Health inspection·February 2, 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 establish a system of surveillance designed to prevent the spread of communicable diseases that included Coronavirus -19 (COVID 19 – a highly contagious disease caused by a virus) for one of 24 sampled residents (Resident 1), who had a positive test result and symptomatic for the COVID 19 virus. In addition, the facility failed to report the COVID 19 positive resident as a potential disease outbreak, to the local health officer and the California Department of Public Health (CDPH). Residents Affected - Some This deficient practice had the potential for the virus to spread among residents, staff, and visitors which can negatively affect the resident ' s health and quality of life. Findings: A review of Resident 1 ' s admission Record dated 2/2/2024, the indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including Corneal transplant (to remove all or part of a damaged cornea and replace it with healthy cornea tissue from a donor), asthma (is a common long-term condition that can cause coughing, wheezing, chest tightness and breathlessness) and diabetes (is a lifelong condition that causes a person's blood glucose (sugar) level to become too high). During a review of Resident 1 ' s Minimum Data Set (MDS) -a standardized assessment and screening tool dated 12/26/23, the MDS indicated Resident 1 was cognitively intact. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) during eating, personal hygiene, toileting, sit to lying, chair/bed to chair transfer, partial/moderate assistance (helper does less than half the effort) with shower/bathing self. A review of Resident 1 ' s Progress Notes dated 1/14/2024 timed at 9:15 AM, indicated Resident 1 had a change in condition. The Progress Note indicated Resident 1 had a fever. The Progress Note indicated the physician was notified. A review of Resident 1 ' s Progress Notes dated 1/14/2024 timed at 10:22 AM, indicated Resident 1 was immediately placed on transmission-based precautions (A method or technique of caring for patients who have communicable diseases.) for suspected case of COVID 19 . Assessed possible exposures and closed contact exposures . Explained to resident guidelines to COVID 19 and treatment to COVID 19, will be Paxlovid for 5 days [sic] . A review of Resident 1 ' s Rapid antigen test for COVID 19 dated 1/14/2024, indicated COVID 19 positive result. Page 1 of 3 555796 555796 02/02/2024 Mission Care Center 4800 Delta Avenue Rosemead, CA 91770

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 1 ' s Order Summary Report dated 1/14/2024, indicated Resident 1 was started on Paxlovid (oral antiviral pill used to treat COVID-19 disease) (300/100) oral tablet therapy with NirmatrelvirRitonavir (treat mild to moderate COVID-19 disease) twice a day for 5 days for COVID 19 disease. During an interview on 2/2/2024 at 3:30 PM with the Infection Preventionist Nurse (IP), the IP stated Resident 1 was symptomatic with headache and a fever on 1/14/2024 and tested positive for COVID 19 and was treated with Paxlovid. The IP stated, she did not report the facility ' s COVID 19 positive resident (Resident 1) to the CDPH because she was told by staff that Resident 1 probably got the virus from his visitors and medical appointments. The IP stated, she should have reported the COVID 19 positive result to CDPH. The IP stated she reported Resident 1 ' s COVID 19 positive result to Redcap (online survey for skilled nursing facilities [SNFs] to report COVID-19 information [local health officer]). The IP stated she could not provide documented evidence or have a confirmation that the possible COVID 19 outbreak was reported to Redcap. The IP stated she did not follow up and did not have any communication with the local health officer or the LA County Public Health Nurse (PHN). The IP stated, she did not have any proof of confirmation, that she reported it to Redcap [local health officer] or CDPH. During an interview and record review on 2/2/2024 at 4:30 PM with the IP, in the presence of the Administrator (ADM), the IP showed a printed picture of 24 Covid test kits with residents' names written on each kit and 17 Covid test kits with names of staff written on each kit that was tested on Day 1 (1/15/2024) of the facility's COVID 19 exposure. The IP stated, she used the picture of the test kits as her list of residents and staff that were tested on Day 1. The IP stated she should have tested the residents exposed on Day 3 and Day 5 of exposure as well, but did not. The IP stated, she did not have a surveillance tracking log or surveillance tool to track residents and staff who had close exposure with Resident 1. The IP stated it was important to have a surveillance tracking to heightened alertness to people who were exposed to COVID 19 to prevent further spread of the virus. During an interview on 2/2/2024 at 5 PM with the ADM, the ADM stated the facility should have notified the CDPH and local health officer or Redcap when Resident 1 turned up positive for COVID 19 on 1/14/2024. The ADM stated the IP should have developed a tracking and surveillance system for COVID-19 when Resident 1 turned out positive for COVID 19 that included those residents/staff that was exposed to prevent the spread of the virus. A review of a LAC DPH document titled Coronavirus 2019 Guidelines for Preventing and Managing Covid 19 in Skilled Nursing Facilities, under reporting requirements, (undated), indicated; a) Skilled nursing facility (SNF) are required to report within 24 hours any suspected COVID-19 outbreak to both Public Health (LAC DPH) and Licensing and Certification, b) note: the current COVID -19 outbreak definition for SNFs in Los Angeles County is at least one PCR/NAAT laboratory confirmed case of covid 19 (symptomatic or asymptomatic) OR at least one symptomatic (sign) case with positive SARS-Cov-2 antigen result who has been in the facility for at least 7 days. A review of the facility ' s policy and procedure (P&P) titled, Infection Surveillance (Outcome) and Reporting , revised 12/2023 , indicated; a) facility to maintain an ongoing system designed to identify possible communicable diseases or infections to ensure that measures are taken to prevent any potential outbreaks, b) Outbreaks and/or individual communicable diseases will be reported to local/state health departments or other agencies, according to CDC guidelines. The P&P indicated; 1) infection control surveillance log is maintained by IP, 2) IP/DNS/Designee will review the log during the morning routine to ensure all potential/actual infections outbreaks are being identified, 3) should 555796 Page 2 of 3 555796 02/02/2024 Mission Care Center 4800 Delta Avenue Rosemead, CA 91770

F 0880 Level of Harm - Minimal harm or potential for actual harm any residents or staff be suspected or diagnosed as having a reportable communicable/infectious disease according to state- specific criteria, such information shall be promptly reported to appropriate local and/or state health department officials. Residents Affected - Some 555796 Page 3 of 3