Ridgecrest Regional Transitional Care And Rehabili

F-F880]

Findings:

1. During a concurrent interview and record review on 3/5/25 at 8:53 a.m. with IP, the facility's surveillance activities for infection control were reviewed. IP stated he only monitored hand hygiene which included hand washing and hand rub, and donning on and doffing of Personal Protective Equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments). IP stated I try to go out to the floor every other day and on every shift. IP stated he observed Certified Nursing Assistants, Licensed Vocational Nurses, Registered Nurses, Administrator, Physical Therapists, Transportation, and Environmental Services. IP stated the glucometer use and cleaning was not part of his surveillance.

During a review of the facility's Hand Hygiene Monitoring Tool (HHMT), dated January 2025, February 2025, and March 2025, the HHMT did not indicate an adherence rate or the actions taken to correct non-compliance. IP stated he did on-the-spot education but did not document it. IP stated he only collected data. IP did not provide tracking and trending reports, analysis of surveillance, or actions taken to correct non-compliance.

During a review of the facility's P&P titled, Monitoring Compliance with Infection Control, dated 8/2019, the P&P indicated, Policy Statement: Routine monitoring and surveillance of the workplace are conducted to determine compliance with infection prevention and control policies and practices. 6. The infection preventionist and/or the IPC committee provides reports to the QAPI [Quality Assurance and Performance Improvement] committee that reflect: all infection surveillance data.

2. During a concurrent observation and interview on 3/3/25 at 10:32 a.m. in Resident 6's room, Resident 6 had a dressing to right leg. Resident 6 state she had an ulcer (open sore) to right side of her heel.

During a review of Resident 6's MDS dated [DATE REDACTED], the MDS indicated Resident 6 had a BIMS score of 15.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 34 555877 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555877 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ridgecrest Regional Transitional Care and Rehabili 1081 North China Lake Boulevard Ridgecrest, CA 93555

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)

F 0882 During an observation on 3/3/25 at 10:55 a.m. outside Resident 6's room, no EBP signage or PPE supplies were observed in Resident 6's room or outside the room. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 6's Active Orders Report (AOR), dated 3/5/25, the AOR indicated:

Residents Affected - Few 1.Venous wound to the Right/Left heel Cleanse venous wounds on the Right and Left heel with wound spray, pat dry, apply Xeroform [treats wounds], then apply non-adherent pad, wrap with Kerlix [gauze] .

2.Right Lower Extremity Open Wound Cleanse with wound spray, pat dry, apply adaptic, apply non-adhesive pad, wrap with kerlix .Non-pressure chronic ulcer [an open sore] of right calf with fat layer exposed.

During a concurrent observation and interview on 3/3/25 at 10:39 a.m. in Resident 34's room, Resident 34 had swelling to bilateral legs with a dressing to her right leg. Resident 34 stated she had cellulitis (a skin infection that causes swelling and redness) to both of her legs.

During a review of Resident 34's MDS dated [DATE REDACTED], the MDS indicated Resident 34 had a BIMS score of 15.

During an observation on 3/3/25 at 10:55 a.m. outside Resident 34's room, no EBP signage or PPE supplies were observed in Resident 34's room or outside the room.

During a review of Resident 6's AOR dated 3/6/25, the AOR indicated, Cellulitis (bacterial infection of the skin) of right lower limb, Cellulitis of left lower limb.

During an observation on 3/3/25 at 2:21 p.m. in Resident 11's room, Resident 11 was sitting in her wheelchair with Foley catheter (a hollow tube inserted into the bladder to drain or collect urine) bag in a private bag behind wheelchair. No EBP signage or PPE supplies were observed in Resident 11's room or outside the room.

During a review of Resident 11's Physician's Telephone Order, (PTO) dated 3/5/25, the PTO indicated, FOLEY CATHETER .Retention of urine.

During an interview on 3/5/25 at 10:05 a.m. with IP, IP stated EBP ws not really implemented in the facility, and he did not know what the criteria was to place residents on EBP. IP stated he did not know what type of PPE was used for EBP.

During an interview on 3/5/25 at 10:41 a.m. with Licensed Vocational Nurse (LVN) 13, LVN 13 stated this was the first time hearing about EBP.

During an interview on 3/5/25 at 10:47 a.m. with Certified Nursing Assistant (CNA) 9, CNA 9 stated she did not know what EBP was.

During an interview on 3/5/25 at 10:52 a.m. with Assistant Director of Nursing (ADON) , ADON stated she did not know much about EBP.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 34 555877 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555877 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ridgecrest Regional Transitional Care and Rehabili 1081 North China Lake Boulevard Ridgecrest, CA 93555

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)

F 0882 During an interview on 3/5/25 at 11:54 a.m. with Director of Staff Development (DSD), DSD stated, I haven't heard much about Evidence Based Precaution. Level of Harm - Minimal harm or potential for actual harm During an interview on 3/5/25 at 12:35 p.m. with Director of Nursing (DON), DON stated she went to an infection prevention conference, but was not sure when EBP or the AFL (All Facilities Letter) was rolled out. Residents Affected - Few

During a review of the California Department of Health's AFL, (CDPHAFL) dated 6/13/24, the CDPHAFL indicated, On March 20, 2024, CMS [Centers for Medicare & Medicaid Services] distributed CMS QSO-24-089 NH (PDF), which updated its infection prevention and control guidance for long-term care facilities to include the CDC [Centers for Disease Control and Prevention] guidance for EBP.

During a review of the facility's P&P titled, Enhance Barrier Precaution, dated 12/2024, the P&P indicated, 2. Enhance barrier precautions apply when: a. A resident is infected or colonized with a CDC-targeted MDRO . b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices .5. Indwelling medical devices include .urinary catheters, feeding tubes .7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities. 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering, c. providing hygiene or grooming; d. changing briefs or assisting with toileting; e. transferring; f. providing bed mobility; g. changing linens; h. prolonged, high-contact with items in

the resident's room, with resident's equipment, or with resident's clothing or skin .10. Residents on EBPs may come out of their rooms and participate in group activities and dining with other residents .16. Staff are trained prior to caring for residents on EBPs. 17. Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required. 18. Personal protective equipment .are readily accessible to staff.

During a review of the facility's CRITERIA-BASED JOB DESCRIPTION INFECTION PREVENTIONIST, (CBJDIP) dated 10/8/20, the CBJDIP indicated, This individual is accountable for decreasing the incidence and transmission of infectious diseases between patients, staff, visitors and the community. Through strategic planning, leadership and consultation, the individual will be the lead in the identification and implementation of infection prevention goals and objectives throughout the facility.

During a review of the facility's P&P titled, Infection Prevention and Control Program, dated 10/2018, the P&P indicated, 3. The infection prevention and control programs a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 4.

The elements of the infection program is coordination/oversight .surveillance, data analysis .5a. The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist). 7b .monitoring adherence to infection prevention and control practices. 9a. Data gathered

during surveillance is used to oversee infections and spot trends. 11a. (3) educating staff and ensuring that

they adhere to proper techniques and procedures .(8) following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 34 555877 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555877 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ridgecrest Regional Transitional Care and Rehabili 1081 North China Lake Boulevard Ridgecrest, CA 93555

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)

F 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 27157 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure essential equipment was Residents Affected - Many maintained in safe operating condition when:

1. A food preparation sink located in the kitchen had an air gap and floor sink drain in accordance with the Food and Drug Administration Food Code (FDAFC), dated 2022. Facility failure to ensure proper plumbing installation may result in potential health hazards such as cross connections, back siphonage or backflow.

These conditions may result in the contamination of food, utensils, equipment, or other food-contact surfaces. (FDAFC, 5-402.11, 2022)

2. Two of two ice-machines located near two different nursing stations had an air gap per the ice-machine's manufacturer's guidelines (MG) and FDAFC, dated 2022. In addition, the ice-machine located near 300 hall nursing station was not stored in a manner that eliminates harborage of pests when there was opened holes/crevices between the baseboard and wall, peeling paint coming off the wall, and the floor was not clean with cracked tiles.

Findings:

1. During an observation on 03/04/25 at 12:02 p.m. in the kitchen, a pipe was observed directly plumbed into

the wall with the other end of the white colored plastic pipe coming out of the wall and connecting to a long thin pipe running underneath, and along the length of, a food preparation counter with the outlet of the pipe extending over a above-ground floor drain in which the water trap was filled with water.

During an interview on 03/06/25 at 09:46 a.m. with Maintenance Supervisor (MS), MS stated the outlet for

the hose connected to the coffee maker was draining into the above-floor drain which caused coffee grounds to accumulate in the drain which was why the drain had standing water. MS stated the pipe under the food prep sink was plumbed into the wall into the water system and the white colored pipe under the food prep sink was a P trap and that was why there was no outlet with an air gap nor a floor sink drain for the food prep sink. MS stated he was unaware of the requirement for a food prep sink to have an air gap per the FDA Food Code 2022.

During a review of an e-mail communication on 03/07/25 at 6:29 a.m. with Compliance Officer (CO) from Department of Health Care Access and Information Office of Statewide Hospital Planning and Development (HCAI), after CO observed a picture of the plumbing structure located underneath the food preparation sink

in the kitchen, the CO's e-mail indicated, The [food] prep sink is a problem, this sink is required to be discharged to a floor sink with copper DWV (Drain, Waste, and Vent) piping per the local health department requirements.

During a review of California Health and Safety Code (HSC) Section 114193, dated 2024, the HSC indicated, All steam tables, ice machines and bins, food preparation sinks, warewashing sinks, display cases, walk-in refrigeration units, and other similar equipment that discharge liquid waste shall be drained by means of indirect waste pipes, and all wastes drained by them shall discharge through an airgap into a floor sink or other approved type of receptor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 34 555877 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555877 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ridgecrest Regional Transitional Care and Rehabili 1081 North China Lake Boulevard Ridgecrest, CA 93555

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)

F 0908 During a review of the FDAFC, dated 2022, the FDAFC indicated, An air gap between the water supply inlet and the flood level rim of the plumbing fixture [such as a food preparation sink], equipment, or nonfood Level of Harm - Minimal harm or equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm potential for actual harm [millimeters] (1 inch).

Residents Affected - Many (FDAFC; 5-202.13 Backflow Prevention, Air Gap).

During a review of the FDAFC, dated 2022, the FDAFC indicated, a direct connection may not exist between

the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.

During a review of an e-mail communication on 03/07/25 at 6:29 a.m. with Compliance Officer (CO) from HCAI, the e-mail indicated, The work at the prep sink will require a HCAI project record. The deficiencies.are beyond normal maintenance.

2. During a concurrent observation and interview on 03/06/25 at 10:46 a.m. with MS, an ice-machine near 200 hall nursing station was observed. MS stated the ice machine did not have a visible air gap nor a drain.

During a concurrent interview and record review on 03/06/25 at 10:55 a.m. with MS, MS provided ice-machine manufacturer's guidelines and stated the MGs were for the ice-machine located near 200 hall nursing station. The MGs indicated, Maintain the air gap required by local code between the end of the drain tubes and the building drain receptacle.

During a concurrent observation and interview on 03/06/25 at 11:33 a.m. with MS, an ice-machine near 300 hall nursing station was observed to have a pipe inserted into a white plastic pipe which did not allow for a 1 inch air gap of space that separates a water line from an ice machine drain.

During a review of an e-mail communication on 03/07/25 at 6:29 a.m. with Compliance Officer (CO) from HCAI, after CO observed a picture of the plumbing structure for the ice machine located near 300 hall nursing station, the e-mail indicated, The ice machine fixed air gap is installed wrong. The pipe should terminate as high as possible in the air gap. The pipe is inserted into the air gap where any blockage would contaminate the pipe. The drain piping should be copper with DWV fittings.

During an observation on 03/06/25 at 11:35 a.m. near 300 hall nursing station where the ice machine was located, the wall surrounding the ice machine above the baseboard had cracks and crevices due to the baseboard separating from the wall with extensive peeling paint coming off the wall. The floor was dirty with cracked tiles.

During a review of the FDAFC, dated 2022, the FDAFC indicated, Floors that are smooth.are required to ensure effective cleaning is possible.

During a review of the FDAFC, dated 2022, the FDAFC indicated, The presence of .dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food [ice is food]. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 34 555877 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555877 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ridgecrest Regional Transitional Care and Rehabili 1081 North China Lake Boulevard Ridgecrest, CA 93555

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)

F 0908 During a review of the FDAFC, dated 2022, the FDAFC indicated, shall be protected against the entry of

Level of Harm - Minimal harm or insects and rodents by: (1) Filling or closing holes and other gaps along floors, walls, and ceilings. potential for actual harm

During a review of the facility's policy and procedure (P&P) titled, Walls, Ceilings, And Light Fixtures (WCL), Residents Affected - Many dated 2023, the P&P indicated, 1.Walls and ceilings must be free of chipped and/or peeling paint. 2. It is important to repair peeling paint areas as soon as they appear.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 34 555877 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555877 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ridgecrest Regional Transitional Care and Rehabili 1081 North China Lake Boulevard Ridgecrest, CA 93555

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)

F 0945 Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Level of Harm - Minimal harm or potential for actual harm 45654

Residents Affected - Some Based on interview, and record review, the facility failed to follow its Policy and Procedure titled, Employee Training on Infection Control, for 11 of 25 sampled Licensed Vocational Nurses (LVN) (LVN 1, LVN 2, LVN 3, LVN 4, LVN 5, LVN 6, LVN 7, LVN 8, LVN 10, LVN 11, and LVN 12) and four of six sampled Registered Nurses (RN) (RN 1, RN 2, RN 4, and RN 5). This failure resulted in licensed nursing staff being unaware of standard infection prevention precautions, increasing the potential for the spread of infectious diseases to residents, staff, and visitors.

Findings:

During a concurrent interview and record review on 3/5/25 at 2:39 p.m. with Infection Preventionist (IP) the facility's education titled,Infection Prevention (IP), dated 6/18/24, 6/19/24, 1/24/24, and 1/25/24 was reviewed. The IP education indicated some of the topics that should have been covered during the training included: the six elements of Standard Precautions, the importance of hand hygiene, contact wet time of disinfectants, proper use of personal protective equipment, the difference between cleaning and disinfecting, and maintaining separation between clean and soiled devices to prevent the spread of infection. IP stated he did not remember what he trained staff on and did not provide training documents.

During an interview on 3/6/25 at 10:27 a.m.with Licensed Vocational Nurse, (LVN)3, LVN 3 stated he could not remember the last Infection Control training he attended.

During a review of the facility's policy and procedure (P&P) titled, Employee Training on Infection Control, dated January 2012, the P&P indicated all staff and personnel would complete orientation and training on preventing the transmission of healthcare associated infections.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 34 555877