Health inspection·June 18, 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, medical record review, and facility P&P review, the facility failed to maintain the infection prevention and control practices to help prevent the transmission of communicable diseases and infections for one of three sampled residents (Resident 1) placed on contact precautions. Residents Affected - Few * The facility failed to ensure the staff donned an isolation gown before contacting with Resident 1 and/or his environment. Additionally, the staff did not properly discard the isolation gown after wearing it in Resident 1's room. * The facility failed to handle the clean linens so as to prevent the spread of infection. These failures posed the risk for transmission of infection and the development of disease-causing microorganisms. Findings: 1. Review of the facility's P&P titled Head Lice and Scabies Exposure and Treatment dated 12/19/22,showed the staff will follow appropriate transmission-based precautions, including PPE use, when providing care to the affected resident/s. Review of Resident 1's medical record was initiated on 6/17/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Order Summary Report dated 6/17/25, showed a physician's order dated 6/11/25, for contact precautions for scabies until further orders. On 6/17/25 at 0740 hours, an observation and concurrent interview was conducted with CNA 4. CNA 4 was inside Resident 1's room feeding Resident 1. CNA 4 was not wearing an isolation gown while in the room. There was a contact precautions sign posted outside of Resident 1's room, to don PPE before entering the room. CNA 4 was asked why he did not don an isolation gown. CNA 4 stated there was no isolation gown by the designated supply area. CNA 4 verified he should have worn a gown before going inside Resident 1's room. CNA 4 then donned an isolation gown continued with Resident 1's feeding. When finished, CNA 4 removed his isolation gown and discarded the used gown in a regular trash bin which was overflowing with used gowns in Resident 1's room bathroom. CNA 4 stated there was no black trash bin available, so he discarded the used gown in the regular trash bin. CNA 4 further stated, if there was a black trash bin, he would have discarded the used gown in there and not in the regular trash bin. Page 1 of 2 555797 555797 06/18/2025 Gordon Lane Care Center 1821 E Chapman Ave Fullerton, CA 92831

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/17/25 at 0742 hours, an interview was conducted with the IP. The IP verified CNA 4 did not don an isolation gown and discarded the used isolation gown in a regular garbage container. The IP stated a gown must be donned when getting inside the isolation rooms and discarded in the appropriate designated garbage bin. On 6/17/25 at 1330 hours, an interview was conducted with the DON. The DON verified the above findings and stated an in-service was initiated regarding the importance of huddle, environmental rounds and to ensure the residents' plan of care are followed. On 6/18/25 at 0740 hours, an interview with the Environmental Services Director was conducted regarding the unavailability of trash bin designated for used PPE for Resident 7's room. The Environmental Services Director stated, I don't know what happened. The Environmental Services Director further stated designated trash bins were provided yesterday and physically checked all rooms to ensure the proper garbage bins were provided. 2. Review of the facility's P&P titled Handling Clean Linen revised 12/2022 showed it is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection. On 6/18/25 at 0827 hours, a facility tour was conducted with the Environmental Services Director in Resident 1's room. CNA 5 was observed placing clean linen on top of the dirty hamper in front of Resident 1's room. CNA 5 acknowledged and verified the clean linen was on top of the dirty hamper and stated, I'm sorry. The Environmental Services Director and CNA 5 acknowledged and verified the findings. On 6/18/25 at 830 hours, during an interview, the IP verified the clean linens were on top of the hamper and were now contaminated. On 6/18/25 at 1620 hours, an interview was conducted with the Administrator, DON, IP, and DSD. The Administrator, DON, IP, and DSD verified the above findin 555797 Page 2 of 2