Health inspection·March 21, 2025

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 follow its policies and procedures (P&P) titled, Hand Hygiene (procedures that included the use of alcohol-based hand rubs (ABHR- containing 60%–95% alcohol) and hand washing with soap and water), and Standard Precautions (SP- a set of evidence-based infection control practices designed to prevent the transmission of infectious diseases in healthcare settings), Enhanced Barrier Precautions (EBP- set of infection control measures that use personal protective equipment [PPE- equipment worn to minimize exposure to hazards] to reduce the spread of multidrug-resistant organisms [MDRO- organism that is resistant to most antibiotics] by wearing a gown and gloves) and Transmission-Based Precautions (TBP- extra measures, used in addition to standard precautions, to prevent the spread of specific infectious agents that can be transmitted through air, contact, or droplets), and recommendations set by the Department of Public Health Medical Doctor (DPH MD) by failing to: Residents Affected - Some 1. Ensure Receptionist (RCT) 1 wore a mask properly while in the facility. 2. Ensure facility staff educated Family 1 to wear a mask while visiting Resident 1 in the facility. 3. Ensure Certified Nurse Assistants (CNA) 1 and 2 wore masks properly while in the facility. 4. Ensure Social Services Director (SSD) wore a mask properly while in the facility. 5. Ensure CNA 3 wore a mask properly while sitting in Resident 10 ' s room. 6. Ensure CNA 4 performed hand hygiene before entering Resident 2 ' s EBP room. 7. Ensure Maintenance Assistant (MA) 1 wore a mask properly while in the facility. 8. Ensure Primary Care Provider/Medical Doctor (MD) 1 wore a mask properly while in the facility. These failures had the potential to transmit and spread infection from staff to residents that could result in widespread infection in the facility. Findings: During an interview on 3/20/2025 at 10:05 am, with the Infection Prevention Nurse (IPN), the IPN stated the facility had a total of 22 COVID-19 cases, with two residents currently positive. The IPN stated there were a total of three residents currently positive with Influenza (flu- an acute Page 1 of 5 555416 555416 03/21/2025 Glendora Canyon Transitional Care Unit 401 W. Ada Ave. Glendora, CA 91741

F 0880 respiratory infection caused by influenza viruses). Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 3/20/2025 at 11:14 am, with the IPN, the DPH MD Recommendations dated 2/27/2025, timed at 5:12 pm, provided by the public health nurse (PHN) were reviewed. The MD recommendations indicated all visitors were required to wear masks and all staff were required to wear N95 masks during the OB. The IPN stated visitors were supposed to wear surgical masks at the very least while in the facility and N95 masks while in a COVID-19 or flu positive resident ' s room. The IPN stated all staff were supposed to help enforce this. The IPN stated all staff were responsible for the health and safety of the residents. The IPN stated every staff was supposed to wear a N95 in the facility, including the receptionist, and it should be covering their mouth and nose to help prevent the flu and COVID-19 from spreading to other residents or themselves. Residents Affected - Some a. During a concurrent observation and interview on 3/20/2025 at 10 am, in the facility lobby, with RCT 1, RCT 1 was observed. There was a sign on the entrance door indicating anyone inside the facility was required to wear a mask. RCT 1 had a mask on, that was pulled down below RCT 1 ' s nose and mouth. RCT 1 stated only clinical staff had to wear a mask. RCT 1 stated RCT 1 was aware there was a COVID and flu outbreak (OB- two or more linked cases of the same illness or the situation where the observed number of cases exceeds the expected number, or a single case of disease caused by a significant microorganism). b. During a review of Resident 1 ' s admission Record (AR), the AR indicated the facility admitted Resident 1 on 1/22/2025 with diagnoses that included chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems) and type II diabetes mellitus (DM2- A condition that happens because of a problem in the way the body regulates and uses sugar as fuel). During a review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool) dated 1/27/2025, the MDS indicated Resident 1 had severely impaired cognition (ability to think, remember, and function). The MDS indicated Resident 1 was dependent (helper does ALL the effort. Resident does none of the effort to completely the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity) with oral, toileting and personal hygiene, showering/bathing self, upper and lower body dressing, putting on/taking off footwear, rolling left and right (in bed), sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfers, and tub/shower transfers. The MDS indicated Resident 1 ' s COVID-19 (infectious disease caused by SARS-CoV-2 virus)vaccine (medical treatment that helps your body's immune system recognize and fight disease) was not up to date. During concurrent observation and interview on 3/20/2025 at 11:05 am, at Resident 1 ' s room, Resident 1 ' s Family 1 was observed. Family 1 was inside of Resident 1 ' s room, walking around the bed, providing water, talking to, and helping Resident 1 adjust in bed. Family 1 did not have a mask on. Family 1 stated, they (as in staff- unidentified), told Family 1 that Family 1 did not have to wear a mask if Family 1 did not want to. c. During a concurrent observation and interview on 3/20/2025 at 11:07 am, in the hallway outside of Resident 1 ' s room, CNA 1 and CNA 2 were observed. CNA 1 and CNA 2 were wearing masks that were pulled down below the nose and mouth. CNA 1 stated the facility had a flu OB. CNA 1 stated wearing a mask help to protect CNA 1 and the residents from getting sick. CNA 2 stated CNA 2 was supposed to wear a mask in the facility because they had a COVID-19 OB. CNA 2 stated wearing a mask helped to prevent the spread of infection, and that visitors were supposed to wear masks as well. 555416 Page 2 of 5 555416 03/21/2025 Glendora Canyon Transitional Care Unit 401 W. Ada Ave. Glendora, CA 91741

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 3/20/2025 at 11:11 am, at Resident 1 ' s room, with CNA 2, Family 1 was observed. Family 1 was not wearing a mask. CNA 2 stated if staff were not wearing masks or appropriately wearing them, then visitors were going to follow what the facility staff did. d. During a concurrent observation and interview on 3/20/2025 at 11:28 am, out of the SSD ' s office, the SSD was observed. The SSD was sitting at a desk, in the office, with the door to the office open to the resident hallway. The SSD had a mask on that was pulled down below the nose and mouth. The SSD stated the floor the office was on housed positive COVID-19 and flu residents. The SSD stated the SSD was supposed to wear a mask because there was an OB of flu and COVID-19. The SSD stated by not wearing the mask as intended, the SSD could catch, spread, or infect others with COVID-19 or flu. e. During a review of Resident 10 ' s AR, the AR indicated the facility initially admitted Resident 10 on 1/31/2025, with diagnoses that included DM2 and Alzheimer ' s Disease (a progressive and fatal brain disorder that gradually destroys memory, thinking skills, and the ability to carry out everyday tasks). During a review of Resident 10 ' s MDS dated [DATE], the MDS indicated Resident 10 had moderately impaired cognition (need for extra assistance with daily activities and/or specific tasks). The MDs indicated Resident 10 required substantial/maximal assistance for toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. During a concurrent observation and interview on 3/20/2025 at 11:32 am, at Resident 10 ' s room door, CNA 3 was observed. CNA 3 was sitting on a chair, watching Resident 10. CNA 3 was wearing a mask that was pulled down below the nose and mouth. CNA 3 stated CNA 3 was supposed to wear the mask properly because of COVID-19 and the flu (in the facility). CNA 3 stated if CNA 3 ' s not wearing the mask as intended CNA 3 could spread infection to everyone. f. During a review of Resident 2 ' s AR, the AR indicated the facility initially admitted Resident 2 on 12/27/2021 and was readmitted on [DATE], with diagnoses that included hemiparesis (one-sided muscle weakness caused by a disruption of the brain, spinal cord, or nerves connected to the affected muscles) and hemiplegia (paralysis of one side of the body) following cerebral infarction (CVA- disruption of blood flow to the brain due to problematic vessels that cause lack of blood supply and oxygen to the brain) affecting left non-dominant side. During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 had intact cognition. The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half effort) with showering/bathing self, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort and lifts or holds trunk or limbs but provides less than half the effort) with toileting and personal hygiene, sitting to standing, lying to sitting on side of bed, sitting to lying, chair/bed-to-chair transfers, and toilet transfers. During an observation on 3/20/2025 at 11:42 am, outside of Resident 2 ' s room, CNA 4 was observed. A sign next to Resident 2 ' s room door indicated EBP, and to perform hand hygiene before entering and immediately upon exiting the room. CNA 4 entered Resident 2 ' s room without performing hand hygiene. CNA 4 asked Resident 2 if Resident 2 needed water and touched Resident 2 ' s bedding. CNA 4 exited the room and performed hand hygiene. 555416 Page 3 of 5 555416 03/21/2025 Glendora Canyon Transitional Care Unit 401 W. Ada Ave. Glendora, CA 91741

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 3/20/2025 at 11:43 am, at Resident 2 ' s room entrance, with CNA 4, the EBP sign was observed. CNA 4 stated the EBP sign indicated to clean hands before entering the room and immediately upon exiting. CNA 4 stated it was important to perform hand hygiene to prevent the spread of infection. CNA 4 stated there was currently a flu and COVID-19 OB at the facility. g. During an observation on 3/20/2025 at 4:45 pm, in the first-floor hallway, MA 1 was observed. MA 1 was talking in the hallway with MA 1 ' s mask on but pulled down below the nose and mouth. During an interview on 3/20/2025 at 4:48 pm, with MA 1, MA 1 stated MA 1 was supposed to wear MA 1 ' s mask properly because there was COVID-19 in the building. MA 1 stated MA 1 could get someone sick or get sick from someone else if MA 1 was not wearing the mask properly. h. During a concurrent observation and interview on 3/20/2025 at 4:58 pm, with MD 1, at the nurses ' station, MD 1 was observed sitting down writing. MD 1 was wearing a surgical mask that was pulled down below the nose and mouth. MD 1 stated MD 1 did not like to wear the mask because it fogged MD 1 ' s glasses. MD 1 stated MD 1 was aware MD 1 was supposed to wear a mask because the facility had a flu and COVID-19 OB. During an interview on 3/21/2025 at 5:36 pm, with the Director of Nursing (DON), the DON stated hand hygiene was the number one way to prevent the spread of infection. The DON stated hand hygiene was important so staff did not spread infection to the residents. The DON stated if staff were no performing hand hygiene before entering an EBP room, then the residents were at higher risk for developing infection and could easily get sick. The DON stated it was important that all staff and visitors wore masks as intended during an OB to stop the transmission of infection and not make any more residents sick. During a review of the facility ' s P&P titled, Hand Hygiene, revised 10/2022, the P&P indicated the facility considered hand hygiene the primary means to prevent the spread of infections. The P&P indicated all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. During a review of the facility ' s P&P titled, SP, EBP, and TBP, revised 8/7/2024, the P&P indicated the purpose was to provide guidelines for infection control practices to reduce the potential for transmission for pathogens (microorganisms) including COVID-19, MDRO, and viruses. The P&P indicated EBP was primarily the use of gown and gloves for specific high contact care activities based on the resident ' s characteristics that are associated with a high risk of MDRO colonization and transmission. The P&P indicated intensified interventions (OB) should be implemented when an unusual or common infectious agent with unusual resistance pattern was identified or in the incidence of new cases of a specific infectious agent was increasing or failed to decrease despite implementation and adherence to standard infection prevention procedures. The P&P indicated staff education was essential in reducing transmission of infectious agents including COVID-19. The P&P indicated staff including those with direct resident contact and those in administrative positions should be educated during new employee orientation, annually concerning the epidemiology (the study of how often diseases occur in different groups of people and why) of specific infectious agents and the role they play in reducing the potential for transmission of these as well as other microorganisms; proper use of PPE; resident hygiene, and when observations indicated that employees are not in compliance with the facility infection control procedures including hand hygiene. The P&P indicated residents, visitors, and volunteers shall be educated and instructed in hygiene protocols, PPE use, and other infection control 555416 Page 4 of 5 555416 03/21/2025 Glendora Canyon Transitional Care Unit 401 W. Ada Ave. Glendora, CA 91741

F 0880 practices. Level of Harm - Minimal harm or potential for actual harm During a review of the facility ' s P&P titled, COVID-19, Prevention and Control, revised 1/17/2025, the P&P indicated the facility followed current guidelines and recommendations for the prevention and control of COVID-19. The P&P indicated visitors shall wear well fitted surgical masks (per CMS QSO 20-39-NH-Revised) for the duration of their visit while indoors when the CDC- COVID-19 community level is high or when the facility is in an OB. The P&P indicated all staff must wear a well fitted surgical mask, KN95 mask, or N95 respirator in all areas in the non-COVID area or non-quarantine room(s) during resident care or when in resident care areas. The P&P indicated all staff during a COVID-19 OB, or when a COVID-19 positive staff or residents were identified, all staff must wear a well fitted N95 respirator in all areas in the COVID isolation area or non-COVID care or non-COVID care or quarantine room(s) when caring for any resident or when in resident care areas. Residents Affected - Some 555416 Page 5 of 5