Health inspection·September 1, 2023

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and administrative policy review, the facility failed to maintain an infection prevention and control program when: Residents Affected - Some 1. Two resident rooms did not have signs posted outside their room indicating precautions before entering the rooms. 2. Certified Nurse Assistant (CNA) 1 incorrectly wore a surgical mask under a N95 respirator mask in an isolation unit for COVID-19. 3. Staff wore the same personal protective equipment (PPE) while working with both positive COVID-19 residents and non-positive COVID-19 residents in the isolation unit. These failures had the potential risk for spreading transmission-based infections to residents, staff, and visitors. Findings: 1. During a concurrent observation and interview in building one with infection control nurse (ICN) on 8/30/23 at 10:45 am and 11:04 am, there was a cart containing PPE to the left of two Resident rooms (Resident 1 and Resident 2). There was no sign observed posted by nor on either door to indicate what precautions were required when donning PPE. ICN stated Residents 1 & 2 tested positive for COVID-19 and confirmed there was no signs posted. During a review of the facility's policy titled COVID-19 Infection Control Precautions dated 3/20/23, indicated, .Personal Protective Equipment (PPE) .7. Signs will be posted outside of resident rooms indicating appropriate infection control, prevention, precautions; including required PPE in accordance with CDPH [California Department of Public Health] and LHD [Local Health Department] guidance . 2. During an observation in building one on 8/30/23 at 11:10 am, CNA 1 was seen with two masks on her face. CNA 1 had a surgical mask underneath a blue N95 mask. (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: 555900 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 555900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Veterans Home of California - Fresno 2811 W Cesar Chavez Blvd Fresno, CA 93706 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)