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. Page 1 of 2 055136 055136 08/07/2024 Berkley West Healthcare Center 1623 Arizona Avenue Santa Monica, CA 90404

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on [DATE] at 11:50 a.m., Director of Nursing (DON) stated, the IP and the Central Supply Director had assured her that the facility had adequate PPE. The DON stated there was a memo from the manufacturer of N95 model DE2322 Foldable Particulate Respirator indicating that the facility could use the masks past the expiration date. The DON stated using expired face mask could fail while in use and that expired fac mask may be ineffective PPE. The DON stated there was no difficulty with purchasing N95 masks. The DON stated that due to the letter, there was no need to purchase any new masks. A review of letter provided to facility entitled Particulate Respirator DE2322 Foldable Single-Use Model: DE2322, indicated, . Warnings 7. DO NOT use masks if they expired. A review of the facility's policy and procedures titled Donning and Doffing of Personal Protective Equipment (PPE) revised on 1/2024, indicated, PPE Requirements: 1. Staff need to wear eye protection (face shield. Goggles), N95 respirator, gown and gloves when caring for symptomatic or confirmed COVID-19 positive residents in isolation. Full PPE will be removed and discarded after each patient encounter. 2. Surgical masks or N95s will not be used beyond their expiration date. 055136 Page 2 of 2