Health inspection·December 28, 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 transmission based infection control measures when Licensed Nurse (LN) 2 entered the room of a resident (Resident 1) who tested positive for COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) without the required personal protective equipment (PPE, equipment worn to minimize exposure to infection and injury in the workplace). Residents Affected - Few This failure had the potential to increase the risk of COVID-19 transmission to all residents, staff, and visitors at the facility. Findings Include: Resident 1 was admitted to the facility on [DATE] with a diagnosis of respiratory failure, per the residents admission record. On 12/5/23 at 11:31 AM an interview was conducted with LN 1 in the hallway outside Resident 1's room. LN 1 stated Resident 1 had tested positive on the routine rapid antigen test for COVID-19 this morning. On 12/5/23 at 11:53 AM an observation and interview were conducted with LN 2 outside of Resident 1's room. LN 2 was observed entering Resident 1's room wearing a gown, gloves, N95 respirator (a respiratory protection device worn over the mouth and nose that filters viruses and particles). LN 2 was not observed wearing a face shield or eye protection upon entering Resident 1's room. LN 2 was observed exiting Resident 1's room at 11:59 AM. LN 2 stated she should have worn eye protection or a face shield in Resident 1's room because Resident 1 tested positive for COVID-19 and had been placed on enhanced droplet precautions (PPE that includes a mask, gown, gloves, eye protection). LN 2 stated not wearing the required PPE while providing care for a COVID-19 positive resident was a problem because it increased the risk of transmission to others. On 12/5/23 at 12:53 PM an interview was conducted with Infection Preventionist (IP) 1 and IP 2. IP 1 stated anyone entering a resident room with COVID-19 was expected to wear goggles, a face shield, gown, gloves and an N95. Stated if staff are observed not wearing the required PPE when entering a COVID-19 positive patient room they increased the risk of COVID-19 transmission to other residents in the facility. On 12/28/23 at 12:57 an interview was conducted with the Director of Nursing (DON). The DON stated staff were expected to wear a gown, gloves, N95 mask, face shield or goggles when caring for COVID-19 positive residents. The DON stated the goal of wear the proper PPE is to prevent COVID-19 positive transmission to other coworkers and susceptible residents. (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: 555301 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 555301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Villas at Poway 15615 Pomerado Rd Poway, CA 92064 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)