated she was rushing because
Resident 8 needed assistance with feeding and should have put on PPE.
During interview on 4/19/2023 at 12:55 pm, the DON stated, if a resident was on contact isolation
precaution, staff must wear an isolation gown and gloves. The DON also stated PPE needs to be donned
(put on) right before entering a room on contact isolation, to protect self. The DON stated the staff must put
on PPE when setting up a food tray and when pushing resident's wheelchair to prevent spread of infection
amongst other residents residing in the facility.
A review of the facility's policy and procedure (P&P) titled, Outbreak of Communicable Diseases, revised
September 2022, indicated all Employees and Staff:
a. Follow standard precautions at all times, and transmission-based precautions as indicated; and
b. Report all symptoms relating to the current disease outbreak to the supervisor
A review of the facility's P&P titled, Unusual Occurrence Reporting, revised December 2007, indicated the
facility will report the following events to appropriate agencies:
a. An outbreak of any communicable disease.
The P&P indicated unusual occurrences shall be reported via telephone to appropriate agencies required
by current law and or regulations withing twenty-four (24) hours of such incident or as otherwise required by
federal and [NAME] regulations.
A review of the CDC guidelines titled, Guideline for Isolation Precautions: Preventing Transmission of
Infectious Agents in Healthcare Settings, dated 2007, indicated Healthcare personnel caring for patients on
Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or
potentially contaminated areas in the patient's environment. Donning PPE upon room entry and discarding
before exiting the patient room is done to contain pathogens (organism that causes disease), especially
those that have been implicated in transmission through environmental contamination
https://www.cdc.gov/infectioncontrol/guidelines/isolation/precautions.html
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555272
If continuation sheet
Page 5 of 5
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the April 20, 2023 survey of Atherton Baptist Home?
This was a inspection survey of Atherton Baptist Home on April 20, 2023. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Atherton Baptist Home on April 20, 2023?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide and implement an infection prevention and control program."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.