Health inspection·November 14, 2024

F 0880 Level of Harm - Immediate jeopardy to resident health or safety - On November 12, 2024, a list of employees not fit tested was posted on the timeclock to ensure that they could not clock in unless the fit testing is completed; - On November 12, 2024, the administrator, the DON, and the MDS (Minimum Data Set - a resident assessment tool) nurse contacted all employees not fit tested , and instructed them to complete their N95 Fit testing; Residents Affected - Some - On November 12 and 13, 2024, the administrator and DON conducted in-services regarding N95 Fit Testing guidelines; - On November 13, 2024, two other IPs reported to the facility to assist the facility in N95 fit testing of affected employees. - The facility added N95 Fit Testing to the annual in-service calendar to ensure that all employees will complete their annual fit tests every January. - The facility will conduct follow up in-service for N95 Fit Testing monthly for 3 months, - The administrator and the DON will check 5 (five) randomly selected employee files each week for 3 months, followed by quarterly and as needed to ensure all employee were fit tested. On November 14, 2024, at 4:53 p.m., the Immediate Jeopardy was removed in the presence of the ADMIN, the DON, and the Director of Staff Development (DSD), upon onsite verification of the implementation of the plan of actions. Findings: On November 12, 2024, at 9:43 a.m., an unannounced visit to the facility was initiated to investigate a report of a facility reported incident regarding COVID-19 outbreak. A review of the LTC [long term care] Respiratory Surveillance Line List, [provides a template for data collection and active monitoring of both residents and staff during a suspected respiratory illness cluster or outbreak at a nursing home or other LTC facility] dated November 1, 2024 through November 11, 2024, indicated 12 staff tested positive for COVID-19. A review of the LTC Respiratory Surveillance Line List dated November 1 to 11, 2024, indicated 32 residents tested positive for COVID-19. On November 12, 2024, at 10:16 a.m., an interview was conducted with the Infection Preventionist, (IP). The IP stated the staff were fit tested for the N-95 respirator mask upon hire, annually thereafter, and when new N95 model supply was to be used. On November 12, 2024, at 11:48 a.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated all staff were required to wear N95 respirator mask while inside the facility. RN 1 stated she was fit tested with the use of the N95 mask when COVID-19 started back in 2020 and stated she had not been fit tested for awhile, maybe about four (4) years ago. On November 12, 2024, at 2:05 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated she was fit tested for the use of N95 mask a few months ago. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555135 If continuation sheet Page 2 of 4 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 555135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Springs Care Center 1441 Michigan Avenue Beaumont, CA 92223 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)

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some On November 12, 2024, at 2:11 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she could not remember when she was last fit tested for the use of N95 mask. On November 12, 2024, at 3 p.m., the Respirator Fit Test Record was reviewed. The document indicated RN 1, LVN 1, and CNA 1 were not included in the list of direct care staff fit tested for the use of N95. Further review of the documents indicated five (5) out of eight (8) direct staff who worked AM shift (7 am to 3 pm) were not fit tested for the use of N95 mask. On November 12, 2024, at 3:12 p.m., a concurrent interview and record review was conducted with the IP. The IP confirmed the list of N95 fit testing provided was current. The IP stated the facility have 106 direct care staff. The list of direct care staff was reconciled with the N95 Respirator Fit Test Record dated November 7, 2023, to November 5, 2024, with the IP. The documents indicated there were 47 direct care staff who had no recorded annual fit testing for the use of the N95. On November 12, 2024, at 4:09 p.m., a concurrent interview and record review of the employee listing and Respirator Fit Test Record, was conducted with the Director of Nursing (DON). The DON confirmed there were 47 direct care staff who did not have a current N95 fit testing. On November 12, 2024, at 4:36 p.m., during an interview with the IP, she stated she had not prioritized N95 fit testing, as she was ensuring vaccinations and the COVID-19 outbreak were handled. On November 12, 2024, at 6:35 p.m., an interview was conducted with CNA 2. CNA 2 stated she could not recall when she was fit tested for the use of N95 mask. CNA 2 stated it could have been in 2020. On November 12, 2024, at 6:38 p.m., an interview was conducted with CNA 3. CNA 3 stated she was fit tested for her N-95 mask when COVID-19 started in the year 2020. A review of the N95 Respirator Fit Test Record, dated November 7, 2023, to November 5, 2024 indicated CNA 2 and CNA 3 did not have a current N95 fit testing. On November 12, 2024, at 6:45 p.m., an interview was conducted with the Administrator (ADM). The ADM stated the facility did not have a Respiratory Protection Program which included fit testing for the use of N95 mask among staff. The ADM stated N95 fit testing should have been conducted on the staff annually. The ADM stated she was unaware that there were about 47 direct care staff who were not fit tested in accordance with the facility's policy and procedure. A review of the undated facility ' s document titled, Respiratory Protection Program, indicated, .The purpose of this Respiratory Protection Program (RPP) is to maximize the protection afforded by respirators when they must be used . The most common potential exposure for employees involved in patient care will be ATDs [aerosol transmittable diseases - are transmitted through the air in droplets from coughs and sneezes, or through direct contact with mucous membranes in the eyes or respiratory tract] such as tuberculosis or pandemic influenza .Before an employee is required to use any respirator with a tight-fitting facepiece .she/he will be fit tested with the same make, model, style, and size of respirator to be used All employees who must wear respiratory protection shall receive medical clearance before fit testing is performed. Fit tests will be provided at the time of initial assignment and annually thereafter . A review of the web article published by the CDC titled, Proper N95 Respirator Use for Respiratory Protection Preparedness, dated March 16, 2020, indicated, .OSHA (Occupational Safety and Health (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555135 If continuation sheet Page 3 of 4 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 555135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Springs Care Center 1441 Michigan Avenue Beaumont, CA 92223 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)

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Administration) requires healthcare workers who are expected to perform patient activities with those suspected or confirmed with COVID-19 to wear respiratory protection, such as an N95 respirator .Fit testing is a critical component to a respiraotry protection program whenever workers use tight-fitting respirators. OSHA requires an initial respirator fit test to identify the right model, style, and size respirator for each worker. Annual fit tests ensure that users continue to receive the expected level of protection. A fit test confirms that a respirator correctly fits the user . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555135 If continuation sheet Page 4 of 4