Health inspection·February 6, 2025

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 current infection control practices were followed for two of five residents reviewed for infection control when: Residents Affected - Few 1. Staff wore an N-95 (a fitted filtering mask) mask over a surgical mask, 2. Staff did not use a face shield upon entrance into a room with COVID-19 (a very contagious respiratory virus). This failure resulted in staff being exposed to COVID-19 and had the potential to spread infection to all residents residing in the facility. 1. Resident 1 was admitted to the facility on [DATE] according to the facility's admission Record. The change in condition progress note for Resident 1 dated 2/3/25 at 4:08 P.M. indicated, .Covid tested via rapid test with positive result . An observation of Resident 1's room on 2/6/25 at 9:02 A.M. was conducted. Resident 1's room had a sign on the wall outside which indicated, Special Droplet [spread of germs passed through speaking, sneezing or coughing] Contact [prevention of infection by direct or indirect contact] Precautions .N-95 . A white, plastic cart with drawers were also observed outside Resident 1's room. An observation and interview was conducted on 2/6/25 at 9:10 A.M. with Certified Nurse Assistant (CNA) 1. CNA 1 stated residents who were positive for COVID-19 had a blood pressure cuff and stethoscope inside the room. CNA 1 stated Resident 1 was positive for COVID-19 and will check the room for a blood pressure cuff and stethoscope. CNA 1 put on a gown, an N-95 mask over her surgical mask (a medical face mask) and face shield. On 2/6/25 at 9:41 A.M. CNA 2 was observed prior to entering Resident 1's room. CNA 2 was observed put on a gown then an N-95 mask on top of the surgical mask. An interview on 2/6/25 at 10:03 A.M. was conducted with CNA 1. CNA 1 stated she saw others putting an N-95 on top of a surgical mask and that was what she followed. An interview on 2/6/25 at 9:59 A.M. was conducted with LN 2. LN 2 stated it was her expectation for staff to not put on an N-95 mask on top of the surgical mask. An interview on 2/6/25 at 10:52 A.M. was conducted with LN 3. LN 3 stated staff should remove the surgical mask prior to putting on an N-95 mask for protection. Page 1 of 2 555290 555290 02/06/2025 Stanford Court Skilled Nursing & Rehab Center 8778 Cuyamaca Street Santee, CA 92071

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Resident 3 was admitted to the facility on [DATE] according to the facility's admission Record. The progress notes for Resident 3 dated 1/27/25 at 4:15 P.M. indicated, .Pt [patient] tested positive for covid-19 . An observation and interview were conducted on 2/6/25 at 9:26 A.M. Resident 3's room, a sign outside the room indicated, Special Droplet Contact Precautions. Licensed Nurse (LN) 1 stated a blood pressure cuff and stethoscope were kept in rooms with residents who were positive for COVID-19. Prior to entering Resident 3's room LN 1 removed her surgical mask, put on an N-95 mask then a gown. LN 1 entered the room without a face shield. LN 1 exited Resident 3's room without the gown and N-95 and a joint observation of the precaution sign outside the room was conducted. LN 1 stated the precaution sign indicated, Wear eye protection, face shield or goggles. LN 1 stated she usually had the face shield over her eyeglasses, but the cart did not have any. LN 1 further stated she should have put on the face shield as protection. During an interview on 2/6/25 at 11:20 A.M. with the infection prevention nurse (IPN), the IPN stated staff should use a face shield inside a COVID room not prescription glasses. The IPN further stated an N-95 mask should not be placed on top of a surgical mask because it made the N-95 ineffective. An interview with the Director of Nurses (DON) was conducted on 2/18/25 at 3:44 P.M. The DON stated staff should not double mask because it compromised the seal of the N-95 mask. The DON further stated it was important to use a face shield inside a room with COVID because it was extra protection for the staff. A review of the facility's policy and procedure (P&P) titled, Coronavirus Disease (COVID-19)-Identification and Management of Ill Residents, dated November 2024 was conducted. The P&P indicated, .Staff who enter the room of a resident with suspected or confirmed SARS-CoV-2 [COVID-19] infection will adhere to standard precaution and use .N95a NIOSH [National Institute for Occupational Safety and Health- a federal agency]-approved particulate respirator [mask that filters particles] with N95 filters or higher, gown, gloves, and eye protection .Provide supplies including masks for source control . 555290 Page 2 of 2