Health inspection·April 28, 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 maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections by failing to ensure staff were not wearing gloves in the hallway after exiting the rooms of three of six sampled residents (Resident 1, Resident 2, and Resident 3). Residents Affected - Some This deficient practice had the potential to spread infections and illnesses among residents and staff. Findings: During a review of Resident 1's Record of Admission, the Record of admission indicated the facility admitted the resident on 6/29/2020, with a diagnosis of hemiplegia (complete paralysis [loss of muscle function] on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (also known as a stroke, damage to the brain from interruption of its blood supply). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/27/2025, the MDS indicated Resident 1's thought process was intact and required substantial assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a concurrent observation and interview, on 4/28/2025, at 8:49 a.m., with Certified Nursing Assistant (CNA) 2, CNA 2 came out from Resident 1's room wearing a glove while holding a plastic bag and entered the dirty linen room. CNA 2 stated she was wearing gloves while holding the plastic bag with dirty linens to throw the bag away in the dirty linen room and she should not wear gloves in the hallway to prevent the spread of infection. During a review of Resident 2's Record of Admission, the Record of admission indicated the facility admitted the resident on 2/19/2025, with a diagnosis of acute respiratory failure with hypoxia (a life-threatening condition where the lungs fail to adequately exchange oxygen and carbon dioxide, resulting in a deficiency of oxygen in the blood). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's thought process was intact and required moderate assistance from staff to complete ADLs. During a concurrent observation and interview, on 4/28/2025, at 8:53 a.m., with CNA 3, in the hallway, CNA 3 wore gloves while transporting Resident 2 in a shower chair. CNA 3 stated she was wearing Page 1 of 2 555583 555583 04/28/2025 MacLay Healthcare Center 12831 MacLay Street Sylmar, CA 91342

F 0880 gloves while transporting Resident 2 in a shower chair and she should not be due to infection control. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 3's Record of Admission, the Record of admission indicated the facility admitted the resident on 11/30/2022 with a diagnosis of type two diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). Residents Affected - Some During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's thought process was intact and was dependent on facility staff to complete ADLs. During a concurrent observation and interview, on 4/28/2025, at 9:04 a.m., with CNA 4, CNA 4 wore gloves while holding linens and entered the dirty linen room. CNA 4 stated she was wearing gloves while holding the dirty linens. CNA 4 stated she did not place the linens in a plastic bag and carried the dirty linens to the dirty linen room. CNA 4 stated that she should put the dirty linens in a plastic bag and throw it away in the dirty linen room. CNA 4 further stated that she should not wear gloves in the hallway to prevent the spread of infection. During an interview, on 4/28/2025, at 9:26 a.m., with the Infection Preventionist (IP) Nurse, the IP Nurse stated staff should not wear gloves in the hallways and staff should remove their gloves inside the room and wash their hands after to prevent the spread of infection and protect other residents and staff. During an interview, on 4/28/2025, at 10:30 a.m., with the Director of Nursing (DON), the DON stated staff should not wear gloves in the hallway to prevent the spread of infection. During a review facility's policy and procedure(P&P) titled, Personal Protective Equipment - Gloves, last reviewed 4/2025, the P&P indicated gloves shall be used only once and discarded into the appropriate receptacle located in the room in which the procedure is being performed. During a review facility's policy and procedure(P&P) titled, Laundry and Bedding, Soiled, last reviewed 4/2025, the P&P indicated Soiled laundry/bedding shall be handled, transported and processed according to best practices for in 555583 Page 2 of 2