Health inspection·August 22, 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 ensure the infection control policy and procedure for masking was followed when: Residents Affected - Few 1. Two Certified Nursing Assistants (CNA) used an N95 mask (a protective device used to achieve a very close facial fit and very efficient filtration of airborne particles) over a surgical mask (face mask); and 2. One CNA used an N95 mask while caring for a Covid 19 (a highly infections respiratory virus) positive resident without a fit test(specialized test to determine the proper fit of a specific N95 for an individual). These failures had the potential to increase staff and resident exposure and transmission of the Covid 19 virus resulting in illness. Findings: 1. During a concurrent observation and interview on August 22, 2024, at 3:05 p.m., CNA 1, was observed wearing an N95 mask over a surgical mask. CNA 1 stated she would lower the N95 mask when was not inside the isolation room and use the surgical mask and vice versa. CNA 1 stated she would lower the surgical mask when she was inside the isolation room. CNA 1 stated she should have not worn the N95 mask over the surgical mask. 2. During an observation on August 22, 2024, at 3:20 p.m., CNA 2 was observed inside the room of a Covid positive resident. CNA 2 was wearing an N95 mask over a surgical mask and did not have an isolation gown on. CNA 2 was talking to the resident. During an interview on August 22, 2024, at 3:33 p.m., with CNA 2, CNA 2 stated he was not a regular staff at the facility. CNA stated he worked for an agency and was assigned to be a sitter (companion assigned to a resident requiring constant monitoring). He stated he was informed the resident had Covid and was given an N95 mask. CNA 2 did not have any knowledge of N95 mask fit testing. CNA 2 stated he was instructed to put on an N95 mask by a facility staff. CNA 2 stated he was not fit tested for the N95 mask by the agency or the facility. He stated he had the N95 mask over the surgical mask for better protection. During an interview on August 22, 2024, at 3:41 p.m., with the Director of Nursing (DON), the DON stated no staff should be double masking. The DON stated the staff should not wear an N95 mask over a surgical mask. The DON stated the surgical mask will create a gap and would break the seal on the face. The DON also stated the facility should have verified with the agency if the staff had been fit (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: 056485 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 056485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arlington Gardens Care Center 3688 Nye Avenue Riverside, CA 92505 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)