Health inspection·April 25, 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 implement infection control standards of practice when staff did not put on a face shield prior to entering resident rooms when COVID-19 airborne transmission-based (precautions to help stop the spread of germs from one person to another) precautions were in place. Residents Affected - Few This failure had the potential for staff to contract COVID-19 infection and spread to other residents. Findings: During an observation on 4/25/23 at 10:08 A.M., room [ROOM NUMBER] had signs on the door. One sign indicated, Airborne Precaution (preventing infectious bacteria or viruses from being inhaled)/Contact Precaution (preventing the spread of infections by direct or indirect contact) . clean hands when entering and leaving room, doctors and staff must keep door closed, N95 MASK (mask that filters out particles in the air)/FACE SHIELD. CNA 1 and CNA 2 were outside room [ROOM NUMBER]. CNA 1 and CNA 2 used the hand sanitizer from the wall, put on gowns and gloves then entered room [ROOM NUMBER]. CNA 1 and CNA 2 had N-95 masks on but did not put on a face shield. On 4/25/23 at 10:15 A.M., CNA 1 and CNA 2 were observed outside room [ROOM NUMBER]. CNA 1 and CNA 2 put on gowns and gloves, then entered room [ROOM NUMBER]. room [ROOM NUMBER] had 2 signs on the door. One sign indicated, Airborne Precaution/Contact Precaution . clean hands when entering and leaving room, doctors and staff must keep door closed, N95 MASK/FACE SHIELD. CNA 1 and CNA 2 had N-95 masks on but did not put on a face shield prior to entering room [ROOM NUMBER]. On 4/25/23 at 10:36 A.M., an interview and concurrent review were conducted with CNA 1. Concurrent review of the sign in room [ROOM NUMBER] indicated, Airborne Precaution/Contact Precaution . clean hands when entering and leaving room, doctors and staff must keep door closed, N95 MASK/FACE SHIELD. C.N.A. 1 confirmed she did not wear a face shield prior to entering room [ROOM NUMBER]. CNA 1 stated she was not sure if the face shield should have been worn. An interview and concurrent review on 4/26/23 at 10:41 A.M. were conducted with CNA 2. The sign in door 2 was reviewed and it indicated, Airborne Precaution/Contact Precaution . clean hands when entering and leaving room, doctors and staff must keep door closed, N95 MASK/FACE SHIELD. CNA 2 stated she was supposed to wear face shield prior to entering room [ROOM NUMBER] according to the sign on the door. CNA 2 stated she did not wear a face shield. An interview on 4/25/23 at 1:50 P.M., with the Infection Preventionist (IP) was conducted. The IP Page 1 of 2 555158 555158 04/25/2023 El Centro Post-Acute Care 1700 S. Imperial Ave El Centro, CA 92243

F 0880 Level of Harm - Minimal harm or potential for actual harm stated residents who were positive for COVID-19 had a sign on their room door which indicated the proper use of Personal Protective Equipment (PPE-equipment worn to protect from injury or illness). The IP stated staff should wear gloves, gown, face shield and an N-95 mask prior to entering the room. The IP stated it was important for staff to wear a face shield in a room with positive COVID-19. The IP stated if the resident coughed, the droplet (tiny drop) from the resident with COVID-19 will enter staff's eyes. Residents Affected - Few During an interview on 4/25/23 at 3:20 P.M., with the Director of Nursing (DON), the DON stated all staff must ensure proper PPE such as N-95 mask, face shield, gown and gloves prior to entering a room with COVID-19 positive residents. The DON stated it was important to have PPE according to the signs on the doors to prevent the spread of COVID-19. A review of the facility's Policies and Procedures (P&P) dated September 2022 titled, Coronavirus Disease (COVID-19) - Using Personal Protective Equipment, was conducted. The P&P indicated, .4. When caring for a resident with suspected or confirmed SARS-CoV-2 (virus causing COVID-19 disease) infection .c. Eye Protection (i.e., goggles or a face shield that covers the front and sides of the face) is applied upon entry to the resident room or care area. 555158 Page 2 of 2