Failure to Report COVID-19 Outbreak and Enforce Proper Mask Use
Penalty
Summary
The facility failed to follow infection control practices during a COVID-19 outbreak. Specifically, the facility did not notify the California Department of Public Health about the outbreak and did not post signs at the front entrance to inform visitors, residents, or staff of the outbreak. Observations revealed that staff, including a receptionist, a CNA, and a Restorative Nursing Assistant, were not wearing their N95 masks correctly, with masks worn below the nose. Additionally, a Certified Nursing Assistant and a Laundry Aid were observed wearing surgical masks instead of N95 respirators in resident hallways, contrary to facility policy during the outbreak. Interviews confirmed that staff were aware of the requirement to wear N95 masks and the importance of proper mask usage, but these protocols were not consistently followed. Resident records reviewed included individuals with significant medical vulnerabilities, such as cognitive communication deficits and immunodeficiency, as well as a resident admitted for COVID-19 screening. One resident reported that staff did not always wear their masks correctly. Facility leadership, including the DON and Administrator, acknowledged the outbreak and the need for N95 masks and signage, but confirmed that the outbreak had not been reported to the state health department and that required signage was not in place at the time of the survey.