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F0880
E

Failure to Enforce Staff Masking Policy During Respiratory Virus Season

North Hollywood, California Survey Completed on 11-08-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

During the respiratory virus season, the facility failed to implement its infection control measures as required by its own policy. Observations revealed that three out of five sampled staff members, including an LVN and two RNs, were not wearing masks while in the facility, despite posted signage and a policy indicating that masking was mandatory in all resident care areas starting from a specified date. The staff were seen in hallways and near resident rooms without masks, and one staff member assisted a surveyor without wearing a mask. Interviews with staff indicated confusion and lack of awareness regarding the updated masking policy, with one staff member stating she was not informed of the change and did not see the posted signage due to using a different entrance. Another staff member acknowledged forgetting to wear a mask, while others confirmed they had been informed of the policy but did not comply. Review of the facility's policy and procedure confirmed that all staff were required to wear masks in resident care areas, including hallways, during the respiratory virus season, regardless of vaccination status. Both the Infection Preventionist and the Director of Nursing affirmed that hallways are considered resident care areas and that the masking policy was in effect. The failure of staff to adhere to the masking policy was acknowledged by facility leadership, who recognized that non-compliance could contribute to the spread of respiratory illnesses among residents, staff, and visitors.

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