Failure to Enforce Mask Use During Covid-19 Outbreak
Penalty
Summary
The facility failed to ensure that staff consistently wore masks during a Covid-19 outbreak, as required by its own Covid-19 Mitigation Plan and the most recent California Department of Public Health PPE guidance. Observations on multiple occasions revealed that four out of ten sampled staff members, including a Certified Nursing Assistant (CNA) responsible for Covid-19 screening, a housekeeper, a Licensed Vocational Nurse (LVN), and the Administrator, were not wearing masks in various areas of the facility. The CNA stated she did not believe mask-wearing was mandatory during the outbreak, while the LVN admitted to not wearing a mask due to discomfort from heat. The Administrator acknowledged forgetting to wear a mask in the nursing station, and the housekeeper was observed vacuuming without a mask in the lobby. Interviews with facility leadership, including the Infection Preventionist Nurse (IPN), Housekeeping Supervisor (HKS), Director of Nursing (DON), and Administrator, confirmed awareness of the Covid-19 outbreak and the expectation that all staff should wear masks. The IPN reported that reminders were given to staff during morning huddles, but some staff may have perceived Covid-19 as a normal illness and did not adhere to mask protocols. The DON and HKS both stated that mask-wearing was necessary to prevent the spread of infection, especially given the vulnerability of the resident population. A review of the facility's Covid-19 Mitigation Plan Manual indicated that all staff should wear recommended PPE, including facemasks, when Covid-19 cases are identified in the facility. Despite this policy, staff non-compliance with mask-wearing was observed and acknowledged by both staff and leadership during interviews. The failure to follow established infection control practices occurred while two residents were confirmed positive for Covid-19, and the outbreak had been ongoing since at least 5/28/2025.