Health inspection·June 30, 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 ensure infection control practices were implemented for two of three sampled residents (Residents 1 and 2) when Licensed Vocational Nurses (LVN 1 and 2) did not wear personal protective equipment (PPE- equipment, such as gloves and gown, used to protect against infection or illness) while administering medications via G-tube (a feeding tube inserted through the abdominal wall directly into the stomach) to residents on Enhanced Barrier Protection (EBP-an infection control intervention to reduce transmission of multidrug-resistant organisms [MDRObacteria that have become resistant to multiple antibiotics).This failure had the potential to expose vulnerable residents to cross-contamination and increase the risk of developing infections.Findings:1. A review of Resident 1's medical record was conducted. Resident 1 was admitted to the facility on [DATE], with diagnosis which included gastrostomy status (an opening into the stomach for food). A review of Resident 1's Order Summary, dated June 9, 2025, indicated, .Enhanced Barrier Precautions-Staff to utilize gowns and gloves for high-contact resident care activities due to Indwelling catheter [flexible tube that is inserted into the bladder to drain urine] and feeding tube [a medical device used to deliver nutrition, fluid, and medications directly into the person's stomach], and wound every shift. A review of Resident 1's care plan dated June 8, 2025, indicated .The resident requires tube feeding .Interventions .Enhanced Barrier Precautions-Staff to utilize gowns and gloves for high-contact resident care activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use .On June 30, 2025, 4:35 p.m., during an observation in Resident 1's room with LVN 1, LVN 1 was seen entering Resident 1's room without wearing an isolation gown while providing contact care and administering medication via Resident 1's G-tube.On June 30, 2025, at 4:55 p.m., during an interview with LVN 1, LVN 1 stated she forgot to wear the isolation gown. LVN 1 further stated she should have worn the isolation gown to protect the residents and prevent the spread of germs.2. A review of Resident 2's medical record was conducted. Resident 2 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke), and gastrostomy status (an opening into the stomach for food).A review of Resident 2's care plan dated June 14, 2025, indicated .Resident requires enhanced barrier precautions to prevent the spread of multidrug- resistant organisms (MDROs).Interventions.Enhanced Barrier Precautions-Staff to utilize gowns and gloves for high-contact resident care activities such. device care or use (e.g . feeding tube.) .A review of Resident 2's Order Summary, dated June 16, 2025, indicated, .Enhanced Barrier Precautions-Staff to utilize gowns and gloves for high-contact resident care activities due to indwelling catheter and feeding tube, and wound every shift.On June 30, 2025, 5:10 p.m., during an observation in Resident 2's room with LVN 2, LVN 2 was seen entering Resident 2's room without wearing an isolation gown while providing contact care and administering medication via Resident 2's G-tube.On June 30, 2025, at 5:30 p.m., during an interview with LVN 2, LVN 2 stated she was supposed to Residents Affected - Few Page 1 of 2 555566 555566 06/30/2025 Corona Post Acute Center 2600 South Main Street Corona, CA 92882

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wear the isolation gown to protect the resident and prevent the spread of infection.On July 1, 2025, at 3:51 p.m., an interview was conducted with the Infection Preventionist nurse (IP). The IP stated her expectation was for all staff to follow the designated precaution protocols designated for each resident and to wear the appropriate PPE as indicated. The IP further stated the LVN should have worn PPE to prevent the spread of infections to residents.A review of facility policy and procedure titled, Enhanced Barrier Precautions, dated April 2001, indicated, . Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities.Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include.device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and wound care (any skin opening requiring a dressing) . 555566 Page 2 of 2