Health inspection·October 16, 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 implement its policy titled, Enhanced Barrier Precautions (EBP - an infection control method that uses targeted gown and gloves to reduce the spread of multidrug-resistant organisms [MDROs - microorganisms, mainly bacteria, that are resistant to one or more classes of antimicrobial [a substance that kills microorganisms such as bacteria or mold, or stops them from growing and causing disease agents]), and Hand washing/Hand hygiene (HH - cleaning hands by either washing with soap and water, or by using a hand sanitizing [removing germs] gel) by failing to ensure: Residents Affected - Few 1. Certified Nurse Assistant 1 (CNA 1) donned (to put on) a gown while changing the bed linen for one of three sampled residents (Resident 1) on EBP. 2. CNA 1 perform HH after removing gloves for one of three sampled residents (Resident 1) on EBP. These deficient practices placed the residents at increased risk of developing an infection. Findings: During a review of Resident 1's admission Record indicated the facility admitted Resident 1 to the facility on [DATE] with diagnoses that included idiopathic peripheral autonomic neuropathy (a type of nerve damage that affects the nerves that control involuntary body functions), diabetes mellitus (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly) with skin ulcer (an open wound on the skin caused by poor blood flow), and cellulitis (a skin infection caused by bacteria) of the lower limb (an arm or a leg of a person). During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 10/5/2024, indicated the resident's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 1 required maximum assistance with toileting hygiene, personal hygiene and moderate assistance with dressing and bed mobility (movement). During a review of Resident 1's Physician Orders, dated 10/2/2024, indicated enhanced barrier precaution for at risk of infection due to wounds. Page 1 of 3 555716 555716 10/16/2024 Park View Nursing and Subacute 6740 Wilbur Ave Opco, LLC Reseda, CA 91335

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 10/16/2024 at 8:49 a.m., in Resident 1's room , observed Resident 1's door had signage which indicated Resident 1 was on EBP, which required everyone to perform hand hygiene before entering Resident 1's room. The signage also indicated to don a gown and gloves when performing linen change. During an observation on 10/16/2024 at 8:52 a.m., in Resident 1's room, observed CNA 1 changing Resident 1's bed linen. CNA 1 was observed wearing gloves but not wearing a gown while changing Resident 1's bed linen. CNA 1 was then observed not performing hand hygiene after removing the gloves. During an interview on 10/16/2024 at 8:55 a.m., with CNA 1, CNA 1 stated that gowns were used to prevent spreading an infection between residents, but she (CNA 1) did not know she (CNA 1) had to wear a gown when changing bed linens. During an interview on 10/16/2024 at 11:10 a.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 1 was on EBP due to the presence of a wound. LVN 2 stated facility staff must wear gown and gloves while providing direct care to Resident 1. During an interview on 10/16/2024 at 11:25 a.m. with Infection Prevention Nurse (IP), the IP confirmed the finding and stated she (IP) observed CNA 1 changed Resident 1's bed linen without wearing a gown and did not perform hand hygiene after removing the gloves. The IP stated that according to the facility's policies regarding EBP, CNA 1 should have donned a gown prior to bed linen change and should have performed hand hygiene after removing her (CNA 1) gloves. During an interview on 10/6/2024 at 3:50 p.m. with the Director of Nursing (DON), the DON stated that residents placed on EBP include residents at increased risk of developing an infection because they have wounds, indwelling catheter (a thin, hollow tube that is inserted into the bladder [organ that stores urine] to drain urine), or gastrostomy tube (G-tube - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration). The DON stated when a resident is on EBP, all staff are required to don gowns and gloves when performing high contact resident care activities (activities that have been demonstrated to result in the transfer of MDROs to hands or clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated) such as dressing, bathing, shower, providing personal hygiene, and changing linens. A review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, last reviewed 7/2024, indicated the facility was to implement enhanced barrier precaution for the prevention of transmission of MDRO. The P&P indicated to wear gowns and gloves while performing the following tasks associated with the greatest risk for MDRO contamination of Health Care Providers (HCP) hands, clothes, and the environment: a. Morning and evening care b. Device care . c. Any care activity where close contact with resident is expected to occur . d. Transferring e. Changing bed linens. 555716 Page 2 of 3 555716 10/16/2024 Park View Nursing and Subacute 6740 Wilbur Ave Opco, LLC Reseda, CA 91335

F 0880 f. Any care activity involving contact with environmental surfaces. Level of Harm - Minimal harm or potential for actual harm g. In multi-bedrooms when moving from contact with one resident to contact with another resident. Residents Affected - Few A review of the facility's P&P titled Handwashing/ Hand Hygiene, last reviewed 7/2024 indicated Use an alcohol-based hand rub (a liquid, gel, or foam that contains alcohol and is designed to reduce the number of microorganisms on the hands) containing at least 62 percent (%) alcohol: a. Before and after contact with the resident . d. After removing personal protective equipment (PPE - protective items (such as gown, gloves) worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission [the transfer of germs from one area to another]) .The use of gloves does not replace hand washing/hand hygiene. 555716 Page 3 of 3