Health inspection·December 12, 2023

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 interventions to prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person) in accordance with the facility's policy and procedures (P&P) titled, Policy Respiratory Protection Program and the Department of Public Health (DPH) guidelines by failing to: Residents Affected - Few Conduct an N95 mask or respirator (a respiratory protective device designed to achieve a very close facial fit and efficient filtration of airborne particles) fit testing (a test to evaluate the fit and determine how effectively a mask or respirator will protect the wearer) upon hire for one of three sampled staff (Certified Nursing Assistant 1) during a COVID-19 outbreak. This deficient practice had the potential to result in the spread of COVID-19 to other residents and staff in the facility. Findings: During a concurrent observation and interview on 12/12/23 at 10:07 AM with CNA 1, CNA 1 was observed wearing a BYD DE2322 model N95 mask. CNA 1 stated, she had been working in the facility for three weeks and had not received a fit tested N95 mask. CNA 1 stated, the facility provided her with BYD DE2322 model N95 mask to wear but was not fit tested for it. CNA 1 stated, she did not know that she must be fit tested for N95 mask. During a concurrent interview and record review on 12/12/23 at 1:50 PM with the Infection Prevention Nurse 1 (IPN 1), the facility's document titled, N95 Respiratory Fit Test Record, for the month of November and December of 2023 was reviewed. IPN 1 stated, the N95 Respiratory Fit Test Record did not indicate CNA 1 was fit tested for N95 upon hire. IPN 1 stated, there was a COVID-19 outbreak in the facility that started on 11/24/23. IPN 1 stated, the staff must be fit tested for N95 upon hire and annually. IPN 1 stated, the Director of Staff Development (DSD) usually conducted the N95 fit testing, but the DSD missed and did not conduct the N95 fit testing for CNA 1. IPN 1 stated, the facility just conducted CNA 1's N95 fit testing on 12/12/23. IPN 1 stated, it was important for staff to wear fitted N95 mask to prevent the spread of airborne particles which can lead to infection and possible death. During a review of the facility's P&P titled, Policy Respiratory Protection Program, (undated), the P&P indicated fit tests will be provided at the time of initial assignment and annually thereafter. The P&P indicated annual respirator training will be provided for all employees covered by the program. The training will be conducted by the designated trained trainer and will include general requirements of the California Division of Occupational Safety and Health (Cal-OSHA) Respiratory (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: 056477 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 056477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Subacute and Rehabilitation Center 3825 Durfee Ave El Monte, CA 91732 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)