Health inspection·February 1, 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, and record review, the facility failed to implement its infection control and prevention practices during a COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) outbreak when: Residents Affected - Few 1. The Licensed Nurse 1 (LN1) did not wash hands before wearing gloves and before entering the room of four residents, Resident 1 (R1), Resident 2 (R2), Resident 3 (R3) and Resident 4 (R4), who were on transmission-based precautions (TBP - used in addition to standard precautions for patients who are known or suspected infections with pathogens that can be transported by airborne, droplet, or contact routes). 2. The LN1 did not remove the surgical mask and put on an N95 respirator (a respiratory protective device designed to protect against particulate matter such as dust, fumes, mists, aerosols, and smoke particulates) and face shield (to protect eyes, nose, mouth and face from flying objects and liquids) before entering the room of four residents, R1, R2, R3, and R4, who were on TBP. 3. The door of the room of four residents, R1, R2, R3, and R4 was left wide open who were on TBP. This failure of the facility had the potential for the spread of infection that can jeopardize the health of residents, staff, and visitors. Findings: During an observation on 2/1/24 at 10:09AM in the hallway, LN1 did not wash hands and wear proper Personal Protective Equipment (PPE- protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission), merely donning (simply putting on) gloves, and a gown instead of N95 respirator and face shield before entering the room of four residents, R1, R2, R3, and R4 who were on TBP. During an observation on 2/1/24 at 11:26AM in the hallway, the door of the room of four residents, R1, R2, R3, and R4 was left wide open who were on TBP. The TBP sign was posted at the side of the doorframe. The TBP sign titled, Enhanced Respiratory and Contact Precautions indicated, . Keep Door Closed at All Times . Page 1 of 3 055968 055968 02/01/2024 Golden Heights Healthcare 35 Escuela Drive Daly City, CA 94015

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation and interview on 2/1/24 at 11:37PM with LN1 in the hallway, LN1 washed his hands, put on gloves and a gown, kept wearing a black surgical mask, didn't put on the required N95 respirator and face shield, held a rectangular container with medications in it, and was trying to get into the room of four residents, R1, R2, R3, and R4, who were on TBP. A PPE supply set-up was observed outside the room. The door was open and had a sign posted on the wall beside the door frame indicating, Enhanced Respiratory and Contact Precautions indicated, . All Staff Must Wear: Gown, Respirator: N95 or higher level respirator, Eye protection: Goggles or face shield, Gloves . LN1 stated, I didn't wear an N95 respirator and an eye shield when trying to get inside this room, I forgot, and I should have. It is important to wear proper PPE to protect the residents since they are immunocompromised and to protect me and other residents that I might expose . It is important to wash hands before entering and when leaving the residents on isolation room to prevent the spread of infection. During an interview with the Director of Nursing (DON) on 2/1/24 at 2:10PM, the DON stated, It is important to follow and wear proper PPE to prevent the spread of infection. PPE should depend on the kind of isolation the resident is in, if it's on enhance respiratory and contact precaution, staff must wear, gown, N95, face shield and gloves, should wash hands before entering and leaving the room. During a review of the facility's census, dated 2/1/24, it was indicated that R1, R2, and R3 were being monitored for signs and symptoms to rule out COVID-19 due to an exposure from their roommate R4, who was on isolation for COVID-19 from 1/26/2024-2/5/2024. During a review of facility's policy and procedure titled, Isolation- Categories of Transmission- Based Precautions, revised January 2012, indicated, .Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others . Droplet Precaution: Resident Placement,1. Place the resident in the private room if possible. 2. When private room is not available, residents with the same infection with the same microorganisms but with no other infection maybe cohorted. 3. When private room is not available and cohorting is not achievable, use a curtain and maintain at least 3 feet of space between the infected resident and other residents and visitors . During a review of facility's policy and procedure titled, Infection Control Guidelines for All Nursing Procedures, revised August 2012, indicated, .Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection .Wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or potentially infectious materials . During a review of facility's policy and procedure titled, Hand Washing/Hand Hygiene, revised August 2015, indicated, .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: Before and after entering isolation precaution settings . During a review of the National Institute for Occupational Safety & Health (NIOSH), Donning and Doffing PPE: Proper Wearing, Removal, and Disposal, revised October 3, 2022, indicated, .Donning means to put on and use PPE properly to achieve the intended protection and minimize the risk of exposure. Doffing means removing PPE in a way that avoids self-contamination . Follow strict donning and doffing procedures, for highly infectious agents: Always wash hands with soap and water before wearing 055968 Page 2 of 3 055968 02/01/2024 Golden Heights Healthcare 35 Escuela Drive Daly City, CA 94015

F 0880 and after removal of PPE . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055968 Page 3 of 3