Health inspection·August 3, 2023

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 observe infection control measures for one of five sampled residents (Resident 1), when Registered Nurse 1 (RN 1) did not wear proper personal protective equipment (PPE) such as gown while providing wound care for Resident 1 who was under transmission-based precaution. This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for residents and staff in the facility. Residents Affected - Few Findings: During a review of Resident 1 ' s admission record, printed on 8/3/23, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and has a medical diagnosis including MSSA Infection (Methicillin-susceptible Staphylococcus aureus, is an infection caused by a type of bacteria commonly found on the skin). During a review of Resident 1 ' s Care Plan, printed on 8/7/23, the care plan indicated Resident 1 was placed on preemptive contact precaution(Contact precautions prevent the spread of bacteria, parasites, and viruses from one person to another which can occur when touching an infected person and their dirty items, such as clothing, and surfaces) due to possible exposure to CRAB (carbapenem resistant acinetobacter baumannii - causes human infections of the blood, urinary tract, lungs, wounds, and other body sites. The bacteria are multidrug-resistant, making infections very difficult to treat.) During an observation on 8/3/23 at 10:18 a.m., in South station, the sign on Resident 1 ' s room [ROOM NUMBER] indicated, contact precautions to be observed while entering the room. The sign indicated to wear gown and gloves before entering the room. During an observation on 8/3/23 at 10:18 a.m., RN 1 was observed to enter room [ROOM NUMBER] without wearing gown for providing wound care for resident 1 who was on contact precaution. During an interview on 8/3/23 at 10:35 a.m., with RN 1, RN 1 stated he provided wound dressing for Resident 1 and should have worn gown as Resident 1 was on contact precaution. RN 1 stated the risk of not wearing the personal protective equipment like gown is that he can spread the infection to himself and others. During an interview on 8/3/23 at 11:09 a.m., with Director of Nursing (DON), DON stated it is unacceptable for staff to work with residents under contact precautions without wearing proper PPE and following infection control guidelines. DON also stated it is important to follow contact precautions to protect staff and residents from getting exposed to infection and spreading the infection to Page 1 of 2 555809 555809 08/03/2023 All Saint's Subacute & Transitional Care 1652 Mono Avenue San Leandro, CA 94578

F 0880 others. Level of Harm - Minimal harm or potential for actual harm During a review of the facility ' s Policy and Procedure (P&P) titled, Isolation- Categories of TransmissionBased Precautions, revised on 09/2022, the P&P indicated, Contact Precautions . 1. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident ' s environment .8. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Residents Affected - Few 555809 Page 2 of 2