Inspection·November 30, 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, facility document review, and facility P&P review, the facility failed to implement the infection control practices designed to provide the safe and sanitary environment and help prevent the development and transmission of diseases and infections for two of sampled residents (Residents 1 and 2). Residents Affected - Few * The facility failed to ensure the staff practiced the contact isolation precautions when entering the room of one sampled resident (Resident 1) who was on contact isolation precautions * The facility failed to ensure the staff practiced the enhanced barrier precautions during high contact-care for one sampled resident (Resident 2) who was on enhanced barrier precautions. These failures posed the risk for the transmission of diseases-causing microorganisms. Findings: 1. Review of the facility's P&P titled Transmission-Based Precautions released on 6/2022 showed contact precaution is a method designed to reduce the risk of transmission of microorganisms by direct or indirect contact. Contact precautions are used for patients with known or suspected infections or evidence of syndromes that represent an increased risk of contact transmission. Increased risks include but are not limited to presence of excessive drainage, fecal incontinence, or other discharges from the body suggesting an increased potential for extensive environmental contamination and risk for transmission. The Infection Preventionist or designee reviews isolation status for patients daily. Further review of the facility's P&P showed the precaution-specific expectations: 1. Contact Precautions a. Hand hygiene - is the most important method of control to prevent transmission. b. Gloves c. Gowns - [NAME] a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. Medical record review for Resident 1 was initiated on 11/3/23. Resident 1 was admitted to the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 555859 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kindred Hospital Brea D/P Snf 875 N Brea Blvd Brea, CA 92821 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)