Health inspection·November 27, 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 ensure current infection control practices were followed when a facility employee did not wear a face shield inside a resident's room (Resident 3) who was on isolation for COVID-19 (an infectious respiratory disease). Residents Affected - Few Failure to follow current infection control practices had the potential to spread infectious disease to all residents, staff, and visitors. Findings: Resident 3 was admitted to the facility on [DATE] with the diagnosis including COVID-19 according to the facility's admission Record. During an observation on 11/15/23, at 9:50 A.M., Resident 3's room had a, Stop sign outside, hanging under the room number. The back of the sign indicated, Droplet (spread of germs passed through speaking, sneezing, or coughing) and Contact Precautions (prevention of infection by direct or indirect contact) .Personal Protective Equipment Needed. Gown, N-95 (a fitted filtering mask), Face shield, Gloves . During observation and interview on 11/14/23, at 9:50 A.M., Resident 3 was sitting up in bed talking to LN 1. LN 1 was standing on Resident 3's left side and was observed wearing a yellow gown, N-95 mask and gloves. LN 1 was not wearing a face shield. Resident 3 confirmed that LN 1 did not wear a face shield upon entrance to Resident 3's room. An interview was conducted with LN 1 on 11/14/23, at 11:13 A.M. LN 1 stated residents with a positive COVID test were placed on isolation precautions. LN 1 further stated staff were expected to wear a face shield, mask, gown, and gloves as protection. LN 1 acknowledged Resident 3 was positive for COVID, and she did not have a face shield inside Resident 3's room. During an interview on 11/14/23, at 1:35 P.M. with the Infection Preventionist (IP), the IP stated it was his expectation for staff to use personal protective equipment (PPE) in COVID rooms. The IP stated staff and visitors should wear an N-95 mask, gown, gloves, and a face shield before entering a COVID-19 room. During an interview on 11/15/23, at 10:56 a.m. with the Director of Nursing (DON), the DON stated staff was expected to have full PPE while inside a COVID isolation room. The DON further stated without a face shield, staff can be exposed to the resident's virus and become positive for COVID. Page 1 of 2 555427 555427 11/27/2023 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility's policy and procedure (P&P) titled, Transmission-Based (Isolation) Precautions (additional measures to the minimum infection control practices to prevent the spread of infection), dated 9/2/22, was reviewed. The P&P indicated .The facility will have PPE readily available near the entrance of the resident's room and will don (put on) appropriate PPE before or upon entry .if there is a risk of exposure of mucous membranes (lining of many structures in the body including the mouth, nose, and eyelids) .gloves and gown as well as goggles (or face shield) should be worn. 555427 Page 2 of 2