Health inspection·April 9, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to implement their infection control program when two staff members did not wear proper full personal protective equipment (PPE- consisted of gown, gloves, N-95 [highly particulate-filtering facepiece] mask, and face shield/goggles) while providing care to residents who were tested with COVID-19 (highly infectious disease), and one staff member failed to properly discard used N95 mask. Residents Affected - Few These failures had the potential for contamination of supplies and spread of infection among staff and residents. Findings: On 4/4/24, the Department received a facility reported incident related to infection control. On 4/9/24, an unannounced onsite to the facility was conducted. During an observation on 4/9/24 at 9:26 A.M. in the east hall was conducted. There was a poster on the wall indicated, all staff should be wearing full PPE: gown, gloves, N-95 mask, a face shield or goggles while inside the residents' rooms. Outside the residents' room, there were PPE carts (cart which contained the PPE supplies for the staff to wear before entering a resident's room). Two Certified Nursing Assistants (CNA) 1 and 2 were inside a COVID positive residents' room. CNA 1 opened the door, held a plastic bag with used clothing/ linens and placed them in a barrel. CNA 1 and CNA 2 were not wearing face shield/ goggles. During an observation on 4/9/24 at 9:40 A.M., CNA 1 entered another COVID positive resident's room. CNA 1, prior to entering, changed her N95 mask and placed the used mask on top of the PPE cart. CNA 1 then went into the residents' room without face shield/ goggles. During an interview on 4/9/24 at 9:43 A.M. with CNA 1, CNA 1 stated she and CNA 2 provided care to the COVID positive residents in the east hall. CNA 1 stated she and CNA 2 changed the resident's incontinence brief and emptied his urinal. CNA 1 stated she and CNA 2 did not wear face shield/ goggles while providing care to the resident. During an interview on 4/9/24 at 10:12 A.M. with CNA 2, CNA 2 stated she and CNA 1 were designated to provide care to the COVID positive residents in the east hall. CNA 2 stated the PPEs used during provision of care to residents who were tested positive with COVID included face shield, N95 mask, gown and gloves, CNA 2 stated she and CNA 1 did not wear face shield/ goggles while providing care to the resident. CNA 2 stated she forgot to wear the face shield because there was no available face shield in the PPE cart. CNA 2 stated it was important to wear face shield to protect their eyes from Page 1 of 2 055114 055114 04/09/2024 Arbor Hills Nursing Center 7800 Parkway Drive LA Mesa, CA 91942

F 0880 splashes while providing resident care. Level of Harm - Minimal harm or potential for actual harm During a joint observation and an interview on 4/9/24 at 9:50 A.M. with Licensed Nurse (LN) 1, LN 1 stated the expectation was for the staff to discard the used N95 mask properly to prevent contamination of clean supplies. LN 1 stated the staff were also expected to wear full PPE while providing care to residents with COVID for their protection and the residents to prevent spread of infection. Residents Affected - Few 055114 Page 2 of 2