Health inspection·September 24, 2023

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 maintain infection control practices when A Certified Nursing Assistant (CNA 1) and A License Vocational Nurse (LVN 2) did not perform COVID-19 (a highly contagious illness caused by a virus) precautions upon entry into Covid positive room on September 19, 2023, in accordance with the facility's policy and procedure. Residents Affected - Few This failure increased the risk of the transmission of Covid 19 to a compromised resident (Resident 1). Findings: During a review of Resident 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include, urinary tract infection (urine infection), difficulty walking, chronic atrial fibrillation (irregular heart rate, poor blood flow), congested heart failure (heart cannot pump blood as well), (COVID-19 (a highly contagious illness caused by a virus). During an observation on September 19, 2023, at 10:43 AM, License Vocational Nurse 1 (LVN1), observed exiting Positive Covid-19 room [ROOM NUMBER] with surgical mask, gown, and gloves. Removes PPE gown and gloves, performs hand hygiene, then preps with new gown, gloves leaving surgical mask on and enters Positive Covid-19 room [ROOM NUMBER] with no N95 mask (filtering facepiece respirator), wearing surgical mask. During an observation on September 19, 2023, at 10:43 AM, Certified Nursing Assistant (CNA), CNA1 observed entering Positive Covid-19 room [ROOM NUMBER] with wearing a gown, gloves and surgical mask, Not wearing N95, only wearing surgical mask. During an interview on September 19, 2023, at 10:47 AM with LVN1, LVN1 stated, the procedure here in facility is full personal protective equipment (PPE) before entering the Positive Covid rooms and exiting. We remove gown and gloves, hand wash in sink in bathrooms and hand sanitize. I have not witnessed any staff coming in and out of the covid rooms not using PPEs. When asked, should you be wearing an N95 mask in Covid positive rooms? Yes, we should, I'm wearing a surgical mask because the N95 hurts my nose, the bridge of my nose. During an interview on September 19, 2023, at 12:26 PM with CNA1, CNA1 stated, Before going in covid positive rooms we gown, glove, mask .I'm supposed to be wearing an N95 mask and I had a surgical mask. On exiting the Covid room, we take off gloves and gown. Disposed and wash hands. I apologize, I should be wearing an N95 mask in Covid positive rooms, I agree I did not have on while entering the Page 1 of 2 055183 055183 09/24/2023 Heritage Gardens Health Care Center 25271 Barton Rd Loma Linda, CA 92354

F 0880 Covid positive room. Level of Harm - Minimal harm or potential for actual harm During an interview on September 19, 2023, at 12:10 PM with Director of Staff Development, DSD stated, when asked, what mask should the staff be wearing while in Covid-19 positive rooms? States, surgical mask while on the floor and N95 mask if they are going into the Covid Positive rooms. We have issue with PM shift, staff not wearing N95 mask just wearing surgical mask. They do pop in with their surgical mask to see what they need but then get the nurse, they don't go in to do care. Regarding my observation, DSD agreed staff should have been wearing a N95 mask while in Covid positive rooms. Residents Affected - Few During an interview on September 19, 2023, at 12:40 PM with Infection Preventionist Nurse (IP), IP states, we let staff know of our Covid-19 positive residents and the precaution signs are at doors. Before entering positive rooms, the staff is in full PPE they need an N95 mask. Regarding my observation, IP nurse agreed staff should have been wearing a N95 mask while in Covid positive rooms. During an interview on September 19, 2023, at 12:47 PM with the Administrator (ADM), (ADM) agreed after observation of CNA1 and LVN1 entering Covid-19 positive room without an N95 mask, states I can agree we are not following protocol and policy on infection control. The staff should have been wearing N95 mask while entering Covid positive rooms, we will address the issue. During a review of the facility's policy and procedure titled, Coronavirus Disease (COVID-19)-Infection Prevention and Control Measures revised April 2020, the policy and procedure indicated, This facility follows recommended standard and transmission-based precautions, environmental cleaning and social distancing practices to prevent the transmission of COVID-19 within the facility .12. For a resident with known or suspected COVID-19: a. Staff wear gloves, isolation gown, eye protection and an N95 or higher-level respirator if available .13. A staff wear all recommended PPE, gloves, gown, eye protection and respirator for the care of all residents on the unit .regardless of symptoms . 055183 Page 2 of 2