Carmel Mountain Rehabilitation & Healthcare Center

F-F584

Findings:

On 4/24/25 at 2:18 P.M., a concurrent interview with the Administrators (ADM 1 and ADM 2), the Director of Nursing (DON) and a review of QAPI program was conducted. The ADMs stated that the main areas that the QAPI team were monitoring were falls, pressure ulcer reduction, weights and urinary tract infection prevention.

During the recertification survey, deficient trends in call light response and the lack of homelike environment were identified. The DON stated that call light response was an ongoing project, but when asked about the root cause of the call light issues, the facility was unable to identify one. The DON stated identifying the root cause of the call light issues was challenging. The DON stated it was important to work towards a reduction

in complaints related to call light response.

Regarding the lack of homelike environment, ADM 1 stated there had been a budget approved for residents' room improvements, but this had not been included in the QAA Committee and/or included in the QAPI plan.

Review of the facility policy titled Quality Assurance and Performance Improvement dated January 2025 indicated .The purpose of the QAPI Plan and processes is to continually assess the facility's performance in all service areas, so that concerns and processes achieve the delivery of person-centered care, and which maximizes the individual's highest physical, mental, and social well-being .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 30 555326 Department of Health & Human Services Printed: 08/28/2025 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 555326 B. Wing 04/24/2025

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

Carmel Mountain Rehabilitation & Healthcare Center 11895 Avenue of Industry San Diego, CA 92128

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49330 potential for actual harm Based on observation, interview, and record review, the facility did not follow infection control practices when: Residents Affected - Some 1) Staff did not don (put on) and doff (remove) Personal Protective Equipment (PPE- gown, gloves, mask) or perform hand hygiene when providing care to a resident on Enhanced Barrier Precautions (EBP, use of PPE when providing high contact resident care to reduce the spread of bacteria), and,

2) Two ice scoops were not stored in a sanitary manner.

As a result, there was the potential for cross contamination, affecting the health of residents.

Findings:

1a. According to the Admission Record, Resident 316 was admitted on [DATE REDACTED] with diagnoses which included fractures (broken bones) of the vertebra (spinal column), and muscle weakness.

During an observation on 4/21/25 at 7:54 A.M., a sign was observed outside Resident 316's room which indicated EBP. A blue sticker was observed next to Resident 316's name, outside the room. A container filled with PPE was observed outside the room.

On 4/21/25 at 7:54 A.M., Certified Nursing Assistants (CNA) 31 and 32 were observed entering Resident 316's room without performing hand hygiene, and without donning PPE. CNA 31 and CNA 32 were observed donning gloves inside the room, then pulled Resident 316's curtain.

On 4/21/25 at 8 A.M., during a concurrent observation and interview in the hallway outside Resident 316's room, CNA 31 opened Resident 316's curtain, removed her gloves, and walked out of Resident 316's room without performing hand hygiene. CNA 31 stated the blue sticker next to Resident 316's name indicated Resident 316 was on EBP precautions, and PPE needed to be donned prior to providing high contact activities. CNA 31 stated she forgot to perform hand hygiene before and after entering the room, and don PPE prior to entering the room. CNA 31 stated, .we are supposed to gown up .whether its for [brief] changes, transferring them, toileting, repositioning. We lifted her up in bed. We should have gowned up .

On 4/21/25 at 8:05 A.M., a concurrent interview and record review was conducted with CNA 32. CNA 32 stated the EBP sign posted outside Resident 316's room indicated PPE was required for high contact care, such as mobility assistance. CNA 32 stated she should have done hand hygiene before putting gloves on, and after removal. CNA 32 further stated she should have followed the guidance posted on the EBP sign. CNA 32 stated, I honestly just forgot to [don PPE] .I just had tunnel vision and went inside [Resident 316's room]. It always says up there [on the EBP sign posted] what you have to wear .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 30 555326 Department of Health & Human Services Printed: 08/28/2025 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 555326 B. Wing 04/24/2025

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

Carmel Mountain Rehabilitation & Healthcare Center 11895 Avenue of Industry San Diego, CA 92128

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 0880 On 4/24/25 at 12:32 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated,

The staff need to adhere to practicing proper hand hygiene .they need to adhere to Enhanced Barrier Level of Harm - Minimal harm or Precautions. If they need to gown up, they are expected to gown up prior to entering the room .for prevention potential for actual harm of contamination and to practice infection control for the safety of the residents and staff .

Residents Affected - Some A review of the Policy and Procedure titled, Handwashing/Hand Hygiene, dated 2021, indicated, .The facility considers hand hygiene as the primary means to prevent the spread of health care associated infections .All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infection to .residents use an alcohol-based hand rub .or, alternatively, soap .and water for the following situations: b. Before and after direct contact with residents; d. Before performing any non-surgical invasive procedures .r. After removing and disposing of personal protective equipment .

1b. On 4/21/25 at 9 A.M., the Certified Phlebotomy Technician (CPT, person who draws blood) was observed drawing blood in a resident room identified as EBP precautions required. The CPT was observed wearing gloves and a surgical mask, but not a gown. A plastic container with laboratory supplies was placed directly on the resident's bed.

On 4/21/25 at 9:07 A.M., the CPT was observed walking out of the resident's room with gloves on, holding

the plastic container. The CPT placed the plastic container on top of the cart without disinfecting.

On 4/21/25 at 9:29 A.M., an interview was conducted with the CPT. The CPT stated the resident was on EBP. The CPT stated, .I'm only drawing her blood, so I only have to wear a glove and mask .I don't know exactly what she has. The CPT stated drawing blood was not one of the high contact activities listed on the EBP signage posted outside the resident's door.

On 4/23/25 at 3:35 P.M., an interview was conducted with the Infection Preventionist (IP). The IP stated it was important for staff to perform hand hygiene before and after using gloves, and to don and doff PPE when providing high contact activities to a resident in an EBP room. The IP stated the high contact activities listed on the EBP signage was not all-inclusive. The IP stated drawing blood was considered a high contact activity, and it was her expectation that staff put on a gown and gloves, .to avoid coming into contact with bodily fluids .it is important to don and doff PPE in an EBP room and to do hand hygiene to avoid cross contamination . The IP stated items that were placed on the resident's bed should have been sanitized prior to placing on the phlebotomy cart because it could have contaminated other items on the cart.

A review of the undated facility Policy and Procedure titled, IPCD Standard and Transmission-Based Precautions indicated, EBP expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities .

39220

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 30 555326 Department of Health & Human Services Printed: 08/28/2025 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 555326 B. Wing 04/24/2025

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

Carmel Mountain Rehabilitation & Healthcare Center 11895 Avenue of Industry San Diego, CA 92128

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 0880 2. An observation was conducted of Station 2's ice/water station on 4/21/25 at 3:54 P.M. The ice/water station contained three shelves with an ice chest and water cooler on the second shelf. The metal ice scoop Level of Harm - Minimal harm or was on the top shelf, resting inside a square metal container. The metal container was not covered, and it potential for actual harm had no drainage for accumulated water. The metal scoop container was observed with an estimated one to three tablespoons of water on the bottom of the container with the metal scoop in direct contact with the Residents Affected - Some water.

An observation was conducted of Station 1's ice/water station on 4/22/25 at 7:50 A.M. The ice/water station contained three shelves with an ice chest and water cooler on the second shelf. The metal ice scoop was on

the bottom shelf resting in a square metal container. The metal container was not covered, and it had no drainage for accumulated water. The metal scoop container had an estimated one to three tablespoons of water at the bottom of the container with the metal scoop in direct contact with the water.

An observation and interview was conducted with the Tx LN of Station 1's ice/water station on 4/23/25 at 10:21 A.M. The Tx LN viewed the metal scoop container on the bottom shelf and stated there was about a half inch of water in the metal container. The Tx LN stated the scoop should be considered contaminated because it was not covered, and it was resting in stagnate water. The Tx LN stated if the ice scoop was used to get ice from the ice chest, it could contaminate all the ice, potentially resulting in resident's getting sick.

An observation and interview was conducted with the Registered Dietitian (RD) on 4/23/25 at 10:23 A.M., of Station 1's ice/water station. The RD viewed the metal ice scoop resting inside the metal container with approximate a half inch of water. The RD stated the ice scoops should be covered, and the container should have drainage, to prevent cross contamination.

An observation was conducted on of Station 2's ice/water station on 4/23/25 at 11 A.M. The RD replaced the ice scoop holder with a clear plastic container with a lid, but no drainage device was added.

A follow up observation was conducted of Station 2's ice/water station on 4/24/25 at 8:45 A.M. On the top shelf was an uncovered square metal container, which contained a metal scoop. Scant water was inside the bottom of the metal container.

A follow up observation and interview was conducted with the RD of Station 2's ice/water station on 4/24/25 at 9:10 A.M. The RD stated she will have the kitchen staff correct it immediately, and get a closed container for the ice scoop.

An interview was conducted with the Director of Nursing (DON) on 4/24/25 at 9:11 A.M. The DON stated she expected ice scoops to be covered when not in use and to have drainage, in order to prevent cross contamination.

According to the facility's policy titled Infection control, undated, .1. Standard Precautions are infection prevention practices that apply to the care of all residents .e. Environmental cleaning and disinfection .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 30 555326