Health inspection·August 7, 2024

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, and record review, the facility failed to ensure staff did not use expired N95 Masks during (an infectious disease caused by the SARS-CoV-2 virus) outbreak in the facility. Residents Affected - Few This failure placed the residents/staff/visitors at increased risk of contracting and spreading covid-19. Findings: During an interview, on [DATE] at 2:25 p.m., the Central Services Director (CSD) stated the facility had adequate Personal Protective Equipment (PPE - face masks, gowns, eye protectors, and gloves used to minimize exposure and help prevent the spread of contagious diseases), to supply all staff members during an outbreak of Covid 19) and for all emergencies when necessary. The CSD stated that she orders supplies on a weekly basis. However, the CSD stated that she did not have any invoice receipts to show that N95 masks were purchased in the past, or currently on order. The CSD stated she has not ordered any new N95 masks since the start of Covid 19 pandemic (A disease that has spread across multiple countries and continents and usually impacts many people), in 2020 because the face masks last for at least five years. The CSD stated she received an email note indicating that the face masks currently in the facility can be used past the expiration date. The CSD stated she decided not to purchase any new face masks because they (facility) did not need them since they already had the ones currently on hand. During observation on [DATE] at 2:35 p.m., of the facilities storage area where all personal protective equipment (PPE) emergency supplies are stored. There was one opened box of N95 respirator masks containing several smaller boxes of N95 masks. The label on NIOSH Foldable N95 Particulate Respirator. Lot 6200807 Production dated [DATE], had an Expiration Date of [DATE]. On further inspection and observation, the BYD N95 masks contained in the smaller boxes were labeled individually as expired. There were no other N95 masks in use within the facility. During an interview, on [DATE] at 8:45 a.m., Infection Preventionist (IP) stated that the Central Supply Director assured the IP that the facility adequate PPE and N95 masks for staff. The IP stated that she was aware that the masks had expired, and that she had received a letter from the manufacturer indicating that the masks can be used for up to five years past the manufacture date. The IP stated the danger of using expired face masks had the potential for direct exposure to the Covid-19 virus while caring for a Covid-19 positive resident. The IP stated that she was not aware of any supply chain problems, or financial problems that the facility was having, that may have cause a shortage of masks, or prompted the need to continue using expired masks. (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: 055136 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 055136 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404 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)