Health inspection·October 10, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff wore eye protection when they entered the room who was on droplet precaution for 1 (Resident #43) of 4 sampled residents reviewed for infection control. Residents Affected - Few Findings included: A facility policy titled, Infection Prevention and Control for Residents with Suspected or Confirmed SARS-COV-2 [severe acute respiratory syndrome coronavirus 2], with a copyright date of 2021, revealed Personal Protective Equipment 13. Staff who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection will adhere to standard precautions and use a NIOSH [National Institute for Occupational Safety and Health]-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e. [id est, that is], goggles or a face shield that covers the front and sides of the face). A Face Sheet indicated the facility admitted Resident #43 on 10/22/2019. According to the Face Sheet, the resident had a medical history that included diagnoses of epilepsy, type 2 diabetes mellitus, and dementia. A physician order dated 10/02/2024, indicated Resident #43 was on droplet precautions from 10/02/2024 to 10/15/2024 due to a diagnosis of coronavirus disease 2019 (COVID-19). During an observation on 10/07/2024 at 9:45 AM, the surveyor noted a sign outside Resident #43's room that indicated droplet precautions were to be taken prior to entry. The signage indicated that before anyone entered the room, they should ensure their eyes, nose, and mouth were fully covered. During an observation on 10/07/2024 at 9:48 AM, Licensed Vocational Nurse (LVN) #3 entered Resident #43's room and did not wear a face shield. In an interview on 10/07/2024 at 10:20 AM, LVN #3 stated when residents were COVID-19 positive staff should wear a gown, N95 mask, face shield, and gloves. LVN #3 acknowledged she did not wear a face shield. During an observation on 10/07/2024 at 9:52 AM, Certified Nurse Aide (CNA) #2 entered Resident #43's room and did not wear a face shield. In an interview on 10/07/2024 at 10:09 AM, CNA #2 stated she was required to wear a gown, gloves, N95 mask, or a face shield before she entered Resident #43's room. CNA #2 read the signage on the resident's door and stated she should have had a face shield on prior to entering the resident's room. (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 2 Event ID: 055079 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 055079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission View Health Center 1425 Woodside Drive San Luis Obispo, CA 93401 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)