Health inspection·January 28, 2026

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 ensure staff were wearing the N95 Respirator (a tight fitting disposable mask that filters out at least 95% of airborne particles including virus') they were approved to wear during Fit Testing (testing that determines the exact make and model of the N95 mask to be worn) for two out of three staff.This failure had the potential for the spread of COVID-19 (A contagious virus spread through respirator droplets) to other residents and staff in the facility. Findings: On January 28, 2026, at 10:05 a.m., an observation of a sign at the facility entrance indicated, . (The facility) currently (has) Covid cases in the building .we ask that you wear a mask during your visit . On January 28, 2026, at 10:43 a.m., an interview was conducted with Registered Nurse (RN) 1 who stated, due to positive COVID-19 cases in the facility, staff are required to wear an N95 mask throughout their shift. The RN stated the facility fit tests to ensure staff wear the correct N95 mask that fits properly to help decrease the spread of COVID-19 to other residents or staff. On January 28, 2026, at 11:35 a.m., a concurrent interview with Certified Nursing Assistant (CNA) 1, and an observation of CNA 1's N95 mask was conducted. CNA 1 was observed wearing a solid white circular N95 mask. The CNA stated she is required to wear an N95 mask in the facility due to COVID-19 positive residents. CNA 1 further stated she was fit tested approximately six months ago, which indicated she is to wear the mask she is currently wearing (solid white circular N95 mask). A review of CNA 1's, Respirator Fit Test Record, dated, March 26, 2025, indicated, 3M N95 mask, signed by the Infection Preventionist (IP). On January 28, 2026, at 12:30 p.m., a concurrent interview with Licensed Vocational Nurse (LVN) 1 and an observation of LVN 1's N95 mask was conducted. LVN 1 was observed wearing a solid white circular N95 mask. LVN 1 stated she is required to wear a N95 mask in the facility due to COVID-19 positive residents. LVN 1 stated the facility fit tested her approximately one month prior, which indicated she is to wear the mask she is currently wearing (Solid white circular N95 mask). LVN 1 stated it is important to wear the correct N95 mask to prevent the spread of infection. A review of LVN 1's, Respirator Fit Test Record, dated, November 24, 2025, indicated the results of a Medline N95 mask, signed by the IP. On January 28, 2026, at 4:20 p.m., a concurrent interview with the IP and record review of CNA 1 & LVN 1's Fit Test results were conducted. The IP stated there were currently eight COVID-19 positive residents in the facility and staff were required to wear a N95 mask while in the facility to prevent the spread of infection. The IP further stated staff are fit tested for N95 masks annually to ensure they are wearing the correct mask that fits properly with no air leaks, preventing infected air from entering their respiratory system, in turn preventing the spread of infection to others. The IP further stated there are three types of N95 masks the facility uses, the Med-line, a green and white striped mask, the [NAME], a solid white circular mask, and the 3M, a white duck bill shaped mask. The IP reviewed CNA 1's fit test record, dated, March 26, 2025, and verified CNA 1 was to wear the 3M N95, not the [NAME] N95 CNA was observed wearing earlier in the day at 11:35 Residents Affected - Few Page 1 of 2 555226 555226 01/28/2026 The Springs Healthcare Center at the Carlotta 41505 Carlotta Drive Palm Desert, CA 92211

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a.m. The IP reviewed LVN 1's fit test record, dated, November 24, 2025, which indicated LVN 1 was to wear the Med-Line, N95 mask, not the [NAME] mask LVN 1 was observed wearing earlier in the day at 12:30 p.m. The IP stated it's important for staff to wear the correct mask indicated by their fit test because wearing the wrong N95 mask does not protect them from infectious disease, and they pose a risk of spreading infectious disease to others in the facility. A review of the facility policy and procedure titled, Fit Tests, dated January 1, 2024, indicated, Policy: We conduct fit testing for employees before they will be required to wear a respirator. An employee's fit test will be performed using the same size, make, model and style of respirator that the employee would actually wear.We provide all employees required to wear a respirator with training on .Why the respirator is necessary and how improper fit .can compromise the protective effect of the respirator . A review of the facility policy and procedure titled, COVID-19: ISOLATION/QUARANTINE, PPE REQUIREMENTS dated August 4, 2023, indicated, .Policy: To prevent the spread of COVID 19 and to protect Residents and Staff affected by this infectious disease .PPE REQUIREMENT .Staff need to wear.N95 respirator.Staff will be fit tested annually for use of N95 respirators . 555226 Page 2 of 2