Health inspection·February 8, 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 implement the facility's infection control policy by failing to ensure staff wore appropriate PPEs (Personal Protective Equipment- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) while in an isolation room of a resident who tested positive for respiratory syncytial virus (a common respiratory virus that infects the nose, throat, and lungs) for one of two sampled residents (Resident 2) Residents Affected - Few This deficient practice had the potential to result in the spread of infection placing residents, staff, and visitors at risk to be infected with respiratory syncytial virus (a common respiratory virus that infects the nose, throat, and lungs) and becoming seriously ill, leading to hospitalization and/or death. Findings: During a review of Resident 2's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including shortness of breath and respiratory syncytial virus. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 1/19/2025, the MDS indicated the resident had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). During a review of Resident 2 ' s order summary report, the order summary report indicated an order dated 2/6/2025 for contact and droplet isolations. During a review of Resident 2 ' s laboratory (lab) test results collected on 2/6/2025 at 9:58 p.m., the lab test result indicated Resident 2 tested positive for respiratory syncytial virus. During an observation on 2/8/2025 at 11:29 a.m., observed Certified Nursing Assistant 1 (CNA 1) enter Resident 2 ' s room, a contact and droplet precaution room, wearing a well fitted mask, gloves and gown. CNA 1 was not wearing a face shield. During an interview with CNA 1 on 2/8/2025 at 11:32 a.m., CNA 1 stated when entering a contact and droplet precaution room CNA 1 is supposed to wear a face mask, gown, gloves, and a face shield. CNA 1 stated that CNA 1 did not wear a face shield before entering Resident 2 ' s because there was no face shield in the isolation cart in front of Resident 2 ' s room. CNA 1 stated that a face mask, gown, gloves, and face shield should be worn before entering Resident 2's room to help protect the resident and staff from infection. Page 1 of 2 555738 555738 02/08/2025 Terrace Post Acute 7447 Sepulveda Blvd Van Nuys, CA 91405

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and concurrent interview in front of Resident 2 ' s room with CNA 1 on 2/8/2025 at 11:33 a.m., observed CNA 1 open the three drawers in the isolation cart in front of Resident 2 ' s room. CNA 1 stated there are no face shields in the isolation cart. During an interview with the Infection Preventionist (IP) on 2/8/2025 at 12:08 p.m., the IP stated that all staff entering a droplet isolation room should wear full PPEs which include, gown, gloves, face mask, and face shield to prevent the spread of infection. During a review of the facility ' s policy and procedure titled Infection Prevention and Control, revised on 12/2023, the policy and procedure indicated the facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infections. During a review of the facility provided policy and procedure titled Isolation- Categories of Transmission-Based Precautions, revised 9/2022, indicated under contact precautions staff and visitors wear gloves when entering the room. Staff and visitors wear disposable gown upon entering the room and remove before leaving the room. Under Droplet precautions masks are worn when entering the room. Gloves, gown, and goggles are worn if there is risk of spraying respiratory secretions. 555738 Page 2 of 2