Bay Crest Care Center

infections) during an influenza (any infection or condition that affects the lungs and makes it difficult

care.This deficient practice increased the risk for transmission of influenza among residents and staff and had the potential to result in additional infections, worsening of the outbreak, hospitalizations, and serious complications for vulnerable residents.Findings:During a concurrent observation and interview on 1/30/2026 at 8:20 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 was wearing a face mask positioned below her nose. LVN 1 did not adjust the mask to fully cover the nose while administering medications. LVN 1 acknowledged that her face mask was worn improperly during the medication administration. LVN 1 stated that the mask should fully cover both the nose and mouth during resident care. LVN 1 stated that not wearing the mask properly could potentially expose the resident to respiratory droplets (tiny, invisible, or sometimes visible, splashes of liquid (saliva and mucus) expelled from the mouth and nose when a person breathes, talks, coughs, or sneezes) and increase the risk of infection transmission.During a concurrent observation and interview on 1/30/2026 at 8:33 a.m. with Certified Nurse Assistant (CNA) 1, CNA 1 was wearing a face mask positioned below her nose, leaving the nose exposed. CNA 1 acknowledged that her face mask was worn improperly. CNA 1 stated that wearing the mask below the nose could potentially expose the resident to respiratory droplets and increase the risk of infection transmission if she entered the room or interacted with the resident. CNA 1 confirmed that facility policy requires masks to fully cover both the nose and mouth while on duty.

During an interview on 1/30/2026 at 9:37 a.m. with Infection Preventionist (IP), the IP stated that all staff are required to wear Personal Protective Equipment (PPE- protective equipment including gown, gloves, masks, and face shield) while providing care to residents.

The IP stated that improper mask use increases the risk of influenza transmission to residents and staff, which could contribute to additional resident illness, worsening of the outbreak and potential hospitalizations.

The IP stated staff observed not following mask requirements, are re-educated, and failure to comply could result in disciplinary action per facility policy.During an interview on 1/30/2026 at 11:00 a.m. with the Director of Nursing (DON), the DON stated that masks are to fully cover both the nose and mouth at all times while in resident care areas and are not to be worn below the nose, on the chin, or removed during care.

The DON stated that proper use for masks is required to prevent the spread of influenza through respiratory droplets and to protect residents, staff, and visitors from exposure.

The DON stated that failure to wear masks or PPE correctly during an outbreak could result in additional residents or staff becoming ill, worsening the outbreak, potential hospitalizations, and increased risk of serious complications or death for vulnerable residents.

During a review of the facility's policy and procedure (P&P) titled, Personal Protective Equipment-Using Face Masks, dated 2025, the P&P indicated, to be sure the face mask covers the nose and mouth while performing treatment or services for the residents.

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE