Health inspection·January 22, 2024

F 0880 Level of Harm - Minimal harm or potential for actual harm On January 22, 2024, at 10:41 a.m., an interview with a concurrent record review was conducted with the Director of Staff Development (DSD). The DSD stated she was the IP designee when the IP was unavailable. The DSD stated she reviewed the Employee's Screening Sheet on the shifts when the IP was unavailable to follow up with employees who marked Yes to symptoms of Covid-19 illness, or if the employee did not complete Covid-19 screening on the log. Residents Affected - Few The DSD stated she was not in the facility when CNA 1 failed to complete the screening sheet on January 10, 2024. The DSD stated the IP or IP designee should have reviewed the Employee's Screening Sheet the following morning on January 11, 2024. 2. On January 17, 2024, at 10:10 a.m., an interview was conducted with the Infection Preventionist (IP). The IP stated, she had a total of eight residents who tested positive for Covid-19, one resident was positive on admission, the other seven residents had facility acquired Covid-19. The IP stated, one resident was hospitalized for respiratory related complications. The IP stated, seven staff members acquired Covid-19 during the outbreak. IP stated, she informed the county health department of the outbreak starting January 10, 2024. On January 17, 2024, at 4:45 p.m., an interview and concurrent record review was conducted with the Infection Preventionist (IP). The IP stated, during the facility Covid-19 outbreak, the Employee's Screening Sheet was expected to be filled out by every employee at the entrance to the facility prior to the start of their shift. The IP stated, the Employee's Screening Sheet was used to check for signs and symptoms of Covid-19 infection. The IP stated, the employee should document and/or report any symptoms of a respiratory infection. The IP stated, the IP or IP designee should assess the employee and document any follow through directly on the screening sheet and/or send the employee home, if exhibiting signs and symptoms of a respiratory illness. On January 17, 2024, the Employee's Screening Sheet, dated January 9, 2024, and January 10, 2024, was reviewed. The screening sheet indicated, the Dietary Supervisor (DS) marked yes to symptoms for muscle or body aches, headaches, sore throat, congestion, and runny nose. The note at the top of the Employee Screening Sheet indicated, .Any temperature >99.0 F and /or presence of symptom(s) will not be allowed to past [sic] the screening station; HCP (health care personnel) should leave the premises immediately . There was no documented evidence to indicate the IP or IP designee assessed the Dietary Supervisor and the DS worked both of her shifts. On January 22, 2024, at 10:05 a.m., an interview and concurrent record review was conducted with the IP. The IP stated the Employee's Screening Sheet is important to help them keep track of employees that have signs or symptoms of the Covid-19 infection, and perform a rapid antigen Covid-19 test, to ensure a staff member has not tested positive for Covid-19. The IP stated, all employees are expected to fill in the Employee's Screening Sheet in its entirety prior to every shift, if an employee has symptoms, a rapid antigen test would be performed and if the results are positive, the employee is sent home. The IP stated, the DS marked the Employee's Screening Sheet, for January 09, 2024, and January 10, 2024, Yes to multiple symptoms. The IP stated, yes, there should have been a follow up with the staff member at the time of the screening. The IP stated, no one followed up on the staff member per facility protocol. On January 22, 2024, at 10:25 a.m., an interview and concurrent record review was conducted with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555492 If continuation sheet Page 2 of 3 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 555492 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Glen Post Acute 9246 Avenida Miravilla Cherry Valley, CA 92223 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 - Minimal harm or potential for actual harm the Director of Staff Development (DSD). The DSD stated, she was the IP designee when the IP was not in the facility. The DSD stated, she reviewed the Employee Screening Sheet on the shifts the IP was unavailable to follow up with employees who marked Yes to symptoms of Covid-19 illness. The DSD stated, the IP or IP designee should have reviewed the Employee Screening Sheet the following morning on January 11, 2024, and followed up with the employee. Residents Affected - Few A review of the facility's policy titled Infection Prevention and Control Program, dated October 2018, indicated .infection prevention and control program (IPCP) is .to help prevent the development and transmission of communicable diseases and infections .The program is based on accepted national infection prevention and control standards .is a facility-wide effort involving all disciplines and individuals .elements .consist of coordination/oversight, policies/procedures, surveillance .outbreak management, prevention of infection, and employee health and safety .The infection prevention and control committee is responsible for .documented IPCP incidents and corrective actions taken .whether there is appropriate follow-up of acute infections .Policies and procedures reflect the current infection prevention and control standards of practice .updating and supplementing policies and procedures as needed; Assessment of staff compliance with existing policies and regulations .Process surveillance .monitoring employee infection, monitoring adherence to infection prevention and control practices .Standard criteria are used to distinguish community-acquired from facility-acquired infections .following established general and disease-specific guidelines such as those of the Center for Disease Control (CDC) .Monitoring Employee Health and Safety. The facility has established policies and procedures regarding infection control among employees .should report their infections or avoid the facility . During a review of the facility's policy and procedure titled, Coronavirus Disease 2019 (COVID-19) Mitigation Plan for Skilled Nursing Facilities, dated July 2023, indicated, .The facility screens and documents every individual entering the facility (including staff) for COVID-19 symptoms and temperature . symptomatic residents and staff, document the date(s) and time(s) of the identification of signs or symptoms, when testing was conducted, when results were obtained, and the actions the facility took based on the results .to prevent Covid-19 transmission and infection . During a review of the Centers for Disease Control and Prevention (CDC) guidance titled, CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated November 29, 2022, indicated, .5e. Minimizing Potential Exposures- Develop and implement systems for early detection and management .of potentially infectious persons at initial points of patient encounter . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555492 If continuation sheet Page 3 of 3