Health inspection·August 6, 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 ensure, for one of (Resident A) five residents, residents with a multidrug- resistant organism (MDRO-bacteria and other microorganisms that have developed a resistance to one or more classes of antimicrobial drugs) was placed in a single room or cohorted with other residents with the same MDRO infection, according to the facility's policy and procedure. Residents Affected - Few This failure had the potential to exposed Resident A's two susceptible roommates to acquiring an infection. Findings: On August 5, 2024, at 9 a.m., an unannounced visit was conducted at the facility for the investigations of three complaints. On August 5, 2024, at 10 a.m., two Certified Nursing Assistants (CNAs) were observed caring for a resident in bed one, wearing gloves. A sign outside the room, indicated, Contact Isolation (a set of precautions used in healthcare facilities to prevent the spread of germs from patients with illnesses that can be transmitted through direct or indirect contact). A cart was observed outside of the room, next to the doorway, containing personal protective equipments (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses). On August 5, 2024, at 10:05 a.m., an interview was conducted with the CNA. The CNA stated she did not know why the contact isolation sign was on the door. The CNA stated a contact isolation sign means we are to put on gloves, a gown, and sometimes a mask or shield before caring for a patient. The CNA stated the other staff member said she only needed to wear gloves. The CNA stated only bed three (Resident A) required contact isolation, the residents in bed one and two bed were okay. The CNA stated she did not know why bed three was placed on contact isolation. On August 5, 2024, at 10:10 a.m., an interview was conductedwith the Licensed Vocational Nurse (LVN). The LVN stated she was the charge nurse for Resident A, and Resident A had ESBL(extended spectrum beta-lactamase: a bacteria that is difficult to kill, because it is resistant to many antibiotics) in her urine. The LVN stated it was okay if Resident A stays in the room, Resident A did not need a private room, the ESBL was contained, and Resident A had a catheter (flexible tube inserted into the body) for draining her urine. The LVN stated she did not know when Resident A tested positive for ESBL and did not know if it was an active infection. A review of Resident A's record indicated Resident A was admitted to the facility on [DATE], with Page 1 of 2 555353 555353 08/06/2024 Villa Health Care Center 8965 Magnolia Avenue Riverside, CA 92503

F 0880 Level of Harm - Minimal harm or potential for actual harm diagnoses which included a fractured left femur (broken upper leg), and dementia (a group of thinking and social symptoms, such as memory loss and judgement). Resident A's History and Physical, dated July 10, 2024, indicated Resident A did not have the ability to make decisions. Resident A's urinalysis laboratory result, dated July 30, 2024, indicated positive for ESBL. Residents Affected - Few Resident A's Order Summary Report, included a physician's order, dated August 2, 2024, indicated, Contact Isolation related to ESBL in urine, every shift until August 8, 2024. Resident A's Progress Notes, dated August 3, 2024, at 3:32 a.m., indicated, .continues on contact isolation as ordered . On August 5, 2024, at 6:20 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident A was not provided a single room when the lab results for the urine test showed Resident A had ESBL of urine, because she had a foley catheter that was containing her urine. The DON stated Resident A was placed on contact isolation, and Resident A's roommates stayed in the room with her. The DON stated Resident A was not moved to a single private room. The DON stated Resident A should have been placed in a private room after Resident A's urine test showed she had ESBL. A review of the facility's policy titled Multidrug-Resistant Organisms, dated November 2023, indicated, .Appropriate precautions are taken when caring for individuals known or suspected to have infection with a multidrug-resistant organism .Multidrug-resistant organisms (MDROs) are bacteria and other microorganisms that have developed resistance to one or more classes of antimicrobial drugs. Infection means that the organism is present and is causing illness. Colonization means that the organism is present in or on the body but is not causing illness .strategies are adopted from the Centers for Disease Control and Prevention and provide current recommendations for MDRO prevention and control .recommendations are incorporated into the facility infection prevention and control processes as indicated .Make MDRO prevention/control an organizational priority .implement a multi-disciplinary process to monitor and improve staff adherence to recommended practices for standard and contact precautions .follow standard precautions in all situations .resident's clinical situation and facility resources in deciding whether to implement contact precautions .when single-resident rooms are available, assign priority for these rooms to residents with known or suspected MDRO colonization or infection .when single-resident rooms are not available, cohort residents with the same MDRO in the same room or resident-care area .implement contact precautions routinely for all residents colonized or infected with a target MDRO . 555353 Page 2 of 2