Health inspection·January 26, 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 interview and record review, the facility failed to develop and implement an ongoing infection surveillance monitoring for 3 of 5 sampled residents (Resident 8, 9, and 11) when: Residents Affected - Few 1. Resident 8's infection surveillance (infection care area and screening tool) assessment did not include Resident 8's symptoms of dysuria (painful or uncomfortable urination) as a urinary tract infection (UTI) symtpom, for on-going surveillance. 2. Resident 9's infection surveillance assessment did not include Resident 9's burning to vaginal area related to the use of a urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag), for on-going surveillance. 3. Resident 11 was diagnosed with corona virus 19 (COVID-19; sickness caused by a virus- severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) upon admission, and was not re-tested or tracked for, infection surveillance. These failures had the potential to affect residents' health and well-being, and spread infections throughout the facility. Findings: 1. A review of Resident 8's Record of admission (face sheet; contains demographic information) indicated Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis that included atrial fibrillation (heart condition that causes an irregular and often abnormally fast heart rate). A review of Resident 8's Laboratory Report dated 1/24/24, indicated a positive urinalysis (urine test that detects the presence of disease) result that Resident 8 had a UTI. A review of Resident 8's clinical record titled Change of Condition (COC), dated 1/25/24 at 1408 (2:08 P.M.), indicated symptoms of .with burning on urination no changes of LOC (level of consciousness) . On 1/25/24, Kelfex (antibiotic; medication that treats bacterial infections) 500 milligrams (mg), was started. This antibiotic was ordered to be taken three times a day for five days, to treat the urinary tract infection (UTI). A concurrent interview and review of Resident 8's clinical record titled Infection Surveillance Page 1 of 6 555804 555804 01/26/2024 Victoria Post Acute Care 654 S. Anza El Cajon, CA 92020

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dated 1/25/24 was conducted with the infection control preventionist nurse (ICPN), on 1/26/24, at 12:50 P.M., in the conference room. The ICPN stated she did not check Resident 8's clinical record titled Change of Condition, dated 1/25/24 at 1408 (2:08 P.M.) that captured Resident 8's symptomatic (positive symptoms) UTI, including .burning on urination . The ICPN stated she only checked the physician orders and vital signs for pain and/or fever. The ICPN stated it was important to accurately assess and document Resident 8's Infection Surveillance because the Mcgeer's (an infection control practice measures that determined appropriateness for on-going monitoring, investigation, treatment, and prevention management) criteria may not be accurate and cause delays in Resident 8's plan of care. An interview with the director of nursing (DON) was conducted on 1/26/24 at 1:30 P.M., in the conference room. The DON stated that the infection surveillance is an on-going process that is tracked. The DON stated that surveillance assessments should reflect all residents with confirmed or suspected infections, to determine if appropriate care measures were in place, and for the purpose of infection control and prevention. A review of the facility's policy, revised/reviewed 10/2022, indicated .1. Surveillance of infections .There is on-going monitoring for infection among residents and personnel and subsequent documentation of infections that occur. Surveillance tools are used to recognize the occurrence of infections, record their number and frequency, detect outbreaks and epidemics, monitor personnel infections, and detect unusual pathogens with infection control implications .a) Under the infection control program, the facility will: investigate, control, and prevent infections in the facility. Decide what measures/interventions should be applied in individual circumstances . Maintain a record of incidence of infection and corrective action taken . 2. A review of Resident 9's Record of admission (face sheet; contains demographic information) indicated Resident 9 was admitted to the facility on [DATE], with diagnoses that included obstructive and reflex uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow). A review of Resident's 9's treatment order, dated 12/20/24 at 2304 (11:04 P.M.), indicated Indwelling catheter #16/10cc to closed drainage system . A concurrent interview and record review of Resident 9's clinical record titled Infection Surveillance, dated 1/24/24 was conducted with the infection control preventionist nurse (ICPN), on 1/26/24 at 1 P.M., in the conference room. The ICPN stated she did not include Resident 9's urinary catheter in her assessment titled, Infection Surveillance, dated 1/24/24. The ICPN stated she was not aware that resident had a catheter, and did not observe Resident 9 prior to completing Resident 9's Infection Surveillance, dated 1/24/24, to confirm Resident 9's urinary catheter status. The ICPN stated that she only checked the first page of Resident 9's Physician's orders and did not know there was a page 2 that confirmed Resident 9 had urinary catheter orders. A concurrent interview and record review of Resident 9's clinical record was conducted with the ICPN on 1/26/24 at 1:10 P.M, in the conference room. Resident 9's progress note, dated 1/21/24 at 1506 (3:06 P.M.) included documentation that .UTI (urinary tract infection) positive U/A (urinalysis; analysis of urine that tests for the presence of disease) C/S (culture and sensitivity; a test to determine what germ is causing an infection). Resident 9's clinical record indicated new orders on 1/21/24 for Pyridium 100 milligrams (mg) PO (by mouth) TID (three times a day) for burning to vaginal area . The ICPN stated she did not know that there was a progress note or new orders related to treating Resident 9's UTI symptoms. The ICPN stated that her Infection Surveillance dated 1/24/24 did not 555804 Page 2 of 6 555804 01/26/2024 Victoria Post Acute Care 654 S. Anza El Cajon, CA 92020

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few accurately reflect Resident 9's UTI symptoms. The ICPN stated it was important to accurately assess and document Resident 9's Infection Surveillance and that her assessment was inaccurate when it did not reflect the presence of Resident 9's urinary catheter. Further, the ICPN stated that the UTI symptoms could possibly change the Mcgeer's criteria (an infection control practice measures to determine appropriateness for on-going monitoring, investigation, treatment and prevention management) for surveillance and infection control due to increased urinary infection risks and complications of urinary catheter use. An interview with the director of nursing (DON) was conducted on 1/26/24 at 1:30 P.M., in the conference room. The DON stated that the idea of infection surveillance is an on-going process that is tracked. The DON stated that surveillance assessments should reflect all residents with confirmed or suspected infections to determine if appropriate care measures were in place, and for the purpose of infection control and prevention. A review of the facility's policy, revised/reviewed 10/2022, indicated .1. Surveillance of infections .There is on-going monitoring for infection among residents and personnel and subsequent documentation of infections that occur. Surveillance tools are used to recognize the occurrence of infections, record their number and frequency, detect outbreaks and epidemics, monitor personnel infections, and detect unusual pathogens with infection control implications .a) Under the infection control program, the facility will: investigate, control, and prevent infections in the facility. Decide what measures/interventions should be applied in individual circumstances . Maintain a record of incidence of infection and corrective action taken . 3. A review of Resident 11's Record of admission (face sheet; contains demographic information) indicated Resident 11 was admitted to the facility on [DATE], with diagnoses that included human immunodeficiency virus (HIV; virus that attacks the body's immune system), pneumonia (PNA; infection of the lungs that may be caused by bacteria, viruses, or fungi) and corona virus-19 (COVID-19) was present on admission. A record review of Resident 11's clinical record titled Infection Surveillance, dated 1/24/24 indicated Respiratory tract infection (PNA) . interpretation of chest radiograph as demonstrating PNA or the presence of new infiltrate, new or increased cough, fever . Chest x-ray showed a RLL (right lower lobe infiltrate) . A record review of the facility's document titled, Respiratory Illness Case Log for Residents and Staff for COVID-19 infections did not include Resident 11 for COVID-19 or PNA for surveillance. Instructions for the document titled, Respiratory Illness Case Log stated List all residents and staff with influenza like illness (ILI) and/or Acute Respiratory Illness (ARI) . A record review of the facility's census indicated Resident 11's room was in an area identified for transmission-based precautions (TBP; used in addition to standard precautions for individuals who may be infected or colonized with certain infectious agents; additional precautions are needed to prevent infection transmission) with another resident who tested positive for COVID-19 while in the facility. There were no records that Resident 11 had been tested for COVID-19 in the facility. A concurrent interview and record review of Resident 11's clinical record was conducted with the ICPN (infection control preventionist nurse) on 1/26/24 at 1:20 P.M., in the conference room. The ICPN stated that Resident 11's Infection Surveillance was also referred to as her antibiotic stewardship to monitor residents on antibiotics. Per the ICPN, she tracked Resident 11 for PNA because Resident 555804 Page 3 of 6 555804 01/26/2024 Victoria Post Acute Care 654 S. Anza El Cajon, CA 92020

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 11 was being treated at the facility with antibiotics for PNA. The ICPN stated she updated her infection surveillance and infection control logs daily. The ICPN was unable to show an infection control log or documentation that included Resident 11 for COVID-19 surveillance. An interview with the DON was conducted on 1/26/24 at 1:30 P.M., in the conference room. The DON stated infection control needed to be monitored and intervened as appropriate on an on-going basis, and explained to the ICPN that the purpose of surveillance is to prevent communicable diseases from spreading and being able to trace back the origin (where the cause originated from) of an infection, and prevent outbreaks. The DON stated that it was important for infection surveillance to include prevention, identifying, reporting, investigating, controlling infections and communicable diseases for all residents, staff, visitors to the facility. A review of the facility's policy, revised/reviewed 10/2022, indicated .1. Surveillance of infections .There is on-going monitoring for infection among residents and personnel and subsequent documentation of infections that occur. Surveillance tools are used to recognize the occurrence of infections, record their number and frequency, detect outbreaks and epidemics, monitor personnel infections, and detect unusual pathogens with infection control implications .a) Under the infection control program, the facility will: investigate, control, and prevent infections in the facility. Decide what measures/interventions should be applied in individual circumstances . Maintain a record of incidence of infection and corrective action taken . 555804 Page 4 of 6 555804 01/26/2024 Victoria Post Acute Care 654 S. Anza El Cajon, CA 92020

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer and administer pneumococcal vaccine (PV, immunization against bacteria that causes pneumonia [lung infection]) for two of five sampled residents (2 and 5). Residents Affected - Few This failure had the potential to cause health complications for the residents. Findings: 1. A record review of Resident 2's clinical record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included influenza (viral infection that causes symptoms including fever, chills, sneezing, coughing, and sore throat) and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). Resident 2 was over [AGE] years of age. A record review of Resident 2's clinical record indicated that resident received Prevnar 13 (a vaccine to prevent pneumonia) on 9/30/15 (historical; administered outside of facility). Resident 2 also received the pneumonia vaccine 23 (PPSV23; a vaccine to prevent pneumonia) on 12/26/17 (historical). A concurrent interview and record review of Resident 2's clinical record with the director of staff development (DSD), who also helps with infection control, was conducted on 1/26/24 at 10:30 A.M., in the conference room. Resident 2's medical record indicated there was no evidence that staff offered or administered the pneumococcal vaccine 20 (PCV20; a vaccine to prevent pneumonia infections) to Resident 2, as recommended by the Centers of Disease Control (CDC). During an interview with the DSD on 1/26/24 at 10:35 A.M., in the conference room, the DSD stated that she was not aware of the CDC's pneumococcal vaccine recommendations for adults. The DSD confirmed that Resident 2 was not offered or administered the PCV 20 vaccine as recommended by the CDC. The DSD stated that Resident 2 should have been offered as recommended to prevent health complications from pneumonia. An interview with the director of nursing (DON) was conducted on 1/26/24 at 1:40 P.M., in the conference room. The DON stated that it was important that all residents are offered pneumonia vaccines according to CDC recommendations to prevent pneumonia related infections and health complications. The DON further stated that a designated person, either the DSD or the infection control prevention nurse (ICPN) should track pneumonia vaccinations. The facility policy and procedure titled, Immunizations-Residents revised/reviewed on 7/2023, indicated, .4 . a. For Pneumococcal immunizations refer to the CDC website: Pneumococcal Vaccination . The CDC website https://www.cdc.gov/vaccines/vpd/pneumo/index.html Vaccines and Preventable Diseases . Pneumococcal Vaccinations . Adults 65 years or older have the option to get PCV20 if they have already received PCV13 (but not PCV15 or PCV20) at any age AND PPSV23 at or after the age of [AGE] years old . 2. A record review of Resident 5's clinical record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (a condition when the body is unable to 555804 Page 5 of 6 555804 01/26/2024 Victoria Post Acute Care 654 S. Anza El Cajon, CA 92020

F 0883 control blood sugar levels resulting in high blood sugar). Resident 5 was over [AGE] years of age. Level of Harm - Minimal harm or potential for actual harm A record review of Resident 5's clinical record indicated Resident 5 received Prevnar 13 (a vaccine to prevent pneumonia) on 7/29/16 (historical; administered outside of the facility). Resident 5 also received the pneumonia vaccine 23 (PPSV23; a vaccine to prevent pneumonia) on 10/23/04 (historical). Residents Affected - Few A concurrent interview and record review of Resident 5's clinical record with the director of staff development (DSD), who also helps with infection control, was conducted on 1/26/24 at 10:40 A.M., in the conference room. There was no evidence in Resident 5's medical record that staff offered or administered the pneumococcal vaccine 20 (PCV20; a vaccine to prevent pneumonia infection) to Resident 5, as recommended by the Centers of Disease Control (CDC). An interview with the DSD was conducted on 1/26/24 at 10:45 A.M., in the conference room. The DSD stated that she was not aware of the CDC's pneumococcal vaccine recommendations for adults. The DSD confirmed that Resident 5 was not offered or administered the PCV 20 vaccine as recommended by the CDC. The DSD stated that Resident 5 should have been offered the vaccine as recommended, to prevent health complications from pneumonia. The facility policy and procedure titled, Immunizations-Residents revised/reviewed on 7/2023, indicated, .4 . a. For Pneumococcal immunizations refer to the CDC website: Pneumococcal Vaccination . An interview with the director of nursing (DON) was conducted on 1/26/24 at 1:40 P.M., in the conference room. The DON stated that it was important that all residents are offered pneumonia vaccines according to CDC recommendations to prevent pneumonia related infections and health complications. The DON further stated that a designated person, either the DSD or the infection control prevention nurse (ICPN) should track pneumonia vaccinations. The facility policy and procedure titled, Immunizations-Residents dated 7/2023, indicated, .4 . a. For Pneumococcal immunizations refer to the CDC website: Pneumococcal Vaccination . The CDC website https://www.cdc.gov/vaccines/vpd/pneumo/index.html Vaccines and Preventable Diseases . Pneumococcal Vaccinations . Adults 65 years or older have the option to get PCV20 if they have already received PCV13 (but not PCV15 or PCV20) at any age AND PPSV23 at or after the age of [AGE] years old . 555804 Page 6 of 6