Every finding on record at DJ Jacobetti Home for Veterans

This citation pertains to Intake #3124682 Based on observation, interview, and record review, the facility failed to supervise to one Resident (#12) of three residents reviewed for accidents, hazards, and supervision. This deficient practice resulted in Resident #12 (R12) wandering unsupervised for approximately 2 1/2 hours before being discovered on the floor after sustaining a fall in a non-resident area where it was later discovered R12 sustained a fractured left femur requiring surgical intervention. Findings include:According to the facility reported incident (FRI), dated 7/26/26, which read in part At approximately 1643 [4:43 PM on 7/26/26], the Director of Nursing was notified that the supervisor in charge had called a code green [missing member] for member [R12]. Minutes later, the supervisor phoned the DON again, indicating that [R12] had been located in an unsupervised area of the home. [R12].was assessed by the supervisor on duty immediately. Upon standing, [R12] had difficulty and the supervisor noted that.left leg buckled, but once sitting on.walker.was able to move both.lower extremities.For precautionary reasons, staff transported [R12] back to.unit utilizing the med-sled. During transfer in [R12's] room.was unable to bare any weight to.left lower extremity and per the nurse on duty [R12's] left leg appeared lengthened.At approximately 2100 [9:00 PM], the DON received confirmation of a concomitant comminuted fracture involving the base of the greater tuberosity via CT [computer tomography] results, and [R12's] subsequent admission to the hospital. On 8/19/26 at 11:20 AM, the Nursing Home Administrator (NHA) was asked to take this Surveyor on the same wandering episode of R12. The NHA got the DON and this Surveyor and all three went to the second floor of the facility via the stairs, walked down to the [NAME] elevators, back down to the stairs and then upstairs to the third floor where the [NAME] end elevators were located. The [NAME] elevator was where R12 got off from the second floor and rode the elevator to the third floor, got off the elevator, proceeded right down the [NAME] hallway all the way to the end and went through a door labeled Maintenance Room. After going through the maintenance room door, there were two small flights of stairs with approximately 9 to 11 steps each aligned with a yellow railing and at the top of the staircase another unlocked door which entered a mechanical room. The mechanical room has a panel of breaker boxes to the left and other mechanical equipment on the right as we proceeded to walk through another 20 to 25 walking steps and came to a door on the left unlocked. This is where R12 was found by staff sitting on the floor with his back against the wall to the left and R12's walker was lying on the floor near them. The door to the back of the mechanical room on the left had a man-made wooden ramp after opening the door on the inside and the sides dropped off approximately six inches to the floor. On 8/19/26 at 11:40 AM, during an interview the NHA and the DON were asked how R12 had gotten to where they were located, been sitting on the floor in the room off to the left of the mechanical room. The DON replied, We think [R12] must have been walking with his walker and got one or two of the walker legs off the ramp and lost their balance and fell. Both the NHA and the DON were unaware the [NAME] elevator went all the way to the third floor and confirmed R12 should have never made it to the third and fourth (not mentioned until now and is not well described earlier in the cite then) floor into the mechanical room. On 8/19/26 at 11:55 AM, an observation was made of the video footage for R12's wandering expedition on 7/26/26 through the facility and the following was observed:At 2:15 PM R12 enters the [NAME] elevators on the second floor,At 2:16 PM R12 exited the [NAME] elevators on the third floor,At 2:37 PM R12 enters the mechanical door to the stairwell (lose video footage of R12 now),At 4:55 PM facility staff are observed on the video footage looking for R12 on the third floor,At 4:57 PM facility staff are observed to enter the mechanical door to the stairwell to the fourth floor and,At 5:10 PM staff are seen with the med sled and R12 inside being transported back down to the second floor to R12's room. Review of R12's incident and accident report, dated 7/26/26, read in part .Activities staff notified this writer that they were unable to find member. This writer stated that he had last seen member on 2W [second floor [NAME] end] walking around. Activities and this writer went and search 2 W after not finding member there, RN [registered nurse] checked the ground floor dining and 2S [second floor South]. After not finding member a code green was activated at 1641[4:41 PM]. Code green policy was printed off and followed. Staff found member in the HVAC [heating, ventilation, & air conditioning] room above the third floor at 1648 [4:48 PM]. Member was found sitting on the floor leaning up against the wall.There is a ramp that goes up and over the threshold into the room where member was found. The floor was free from clutter and lighting was adequate. Member was not wearing his glasses at the time of the fall.Resident Description: Member stated that he wasn't sure where he was. That he was just wandering around checking it out. Member originally stated that he just fell without any other details. When EMS [emergency medical services] asked him what happened he described his walker going off the side of the ramp and falling. Review of R12's care plan, dated 12/5/25, read in part .Problem: [R12] is at risk for wandering / Elopement related to his Lewy body Dementia. [R12] can safely ambulate and wander throughout the facility.[R12] can sign out a temporary elevator key card for daily use.Goal: [R12] will have no issues with exit seeking through the next review [target date 8/26/26]. Interventions.[R12] will NOT be issued his own elevator key card. He can sign one out. On 8/20/26 at 8:35 AM, during an interview RN C was asked about R12 and their incident on 7/26/26. RNC confirmed the chain of events from the video footage. RN C was asked if R12 had ever used the [NAME] elevators and replied, Members are to use the central elevators and not the [NAME] elevators. I had never seen them use the [NAME] elevators. RN C was asked if R12 would have been able to open the [NAME] elevator because the key card access was off to the right of the elevators and the central elevators the key card access is in the middle and replied, I am not sure actually if [R12] would have been able to access the [NAME] elevators. It just happened a new staff member was coming off, and it appeared [R12] just walked right on. On 8/20/26 at 8:50 AM, during an interview with R12 who was asked about their adventure could not recall the event. Review of elevator key card sign out sheet, dated 7/26/26, revealed R12 did sign out an elevator key card with number 9 at 8:40 AM. On 8/20/26 at 9:40 AM, an observation and interview were conducted with the NHA, and the Maintenance Mechanic (MM) E were asked to open the [NAME] elevators to observe the inside keypad and revealed a different keypad set-up than the central elevators. The NHA was asked if it were possible R12 got confused and pushed the wrong button for the ground floor as the third-floor button were in the same spot on both elevators and replied, I am not sure. [R12 was not to be in the [NAME] elevator and should have never made it through the maintenance door to the fourth (third?) floor. During an interview on 8/20/26 at 9:45 AM, both the NHA and the DON were unaware the [NAME] elevator went all the way to the third floor and confirmed R12 should have never made it to the third and fourth (not mentioned until now and is not well described earlier in the cite then) floor into the mechanical room. Review of policy titled, Safety & Accident Prevention, dated 1/7/26, read in part Policy: The member environment will remain as free of accident hazards as is possible. Each member will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazards and risks.Policy Interpretation and Implementation: The Home will establish and utilize a systematic approach to address member risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks - the process through which the Home becomes aware of potential hazards in the member environment and the risk of a member having an avoidable accident. a. All staff (e.g., professional, administrative, maintenance. ect.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each member. Review of policy titled, Member Behavior & Safety, dated 12/31/25, read in part Policy: The Home will ensure that members who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.Best Practice - Missing Member.Inaccessible Member Areas (Mechanical, Electrical, Storage, Etc.). These rooms and areas will be always remained locked. Keypad or key access is required to search and enter the room. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included.One 7/26/26 the facility identified all other members who utilize the elevator key cards and reviewed safety of usage. The facility audited all residents regarding elevator key cards and doors/areas considered unauthorized completion. Care plans were reviewed and revised as necessary. The maintenance stairwell was secured, locked, and all other doors were checked. On 7/27/26 the maintenance door hardware was replaced with an auto-locking mechanism. All doors designated for authorized personnel only were identified, and auto-locking mechanisms were ordered and replaced with auto-locks. Implementation on 8/7/26 of code alert system installed fire/smoke doors on second floor activated with keypad exit and entry and staff made aware of new door codes for exit/entry and alarm codes for disabling. Education was provided to all staff regarding locked doors, elevator usage, [NAME] elevator shut down, and unauthorized areas. Maintenance shut down the [NAME] elevator on 7/26/26 at 7:30 PM. Audits were completed to ensure completion. The facility was able to demonstrate monitoring of the corrective action and maintained compliance. The date of compliance was 8/12/26. The event has been added to QAPI [quality assurance plan improvement]. Parts were ordered for the [NAME] elevator to add a physical key to be inserted to access the third floor.

This citation pertains to intake 1361257.Based on observation, interview, and record review the facility failed to prevent staff to resident physical abuse for one Resident (R18) out of one reviewed for abuse. This deficient practice resulted in a fall, emotional distress, and fear based on the reasonable person.Findings include: R18 Review of R18's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnosis including frontotemporal neurocognitive disorder, aphasia, and adjustment disorder with mixed disturbance of emotions and conduct. R18's Brief Interview for Mental Status (BIMS) score in October 2025 was unable to be completed, but staff noted R18 to be severely cognitively impaired. R18 has a Designated Power of Attorney (DPOA) to make health and financial decisions. R18 was independent for ambulation. Review of R18's Care Plans read, in part, [NAME] has potential to be physically aggressive towards staff r/t (related to) dementia and inability to communicate his needs. (Date initiated: 10/14/25) .Interventions/Tasks .(R18's) triggers for physical aggression include being redirected away from what he is trying to do .The resident's behaviors is de-escalated by providing distraction with an activity of interest, allowing as much independence as possible and giving him space (Date initiated:11/26/25) .When (R18) becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in an activity or a walk; If response is aggressive, staff to walk calmly away, and approach later ([NAME] Initiated: 10/14/25) Review of the Facility Reported Incident (FRI) dated 12/8/25 read, in part, On December 2, 2025 at approximately 10:00 a.m., The Director of Nursing (DON) was notified of a concern during a camera review of a witnessed fall that occurred on December 1, 2025 at approximately 1815 (6:15 p.m.) with a member of the Memory Care Unit, (R18). According to reports, (R18) was ambulating with a staff member, (Certified Nurse Aide (CNA) H) when he was attempting to pull a Christmas decoration off the wall. Statements describe (R18) pulling backward forcefully, and when the decoration was pulled from the wall, it causes him to lose his balance and fall to the floor, causing him to come to rest on his right side. He (R18) was assessed immediately by the nurse on duty who did not note any injuries at that time and his DPOA was notified of the fall without injury. Initially following the fall, the home did not have concerns for abuse. After clinical review on the morning of 12/2/25, the home reviewed camera footage to confirm if (R18) had hit his head during the fall, and upon video review concerns for abuse were noted . The facility's video surveillance was reviewed with the Nursing Home Administrator (NHA) on 12/10/25 at 2:38 p.m. The timing on the video was noted to be 12/1/25 at 6:09 p.m. with CNA H and R18 located in the main hallway of the memory care unit and across from the sitting area. R18 is observed attempting to take down a Christmas decoration on the wall. CNA H comes over to R18 and attempts to stop him by taking R18's hands and removing them from the decoration. R18 then attempts to strike CNA H with his right hand two times with CNA H blocking both hits with his left forearm. CNA H is then observed extending his left arm towards R18 and placing his left hand on R18's on his abdomen below the breast. CNA H removes his hand briefly then places his left hand again on R18, this time higher in the chest area while taking a step forward toward R18. CNA H then is seen taking a forward rocking motion with his hand making contact with R18's left upper chest/shoulder area. This is when R18 starts to lose his balance and stumbles backwards, hitting his right side onto the floor. An interview with the NHA on 12/10/25 at approximately 2:50 p.m. confirmed that CNA H should not have placed his hands on R18 and did not follow R18's Care Plans. An attempted phone call with CNA H was conducted on 12/10/25 at approximately 3:00 p.m. There was no return phone call before the end of the survey on 12/11/25. Review of the facility's Recognizing Signs & Symptoms of Abuse policy read, in part, The home will not condone any form of member abuse or neglect. 'Abuse' is defined as the willful infliction of injury.intimidation, or punishment with resulting physical harm, pain or mental anguish.Physical Abuse includes, but is not limited to hitting, slapping, biting, punching, or kicking.Some situations of abuse do not result in an observable physical injury, or the psychosocial effects of abuse may not be immediately apparent.other members may not be able to speak due to a medical condition and/or cognitive impairment (e.g., stroke, coma, Alzheimer's disease), cannot recall what has occurred, or may not express outward signs of physical harm, pain, or mental anguish. Neither physical marks on the body nor the ability to respond and/or verbalize is needed to conclude that abuse has occurred.The follow situations are recognized as those that are likely to cause psychosocial harm which may take months or years to manifest and have long-term effects on the member and his/her relationship with others:.(d) Any staff-to-member physical, sexual, or mental/verbal abuse.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety, resulting in the potential to spread food borne illness among all residents that consume food from the kitchen. Findings include:On 12/10/2025 at 1:40 PM During a facility main kitchen tour with Certified Dietary Manager (CDM) B and Assistant Dietary Manager (ADM) C, the vegetable wash sink was observed without an air gap. A tin can was observed surrounding the outlet drain, sitting on the floor drain. When asked about the tin can, CDM B stated the can was in place as a splash guard since before he came on board at the facility. When moved, the can, drain line and floor drain were noted heavily soiled with black slime mold and food debris. On 12/10/2025 at 2:15 PM while on a tour of the 2 North kitchen on the second floor with Certified Dietary Manager (CDM) B and ADM C, ready-to-eat food items were noted with a dispose by date totaling 8 days. Items included cream corn souffle cup with a made-on date of 12-9 and a dispose-by date of 12-16, chef salad 12-9 through 12-16, tossed salad 12-9 through 12-16, and shredded cheddar cheese with 12-9 through 12-16. Upon review of the facilities log sheet on the outside of the refrigerator with the CDM, it was noted the facility policy is that all foods are to have been kept for no more than seven days, including the day of preparation.According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.On 12/10/2025 at 2:30 PM while on a tour of the 2 North kitchen and dining rooms with CDM B and ADM C the [NAME] high temp dish machine was noted with towels lying on the floor tucked up under the front of the machine. CDM B stated the machine has been leaking when it is running and water comes out onto the floor, and the towels have been put in place to prevent water from getting further out onto the kitchen floor.According to the 2022 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications.On 12/10/2025 at 3:15 PM Observed a bag of Oreo bits sitting on a shelf in the kitchen with the top of the bag open exposing the cookie bits inside. Staff did not know who these belonged to, or how long they had been there. ADM C disposed of them.According to the 2022 FDA Food Code section 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor.On 12/10/2025 at 3:25 PM while in the main kitchen, it was noted the slicer had been covered with a plastic bag to keep it clean. The ADM C stated it had been cleaned and then covered to keep it clean. When asked how the unit is cleaned after being used for prepping food, ADM C stated the pieces that are able to be removed from the unit are taken to the three-compartment sink to be washed, rinsed and then sanitized. When the plastic bag was removed to inspect the slicer, the underneath side of the removable blade and casing were observed to have been left soiled with food debris after the last prep period. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch.

Based on observation, interview, and record review, the facility failed to provide a homelike environment and honor the meal service preferences for five Residents (R4, R37, R50, R57, R62) of 15 residents reviewed. Findings include:On 12/9/2025 at 11:58 AM, the lunch meal was observed in the 2nd floor dining room. Four staff members were present and serving lunch. All residents in the dining room were served their lunches on institutional trays. Resident #4 (R4) was observed with a tray card containing preferences which read: blue placemat NO TRAY [sic]. R4 did not have a blue placemat, and his meal was resting on a tray which sat on the table. Further observations included R37, R50, R57 and R62 all received their meals on trays while their tray cards indicated they did not prefer a tray. (Their tray cards read: NO TRAY.)During an interview on 12/11/2025 at 8:44 AM, the Certified Dietary Manager (CDM) B stated it was his practice to make the facility as homelike as possible and he stated, Trays are not homelike.During an interview on 12/11/2025 at 8:53 AM, the Nursing Home Administrator (NHA) discussed the culture of the facility and stated residents should not get a tray if that was their preference.

Based on observation, interview, and record review, the facility failed to provide dining adaptive equipment for three Residents (#4, #56, & #62) of four residents reviewed for dining assistive devices. Findings include: On 12/9/2025 at 11:58 AM, the lunch meal was served in the 2nd floor dining room. Four staff members were present and serving lunch. The following was observed:Resident #4 (R4)- - R4 was observed with a tray card containing instructions which included, Adaptive Equip(ment): Blue Handled Mug with Lid, Scoop plate (plate with an edge to facilitate catching food), Blue placemat (made of material to prevent plate slippage) and All Soup in a Mug. R4 had his meal on a regular non-scooped standard plate sitting on the service tray without a blue mat and his soup was not in a mug but instead served in a bowl. R4 did not receive his coffee in a blue handled mug. Resident #56 (R56)- - R56 was observed with a tray card containing instructions which included, Adaptive Equip: Built-Up Utensils, Cold liquids: 2-handle Cup with Straw., Mug with Tumbler lid for Hot Liquids, Straw. R56 did not receive built up utensils or a 2 handled cup for his beverages. R56 had hot soup served in a bowl and not in a mug for hot liquids as printed on his tray card. Resident #62 (R62)- - R62 was observed with a tray card containing instructions which included, Adaptive Equip: Blue Handled Mug with lid. R62 had a cup of coffee in a regular mug with lid - a special blue handled mug was not used.During the breakfast meal service on 12/10/2025 at 7:52 AM, R62 was observed with a tray card containing instructions which included, Adaptive Equip: Blue Handled Mug with lid. R62 stated he would like a cup of coffee. Certified Nursing Assistant (CNA) D served R62 coffee but did not use a blue handled mug with lid. When asked about the different mug, CNA D did not know R62 had specifications for a blue handled mug on his tray card.During the lunch meal service on 12/10/2025 at 12:17 PM, R62 was observed with a tray card containing instructions which included, Adaptive Equip: Blue Handled Mug with lid. R62 had coffee in a regular mug and did not receive a blue handled mug with lid. R4 was observed with a tray card containing instructions which included, Adaptive Equip: Blue Handled Mug with lid but did not receive a blue handled mug with lid for the hot beverage.The electronic medical record (EMR) was reviewed for R4, and the quarterly nutrition assessment note dated 11/6/2025 included, .He uses built up utensils, a scoop plate, and blue dycem as a placemat. These help to increase eating independence. He can feed himself after set up and he is able to make his needs known. The ADL (Activity of Daily Living) care plan included interventions of: .uses a scoop plate for meals, blue dycem as a place mat, built up utensils. All beverages should be served in a cup with a disposable lid with a straw.At times, he is able to feed himself with set up, other times he needs staff to feed him due to tremors. He does drink hot liquids out of a standard mug with disposable straw lid and straw. The care plan also included a problem of weight gain and the same interventions were repeated with additional notes which read, Kitchen staff will sometimes offer foods to be served in individual bowls instead of the scoop plate, and they usually ask (R4) what he prefers. Date Initiated : 09/11/2025. During the lunch meal observation on 12/09/2025 at 11:58 AM, R4 did not have a scoop plate or individual bowls, instead his meal was served on a regular non-scooped standard plate sitting on the service tray without a blue mat.The EMR was reviewed for R56, and the care plan included a problem of: (R56) has potential for altered NUTRITION related to his diagnosis of Dementia, Diabetes, and Parkinson's Date Initiated: 09/18/2025. The interventions included: DIET: Soft with ground meats. Built-up utensils. 2 handled mug with a lid and straw for cold beverages. Date Initiated: 09/29/2025. The EMR was reviewed for R62, and the care plan included a problem of: .an ADL self-care performance deficit. Revision on: 04/24/2023. The interventions for this problem included. (R62) to have hot liquids with blue handled mug with lid for safety, to avoid spills and potential burns. Cool hot items slightly with a little ice. There was an additional care plan problem listed as a history of weight gain and loss. The interventions for this problem also included, Cool coffee to luke warm with ice prior to giving to (R62) and (R62) to have hot liquids with blue handled mug with lid for safety, to avoid spills and potential burns. Staff should cool slightly with a little ice. Date Initiated: 05/12/2025.During the breakfast meal service observation on 12/10/2025 at 7:52 AM, CNA D served R62 coffee but did not add ice or give R62 a blue handled cup as per the several care plan interventions.During an interview on 12/11/2025 at 8:44 AM, the Certified Dietary Manager (CDM) B stated the staff serving the residents should follow the tray cards and give the adaptive equipment as indicated on the cards.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any and all 61 residents of the facility. Findings include: On 10/14/24 at approximately 12:05 PM, Kitchen Staff (KS) B was observed cleaning cook ware at the three compartment sink. KS B was observed to wash utensils (food whip; spatulas; stirring spoons, sheet pans) and other food contact surfaces in the wash compartment, then rinsed in the center rinse compartment. KS B then quickly dipped each of the objects into the sanitizing solution of the third compartment for less than two seconds, then placed on the flanking drain board to the left of the sink. An interview was conducted at this time with KS B who was asked Do you know what you are doing wrong here? KS B replied No. When asked what type of sanitizing chemical was being used in the sanitizing solution, KS B replied Quat. When asked to define the amount of time a food utensil should be soaked in the Quat solution, KS B stated A minute?. The question was responded to in the affirmative. At this time KS B made no attempt to take the items from the draining board and replace them into the sanitizing solution for the required time. A review of the label on the sanitizing solution affirmed the minimum contact time for proper sanitizing of food contact surfaces was 60 seconds. At approximately 12:15 PM Kitchen Manager (KM) A entered the area. The above observation and interview was shared with KM A. KM A stated She knows better than that. A review of the FDA Food Code 2017 was conducted and it states: 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization -Temperature, pH, Concentration, and Hardness. A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under S7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, P and shall be used as follows: (C) A quaternary ammonium compound solution shall: (1) Have a minimum temperature of 24 C (75 F), P (2) Have a concentration as specified under S 7-204.11 and as indicated by the manufacturer's use directions included in the labeling,

Based on interview and record review, the facility failed to ensure collaboration and communication between the facility and hospice provider for one Resident (#R44) of two residents reviewed for hospice services. This deficient practice resulted in gaps in communication for coordination of care. Findings include: Review of R44's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnoses including Alzheimer's disease, neurocognitive disorder with Lewy Bodies, and Parkinson's disease. Review of R44's 8/21/23 Minimum Data Set (MDS) assessment revealed he was unable to complete the Brief Interview for Mental Status (BIMS) and noted to have severely impaired cognition. R44 was admitted to hospice services on 5/12/23. Review of R44's Skilled Nursing Visit Note [Hospice Name] written 10/18/23 read, in part, Narrative Notes: .61 Y.O. (year old) male hospice patient with Alzheimer's and Parkinson's, lives at memory care unit at [facility name] .wife states he does have a decline every September an we are monitoring for this. Will continue with every other week SNV's (Skilled Nursing Visits) for assessment and monitoring of ss (signs & symptoms) of decline . On 11/29/23 at 9:30 a.m. a request was made for R44's hospice visits since 10/18/23. An interview was conducted with the Director of Nursing (DON) on 11/29/23 at 10:20 a.m. The DON confirmed there was no additional documentation from R44's hospice provider since 10/18/23. The DON agreed the information from the hospice provider should have been readily available at the facility for nursing staff to review and to ensure collaboration of care between the facility and the hospice provider. Review of the facility's Clinical Services & Quality of Care End of Life Hospice Services, Coordination of policy reviewed 9/12/23 read, in part, Hospice services are available to members at the end of life. The home will coordinate and provide care in cooperation with hospice staff to promote the member's highest practicable physical, mental, and psychosocial well-being .Hospice providers who contract with this Home .are held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the Home .

This citation has two parts: A and B. A. Based on observation, interview, and record review, the facility failed to maintain a complete infection control program, as evidenced by failure to perform appropriate hand hygiene, clean/disinfect a medication injection pen, and don appropriate personal protective equipment (PPE) during resident care for two Residents (R20 and R29), out of four residents reviewed for infection control. These deficient practices resulted in the potential for transmission of infectious organisms and an increased risk for infection. Findings include: Resident #29 During a medication pass observation on 10/18/22 at 8:19 a.m., Licensed Practical Nurse (LPN) A prepared an insulin syringe filled with 70 units of long-acting insulin and an additional noninsulin diabetic medication ([MEDICATION(S)], contained in an injection pen) for R29. LPN A did not cleanse the hub of the [MEDICATION(S)] pen prior to placing a new needle onto the pen injector. Upon entrance into R29's room, the insulin syringe and pen injector were placed on R29's uncleaned overbed table and without the use of a barrier cloth. LPN A dropped the [MEDICATION(S)] pen injector onto the floor prior to administration of the medication, which bent the pen injector needle. LPN A picked up the [MEDICATION(S)] pen from the floor with gloved hands, took the dirty pen out to the medication cart and placed it on a spiral-topped notepad (with written notes) on the cart. LPN A removed her dirty gloves and used her bare hands to remove the damaged needle from the pen. LPN A did not sanitize her hands after contact with the [MEDICATION(S)] pen, contaminated from contact with the floor, prior to donning new gloves. LPN A placed a clean needle on the pen injector without cleansing of the hub, for a second time. The outside of the pen was never cleaned or sanitized. The medication was administered to R29, and the dirty pen was placed inside LPN A's medication cart. Review of the (Name Brand) [MEDICATION(S)] injection Instructions for Use dated 12/2020, revealed the following, in part: .If you drop your [Name Brand] pen, repeat First Time Use For each New Pen (steps A through D). Be careful not to bend or damage the needle . First Time Use for Each New Pen: Step A. Check the Pen . wash hands with soap and water before use . Wipe the rubber stopper with an alcohol swab . Routine Use . Wipe the rubber stopper with an alcohol swab . If cleaning is needed, wipe the outside of the pen . Review of the Infection Control, Standard Precautions, Handwashing-Hand Hygiene policy, dated 4/28/21, revealed the following, in part: .Use an alcohol-based hand rub containing at least 62% (percent) alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial and water for the following situations: . Before preparing or handling medications . After handling used dressing, contaminated equipment, etc. After contact with objects (e.g., medical equipment) in the immediate vicinity of the member . After removing gloves . The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. During an interview on 10/18/22 at 11:03 a.m., the Director of Nursing (DON) acknowledged he had been informed of the [Name Brand] pen injector being dropped onto the floor. The DON confirmed the pen should have been cleaned and sanitized when picked up from the floor and not placed on top of the medication cart without a barrier following use. The DON acknowledged that the pen hub should have been cleansed with an alcohol wipe prior to placing the needle on the [Name Brand] pen. The DON expressed understanding of the concerns related to infection control with the above observation. Resident #20 During an observation of [CONDITION(S)] ([CONDITION(S)]) care on 10/18/22 at 12:14 p.m., LPN A entered R20's room with face mask, gown, and gloves donned. No eye protection (goggles or face shield) was worn while sterile cotton-tipped applicators were inserted into R20's [CONDITION(S)], rotated quickly multiple times, and withdrawn to encourage mucous expectoration from the [CONDITION(S)] and upper respiratory tract. R20 cough multiple times with this repeated procedure, and a significant amount of mucous was expectorated. LPN A returned to the medication cart, in the door of R20's room, picked up the goggles still on the medication cart, returned to R20, and placed the goggles down on R20's uncleaned (dirty) overbed table. Hand hygiene was performed, and sterile gloves donned. LPN A used her right hand to handle dirty medical supplies on the overbed table set up with a clean barrier. LPN A stated, My right hand will now be my dirty hand. R20's [CONDITION(S)] was removed and placed in the cleaning solution. LPN A picked up the goggles, sitting on R20's dirty overbed table, and placed them on her face using her sterile gloved clean left hand. At this point both hands donned in sterile gloves, were contaminated. LPN A used the right hand to hold the [CONDITION(S)] cleaner, and left hand to hold [CONDITION(S)]. The cleaned [CONDITION(S)] was placed in a new clean solution divider in the sterile [CONDITION(S)] kit. LPN A wiped under R20's [CONDITION(S)] color with a sterile gauze and placed the clean [CONDITION(S)] on sterile gauze both handled by the contaminated left glove. Review of a list of TBP residents provided by the facility revealed R20 was on Enhanced Barrier precautions related to his [CONDITION(S)] and PEG (percutaneous endoscopic gastrostomy/feeding) tube. During an interview on 10/18/22 at 12:44 p.m., LPN A confirmed she did not wear eye protection during the cleaning of the [CONDITION(S)] with multiple sterile cotton-tipped applicators, that produced significant mucous from R20. LPN A stated, I looked down and realized that my goggles were on his overbed table, and I picked them up with my sterile left hand and put them on. LPN A acknowledged the lack of any sterile hand at that point of the observation. LPN A confirmed she continued to work with two dirty gloves during cleaning and re-insertion of R20's [CONDITION(S)]. LPN A said she had additional sterile gloves in the drawer that she could have changed into, had she realized her error. Review of the Lippincott Nursing Procedures, Seventh Edition, dated October 17, 2015, provided by the facility on 10/18/22, revealed the following, in part: . Explain the procedure to the patient, even if he's unresponsive. Tell him that suctioning (clearing the respiratory tract of secretions) usually causes transient coughing or gagging but that coughing helps to remove secretions . Put on a mask and goggles or mask with face shield and other personal protective equipment as appropriate . [CONDITION(S)] Care . Cleaning a nondisposable inner cannula: Put on sterile gloves . During an interview on 10/18/22 at 1:30 p.m., the DON confirmed LPN A should have worn eye protection in the form of goggles, or face shield when cleaning of the [CONDITION(S)] that resulted in mucous expectoration. The DON also acknowledged that all facility staff were currently required to wear eye protection while present in resident care areas, due to high community spread of COVID-19. B. Based on interview and record review, the facility failed to develop a comprehensive Water Management Plan (WMP) to address the control and spread of Legionella bacteria in the facility water system, in accordance with QSO 17-30 Hospitals/CAHs/NH, Revised 7-6-2018. The facility failed to develop and implement a water management program that considers the ASHRAE 188 (American Society of Heating, Refrigerating and Air-Conditioning Engineers) and the CDC (Centers for Disease Control) tool kit. The failure to develop a comprehensive Water Management Plan has the potential for the proliferation and transmission of Legionella in the circulating water of the building and the spread of Legionella infections in all 52 residents. Findings include: On 10/18/22 at approximately 3:30 PM, an interview with the Nursing Home administrator was conducted to review the Water Management Plan (WMP) for Legionella control in the potable water supply of the facility. The document titled Air and Water Management Program Sec 02 Policy 14 was provided for review. A review of the above document was conducted to determine the scope of the plan. Under the section titled GUIDELINES, the document directed the facility to: 3. A risk assessment will be conducted by the air and water management team annually to identify where Legionella and other opportunistic Pathogens could grow . 5. Based on the risk assessment, control points will be identified. 6. Control measures will be applied to address potential hazards at each control point. 7. Testing protocols and control limits will be established for each control measure. 8. The air and water management team shall regularly verify that the air and water management program is being implemented as designed. 9. The effectiveness of the water management program shall be evaluated no less than annually. The policy had not been followed with the development of a comprehensive water management plan. The following components were absent from the facility WMP: A. Designation of a Water Management Team (WMT), identifying names and their roles. B. An assessment of the facility's water system to identify risk locations such as areas of stagnation or low flow, disinfection level and/or temperature control. C. Identification of control points where effective monitoring and mitigation measures can be used. D. Identification of critical limits related to the risk areas identified and which can be controlled. E. Implementation of regular scheduled monitoring program collecting data on limits set. F. An evaluation process to determine how the WMP is functioning. G. An annual review of the plan and collected information to ensure the plan was effective. On 10/19/22 at approximately 10:15 AM, the NHA confirmed that the facility had not developed the above components of the water management plan.

Based on observation, interview and record review, the facility failed to provide supervision, staff education, assessment, and monitoring of the physical plan to prevent the elopement of one Resident (#5) and the potential for elopement for nine Residents (#4, #12, #15, #16, #21, #31, #35, #46, #52) out of 63 residents reviewed for supervision/elopement. This deficient practice resulted in the elopement of Resident #5 who was witnessed leaving the building by staff and was outside of the building for 48 minutes, and the likelihood of elopement for the other elopement risk residents while exits were unlocked/unsupervised, with the potential for severe injury or death. Findings include: The Administrator was notified of the Immediate Jeopardy (IJ) on 6/30/21 at 3:55 p.m., and was asked for an abatement plan to remove the immediacy. The IJ started on 6/20/21 at 9:58 a.m., when Resident #5 eloped from the facility after exiting though an unlocked exit door. The staff who witnessed Resident #5 leaving did not ensure supervision was provided for this cognitively impaired resident who was leaving the building unacommpanied. The IJ was removed on 6/30/21 at 5:48 p.m., based on the facility's corrective action taken to address the unlocked exit doors on 6/30/21. The deficient practice continued at a level of more than minimal harm until implementation of the complete removal plan is verified onsite. Resident #5 A review of the facility reported incident dated 6/20/21 involving Resident #5 revealed the following: On 6/20/21 at approximately 1045 (a.m.), member of (name of Facility) 1 North Hall (Resident #5) was reported by health care staff outside at the 1 East/North (1N East) door in his wheelchair. (Resident #5) reported that he wanted to go outside so he went to the door and read the sign that said the door will open after 15 seconds and exited through the 1 East/East stairwell door. Health care staff reported that (Resident #5) was witnessed exiting the 1 East/East (1N E stairwell) door . He (Resdient #5) was seen after he received his morning medications but before eleopement sitting outside room 134 observing the activitiy on the hallway. He was witnessed exiting the 1 East/East (1N East) stairwell door sometime after breakfast. Upon video surveillance review, at 0958 (Resident #5) exited the 1 East/East (1N East) stairwell door and stopped at the gate to the patio gate, he then moves and turns down the sidewalk at 1014 (a.m.) and ambulates in his wheelchair to (the) driveway. (Resident #5) was then witnessed by two health care staff at 1046 at the 1 East/North exit door . The health care staff member who observed member (Resident #5) exiting door was reeducated on the facilities policies on Elopement Prevention. A Velcro mesh passive deterrant was placed at the 1 East/East stairway door . A temporary audible alarm was intalled. A contractor has been to the facility to provide a quote to install a permanent audible door alarm. The facility reviewed all members with a Brief Interview for Mental Status (BIMS) of zero that are independently ambulatory for elopement risk . A review of Resident #5's medical record revealed he admitted to the facility on [DATE] with diagnoses including dementia and repeated falls. A review of his 4/2/21 Minimum Data Set (MDS) assessment reveled he scored 0/15 on the BIMS assessment indicating severely impaired cognition and used a wheelchair for locomotion. A review of Resident #5's 4/8/21 Elopement Evaluation assessment revealed he scored a 0. This assessment did not calculate the Resident's cognition into the risk for elopement. A review of Resident #5's care plan revealed a new care plan for elopement risk dated 6/20/21, after his elopement. On 6/29/21 at 2:32 p.m., an interview was conducted with Certified Nurses Aide (CNA) X. CNA X reported that she was out on break when another staff came up to her and asked if Resident #5 was supposed to be outside. CNA X reproted she called the facility to meet her at the 1 North Front Entrance to get Resident #5 back inside, and reported that Resident #5 was out of breath because he had to go up a hill to get to the entrance. Per CNA X Resident #5 did not have a code alert on at the time, but had a history of asking staff to go outside but is usually able to be redirected. On 6/29/21 at 3:45 p.m., the 1N East Interior door was observed with a sign that stated Push Until Alarm Sounds Can be Opened in 15 Seconds. This door was able to be opened with no alarm and no locking mechanism. The 1N East Exterior door in the stairwell was observed with a tab alarm that was clipped to an eye pin on the wall. This tab alarm was easily removed and the door was able to be opened with no locking mechanism and no alarm. On 6/29/21 at 4:00 p.m., the facility was toured to observe each exit door. The 1W Stairwell Interior door had a sign on it that stated, Push Until Alarm Sounds Can be Opened in 15 Seconds, yet when pushed it freely opened with no lock and no alarm. The 1W Stairwell exterior door to the outside also opened with no alarm or lock. This exit allowed entry to a rocky roof area with foam pads that led to the Business Entry parking area and was situated next to a street. The 1C Central Stairwell interior door was able to be opened with no alarm or lock. This door opened into a stairwell that had an exterior door that was not locked or alarmed, and opened freely to the outside into a parking lot. The Chapel double doors were able to be opened and entered. Behind the stage of the chapel the Back Chapel interior and exterior doors were unalarmed and unlocked, giving free access to the outside parking lot. The 1N East interior door was able to be opened with no alarm or lock and opened into a stairwell with options to go up the stairs, down the stairs (over a gate), or out through the exterior door to the outside, which had the attached tab alarm. The 1S Part F Stairwell interior door was unlocked and unalarmed and allowed free access into the stairwell, with options to go up the stairs or down the stairs (gaited). At the bottom of the stairs the 1S Part F exterior door allowed entry to a back parking area and was unlocked and unalarmed. The 1North interior door was found to be unlocked and unalarmed. The 1North exterior door was found to be the only exterior door that had a functioning lock that did not allow exit from the building. On 6/29/21 at 4:18 p.m., an interview was conducted with Dietary Staff P who was in the hallway near the maintenance department. When asked if she could locate a maintenance staff to discuss the doors with, Dietary Staff P reported the maintenance staff leave at 4:00 p.m., and that any maintenance issues would be handled by the first floor charge nurse. On 6/29/21 at 4:22 p.m., the Administrator was asked to tour the exits with this Surveyor. The 1W Stairwell doors were observed with the Administrator, and while the personal alarm system was functioning, the doors only locked if the personal alarm was present. The 1 C Center stairwell doors were observed to be able to be exited through with no alarms or locks. When asked about this, the Administrator reported that the situation was just temporary and that the facility would get a quote to get alarms with keypads on the doors. The Chapel interior and exterior doors were reviewed with the Administrator and when he observed no locking or alarming stated, They all used to be keyed (to exit). The 1S Part F stairwell was also observed with the administrator. When asked about why all of the doors were able to be exited with no system in place to prevent residents without personal alarms to exit without supervision, the Administrator reported that it was due to a previous fire safety issue, and that the issue could be discussed on the following survey day. On 6/30/21 at 11:27 a.m., an interview was conducted with CNA Q who was the staff who watched Resident #5 exit the 1N East stairwell door on 6/20/21. When asked to describe what she remembered about that incident, CNA Q reported she had walked out of another door and had observed Resident #5 in the open doorway of 1N East stairwell. CNA Q reported that it was fathers day and there had been many activities going on so she assumed that Resident #5 was going out with a staff member, despite not actually seeing any staff with the Resident. When asked if she had been interviewed about the event, CNA Q stated that she had just been asked about what time she had witnessed Resident #5 in the doorway. When asked if she had been educated or disciplined, CNA Q reported that she had just completed a Relias (education program training) on elopement on the computer. When asked if she had received any one on one education on the facilities specific elopement policy and procedure, CNA Q reported that she had not. When asked about what had been done to prevent a subsequent elopement, CNA Q reported that Resident #5 had been given a code alert and the facility had implemented a hall monitor (staff) and a velcro yellow fabric to go across the door. CNA Q stated, I didn't even know that that door was unlocked. When asked when she recalled the door last being locked, CNA Q reported she didn't know. When asked about the other exterior doors, CNA Q stated, Yeah, to get out the door you had to put a code in or it would alarm. A review of CNA Q's education since hire revealed she had completed online Relias education regarding elopement on the following dates: 5/24/19, 6/20/19, and 6/28/21. On 6/30/21 at 4:15 p.m., an interview was conducted with CNA R who was working on the first floor. When asked about the last time she was educated on the how the exterior doors worked and what type of locks or alarms were in use, CNA R stated, Someone just came around and said that all the stairwells are key pad locked now. CNA R also reported that she was not sure when the last was that there was an education on how the doors and alarms worked. On 6/30/21 at 4:21 p.m., an interview was conducted with Licensed Practical Nurse (LPN) T, who when asked about the last time she was educated on which doors locked and which doors alarmed stated, When I first came here I know they did an education. LPN T reported that previously (date unknown) the doors locked with key pads. LPN T reported that she knew that the 1North exterior door locked and wasn't sure if any of the others ones locked. On 6/30/21 at 4:28 p.m., an interview was conducted with LPN S, who when asked when she was last educated on which doors locked and which doors had alarmed stated, Well last year there was a shooting in a veterans home so they locked all the doors. Then it changed. And then with COVID they were all locked and we could only come in through downstairs. Then it changed again at some point. LPN S reported that previously the 1North interior door was not locked, but today (6/30/21) it was locked. LPN S could not recall when she had her last education on how the doors/alarms functioned. On 7/1/21 at 10:15 a.m., the DON and the Administrator were asked about the Elopement Evaluation assessment that was being used. The Administrator reported that he believed it was an assessment that came with the medical records program. When asked if this Elopement Evaluation tool had been reviewed to see if it was appropriate for capturing the true elopement risk of a Resident, the Administrator reported that he did not believe that it had been reviewed. On 7/1/21 at 10:23 a.m., Registered Nurse (RN) V was asked via telephone about how she educated or disciplined CNA Q and reported that she had CNA Q complete a relias training on the computer about elopement. When asked if it was a facility specific education, RN V reported she did not believe it was. When asked about what disciplinary action was taken for CNA Q failing to follow the facility's elopement policy, RN V stated, If it's the very first offense we just do a verbal warning. When asked for the documentation that this discipline had taken place, RN V reported that she was instructed to just keep track of it on her Outlook calendar and if there was a subsequent issue then there was would be something in writing. RN V was asked to have the facility provide a screen shot of her Outlook calendar with this note on it, but it was not provided by the time of exit. On 7/1/21 at 10:45 a.m., an interview was conducted with Certified Occupational Therapy Assistant (COTA) U and Physical Therapist (PT) W. When asked about whether they felt that cognition should be considered in the Elopement Evaluations, PT W stated, I think it's important to consider cognition and mobility. PT W reported she was not sure what the Elopement Evaluation tool that the facility was using included. On 7/1/21 at 10:50 a.m., the Administrator reported that he had spoken with upper management, and that the Elopement Evaluation tool had been reviewed and was deemed to be appropriate. When asked why the BIMS score was noted in the assessment, but the BIMS score and mobility status were not reflected in the scoring of the assessment, the Administrator stated, The BIMS is not a measure of cognition, not in my opinion. The Administrator also reported that he did not believe there was any correlative link between cognition and elopement risk. The facility was asked to provide a list of Residents that did not have code alerts and their cognition levels. The facility provided a full Residents list and noted in highlighter which Residents had code alerts and wrote their BIMS beside it. Residents who were documented by the facility staff as being dependent on this staff for ambulation/locomotion were not included in the review. From this list, Residents without code alerts and also having a BIMS of 12 or less included the following: #4, #12, #15, #16, #21, #31, #35, #46, and #52. Resident #4 A review of Resident #4's 6/25/21 MDS revealed she scored 99 on the BIMS assessment and was assessed by staff to be Severely Impaired in cognition. A review of Resident #4's Elopement Evaluation dated 6/21/21 revealed a BIMS score of 6 and a Confusion Assessment Method (CAM) score of 2, with no question marked yes, resulting in a risk score of 0, not at risk. Resident #12 A review of Resident #12's 4/15/21 MDS revealed he scored 10/15 on the BIMS assessment, indicating moderately impaired cognition. A review of Resident #12's Elopement Evaluation dated 4/18/21 revealed a BIMS score of 13 and a CAM score of 0, with no question marked yes, resulting in a risk score of 0, not at risk. Resident #15 A review of Resident #15's 4/22/21 MDS revealed he scored 12/15 on the BIMS assessment indicating moderately impaired cognition. A review of Resident #15's Elopement Evaluation dated 6/8/21 revealed a BIMS score of 12 and a CAM score left blank, with two question marked yes (Does the resident have a history of elopement or an attempted elopement while at home? Does the resident have a history of elopement or attempted leaving the facility without informing staff?) Resident #15's elopement risk score was 2, at risk. A review of Resident #15's care plan revealed no elopement care plan. Resident #16 A review of Resident #16's 4/22/21 MDS revealed she scored 3/15 on the BIMS assessment indicating severely impaired cognition. A review of Resident #16's Elopement Evaluation dated 4/15/21 revealed a BIMS score of 4 and a CAM score of 0, with no question marked yes, resulting in a risk score of 0, not at risk. Resident #21 A review of Resident #21's 4/29/21 MDS revealed she scored 11/15 on the BIMS assessment indicating moderately impaired cognition. A review of Resident #21's Elopement Evaluation dated 5/14/21 revealed a BIMS score of 11 and a CAM score of 0, with no question marked yes, resulting in a risk score of 0, not at risk. Resident #31 A review of Resident #31's 5/14/21 MDS revealed he scored 1/15 on the BIMS assessment indicating severely impaired cognition. A review of Resident #31's Elopement Evaluation dated 5/21/21 revealed a BIMS score of 2 and a CAM score of 0, with no question marked yes, resulting in a risk score of 0, not at risk. Resident #35 A review of Resident #35's 5/18/21/21 MDS revealed he scored 12/15 on the BIMS assessment indicating moderately impaired cognition. A review of Resident #35's Elopement Evaluation dated 5/11/21 revealed a BIMS score of 11 and a CAM score of 0, with no question marked yes, resulting in a risk score of 0, not at risk. Resident #46 A review of Resident #46's 6/4/21 MDS revealed he scored 3/15 on the BIMS assessment indicating severely impaired cognition. A review of Resident #46's Elopement Evaluation dated 4/26/21 revealed a BIMS score of 3 and a CAM score of 0, with no question marked yes, resulting in a risk score of 0, not at risk. Resident #52 A review of Resident #52's 6/11/21 MDS revealed she scored 10/15 on the BIMS assessment indicating moderately impaired cognition. A review of Resident #52's Elopement Evaluation, dated 6/9/21, revealed a BIMS score of 12 and a CAM score of 0, with 4 questions marked yes (Does the resident have a history of elopement or attempted leaving the facility without informing staff? Does the resident wander? Is the wandering behavior a pattern, goal-directed (i.e. specific destination in mind, going home etc.)? Is the resident's wandering behavior likely to affect the safety or well-being of self/others?) This assessment also revealed under Clinical Suggestions: Apply personal safety alarm devices. Monitor location frequently. Utilize exit alarm(s). This assessment revealed a risk score of 2, at risk. An interview was conducted with LPN M on 7/1/21 at approximately 9:00 a.m. in regard to Resident #52's wanderguard. LPN M stated that Resident #52 does not have a wanderguard or any alarming system on her. A review of Resident #52's care plan revealed no elopement risk care plan with interventions to prevent elopement. On 7/1/21 at 10:15 a.m., an interview was conducted with the DON and the Administrator. When asked about why Resident #52 didn't have her code alert on and why there was no elopement care plan, the DON reported that the family of Resident #52 didn't want her to have a code alert, which had occurred prior to the DON starting at the facility. When asked why then did Resident #52 have a signed consent for the code alert by her family representative on 11/10/20, the DON reported he did not know and would check into it. When asked if Residents at risk for elopement should have care plans for elopement with interventions to prevent it from occurring, the DON confirmed that they should. On 7/1/21 at 10:50 a.m., the Administrator was asked to provide any further information on Resident #52's lack of code alert bracelet and care plan, and reported he had nothing to provide yet. As of the survey exit on 7/1/21 at 11:00 a.m., the facility provided no further information as to why Resident #52 did not have a code alert in place per her assessment. A review of the facility policy titled, Elopement Code Green (undated) revealed, .**NOTE** All facility staff are responsible to identify wandering members and intervene in the event of an elopement . A review of the facility policy titled, Elopement Prevention (undated), revealed, .It is the policy of (name of facility) to assess each members ' risk for elopement and implement a care plan with appropriate interventions to prevent confused members from elopement from the facility or safe area without authorization or appropriate supervision .1. Assesses each member for a history of wandering/elopement behavior. Determines frequency of its occurrence and any factors that trigger and/or decrease the episodes .3. Initiates an Elopement Care Plan and implements appropriate interventions if a member is determined to be as risk for elopement . The facility abatement plan accepted 6/30/21 included the following: All 13 exit doors have alarms activated 6/30/21 . The staff who had witnessed the resident [#5] going through the door was reeducated on the facility's Elopement Prevention Policy 6/28/21 . Maintenance temporally [sic] placed an audible alarm on the 1East North door. A process was initiated to install a permanent audible alarm and this process will be completed when contractor and materials available. Perimeter door alarms were activated 6/29/21 . All staff have been educated on the activated exit door alarms 6/30/21 . All staff have been reeducated on the Elopement prevention policy 6/30/21 .

Based on observation, interview, and record review, the facility failed to properly perform hand hygiene during meal services, resulting in the potential for food borne illness that could affect those who receive their food from the second-floor dining hall. Findings include: On 6/29/21 at approximately 7:50 a.m., the breakfast meal was observed on the second-floor dining hall. Cook/Staff E was observed wearing single use gloves while touching dirty dishes, wiping the back of her forehead, and refilling a hot coffee for an unidentified resident using the original mug the resident had previously used. Staff E doffed (removed) the used gloves and did not perform proper hand hygiene prior to donning (putting on) clean gloves. An interview was conducted following this observation with Staff E who explained that during the breakfast meal, there were approximately 11 residents who ate in the dining room, and she was responsible for handing out the breakfast meals and to meet their request during the meal service. On 6/30/21 at approximately 8:00 a.m., the breakfast meal was again observed on the second-floor dining hall. Staff E was observed wearing single use gloves during this observation and was seen helping various unidentified residents with their breakfast meals which included: buttering bread and mixing oatmeal with the resident's spoon at the table. Staff E then doffed her gloves and did not sanitize her hands prior to donning clean gloves. Staff E removed dirty dishes and returned them to the kitchen unit in the second-floor dining hall, doffed her gloves and proceeded to the sink. Staff E rinsed her hands with water for under 10 seconds, dried her hands with paper towel, and donned clean gloves. An interview was conducted with Staff E at this time, and she explained her process was that she removes her gloves when they are dirty and replaces them with clean gloves. Staff E did not state during this interview that she was to sanitize her hands after removing the dirty gloves. On 6/30/21 at 8:26 a.m. an interview was conducted with the Dietary Manager (DM) F. DM F explained that the expectation of dietary staff was to sanitize their hands often especially when touching residents' foods and dishes. When queried about Staff E touching residents' utensils, removing dirty dishes, touching her forehead, and not changing her gloves or properly sanitizing her hands, DM F stated that she should have washed her hands more frequently and in between glove changes. Review of the facility's Infection Control Standard Precautions: Handwashing - Hand Hygiene dated 4/28/21 read, in part: .all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, members, and visitors .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .before donning sterile gloves .after removing gloves .before and after assisting a member with meals .The use of gloves does not replace hand washing/hand hygiene .

Based on observation, interview and record review, the facility failed to maintain acceptable medication storage temperatures for three of three medication refrigerators. This deficient practice resulted in the potential for reduced efficacy of stored medications in the refrigerators. Findings include: On 6/30/21 at 9:37 AM, the memory care unit medication room was observed with Licensed Practical Nurse (LPN) N. Upon inspection of the temperature log for the medication refridgerator for the unit, there were six temperature observations missing from the log for June 2021. The missing temperatures for June 2021 were on 6/2, 6/5, 6/11, 6/22, and 6/30. There were seven temperatures below the safe range (35-40 degrees Fahrenheit[F]) for stored medications on 6/4, 6/10, 6/13, 6/15, 6/20, 6/23, and 6/28. There was an opened [MEDICATION(S)] solution vial (for TB testing) and 8 resident specific insulin vials stored inside the refrigerator. Four [MEDICATION(S)] insulin vials were open for four separate Residents (#25, #41, #42 #55), and there were two unopened [MEDICATION(S)] for Residents (#25, #41). There were also two opened Novolog insulin vials for Residents (#25, #55). [MEDICATION(S)] and Tylenol Suppositories were also stored in the medication refrigerator. On 6/30/21 at 10:35 AM, the medication room for the second floor was observed with Registered Nurse (RN) O. The refrigerator temperature log for June 2021 was observed with 11 temperatures below the safe range on 6/1, 6/3, 6/9, 6/17, 6/19, 6/20, 6/21, 6/23, 6/24, 6/26, and 6/30. There were five opened [MEDICATION(S)] insulin vials in the refrigerator for Residents (#11, #33, #38, #413, #414). There was also a [MEDICATION(S)] pen injector in the refrigerator for Resident # 413. There was an opened [MEDICATION(S)] solution vial and [MEDICATION(S)] and Tylenol suppositories present in the refrigerator. There was also plastic and Styrofoam cups stored in a cupboard directly under the sink. On 6/30/21 at 11:00 AM the first floor medication room was observed with RN K. The refrigerator temperature log for June 2021 revealed four temperatures below the safe range on 6/18, 6/20, 6/23, and 6/24. There were multiple vials of insulin stored in the refrigerator as well as an opened [MEDICATION(S)] solution vial, [MEDICATION(S)] suppositories and Tylenol suppositories. On 6/30/21 at 11:55 AM, during an interview, the Director of Nursing (DON) was informed of the temperatures below safe storage parameters for insulin and was asked for the medication storage policy. On 6/30/21 at 12:00 PM, during an interview, RN K was asked what she was going to do with the medications located in all three medication refrigerators. RN K stated she would have to dispose of and replace the insulin located in each medication refrigerator. A review of the policy, Storage of Medications Requiring Refrigeration, no date, read in part: .b. Each refrigerator/freezer shall have an accurate functioning thermometer. Refrigerator temperatures are maintained within 35-40 degrees F .temperatures are recorded daily by the night shift medication nurse .d. Any medicines at improper temperature will be removed from active stock and returned to the Pharmacy for disposal. A review of the facility provided [MEDICATION(S)] Manufacturer Information, Revised December 2020, read in part: .cool storage (36F-46F[2C(Celsius)-8C]) .Do not allow it to freeze. A review of the facility provided [MEDICATION(S)] Manufacturer Information, dated 12/2020, read in part: .Do not freeze [MEDICATION(S)] or use [MEDICATION(S)] if it has been frozen. Do not store [MEDICATION(S)] near the refrigerator cooling element . .Store your [MEDICATION(S)] pen at 59F to 86F, or in a refrigerator at 36F to 46F (2C to 8C) . A review of the facility provided Novolog Manufacturer Information, revised 03/2021, read in part: .Do not freeze Novolog. Do not use Novolog if it has been frozen . .Store unopened Novolog vials in the refrigerator at 36F to 46F (2C to 8C) .

Based on interview and record review, the facility failed to assist residents in scheduling Resident Council (group) meetings following return to group activities and failed to respond promptly to group member grievances and recommendations related to life in the facility. This deficient practice resulted in ongoing resident dissatisfaction, and the potential to adversely affect Residents' health and quality of life and had the potential to affect all residents participating in the Resident Council. Findings include: During an interview in 6/28/21 at 5:00 p.m., Registered Nurse/Infection Preventionist (IP) A confirmed that Resident Council had not been meeting in person since discontinuation of group activities related to COVID-19. IP A said Social Worker (SW) B oversaw the Resident Council. SW B provided the monthly Resident Council minutes, which upon review did not identify the individuals who had completed monthly Member Council Questionnaires, but only identified the residents as Member. When SW B was asked which residents had written or verbalized the following Old Business concerns from the May 18th, 2021 Member Council Minutes (Old Business concern expressed in April, 2021 or earlier): 1. Member would like more in-person visit. 2. Member would like to be able to go home for a visit and then come back. 3. Member would like his family member to have their calls returned regarding trying to schedule a family visit. Is there anyone that she can meet with to have her concerns addressed? 4. We need to be let out of these rooms. We don't care about the disease. This is not a prison. 5. Why did we all get the vaccine if we are still being locked down? SW B was unable to identify any of the specific residents expressing those concerns. The May 18, 2021 Member Council Minutes, with Old Business concerns expressed by residents in April, 2021 (or earlier) were published and delivered to the facility Residents during the first week of June, approximately six weeks or greater from the concerns being written. The facility response to all of the above resident concerns was printed in the facility Resident's News newsletter as Refer to [Director of Nursing (DON)]. No response received - see previous COVID restriction concerns. Resident interviews revealed the following: Interview on 6/29/21 at 3:20 p.m., Resident #44 said he had not participated in a Resident Council meeting in a long time, and he reported not filling out a survey (questionnaire) form related to Resident Council. Interview on 6/29/21 at approximately 3:25 p.m., when asked about visits with her family Resident #21 stated, I only get visits when they arrange it. Resident #21 said the visits were not very often. Interview on 6/29/21 at approximately 3:30 p.m., Resident #13 confirmed there had not been any Resident Council meetings in a long time, probably since the beginning of COVID-19. Resident #13 said he did not say much because nothing ever gets changed. Interview on 6/29/21 at 2:39 p.m., Resident #22 said he had not been to the Resident Council meetings, nor filled out any questionnaire. The Member Council Questionnaires were requested from the DON for April through June of 2021. These questionnaires formed the basis for the de-identified resident concerns noted on the Member Council Minutes. Eight resident questionnaires were received for review: zero for April 2021, three for May 2021, and five for June 2021. The forms identified the date it was written, received, and entered, with seven of the eight forms having the identity of the resident clearly noted on the form. During an interview on 6/30/21 at 8:27 a.m., the DON was asked if he could identify the residents who had voiced the above concerns in the May 18, 2021 Member Council Minutes. The DON stated, I did not know who it was. The DON said he did not respond directly to the residents because he did not know who the residents were. The DON provided a response back to Executive Assistant (H), failing to respond to the concern for period of up to six weeks or longer. The DON agreed that the residents expressing concerns had the right to voice their concerns and receive a response related to their grievances. During a telephone interview on 6/30/21 at approximately 9:06 a.m., IP A, in the presence of the DON, was asked about the lack of Resident Council meeting reinstatement. IP A stated, I was not aware of that (Resident Council was not meeting). IP A said when she called to assist this Surveyor with the Resident Council survey task was when IP A realized they were not doing the meetings in person. IP A stated, They definitely can be, and agreed Resident Council group meetings should have started when communal dining and group activities were reinstated (at the end of May 2021). IP A confirmed no staff had asked about the possibility of having a Resident Council meeting in May or June. During an interview on 6/30/21 at approximately 9:10 a.m., the DON stated, Obviously we have a system issue. I have a serious concern related to this. During this interview, a Member Council Questionnaire, completed by Resident #33 on 5/25/21, was reviewed with the DON. The form identified the writer, the date, and was noted on the bottom of the form as follows: Responses will be provided in written format either in a direct response to the member or in the monthly newsletter. When asked if a response had been provided to Resident #33's concern, the DON stated, I have not responded to that concern yet. My due date (for a response) was July 7th. The DON provided a 6/18/21 email from Executive Assistant H that first brought Resident #33's concern to the DON's attention. The DON acknowledged the response would be published and distributed in the facility newsletter approximately six weeks after Resident #33 provided the written concern on the Member Council Questionnaire. The DON stated, I absolutely understand the concern. Review of the Member Advisory Council, policy, undated, revealed the following, in part: The purpose of this policy is to provide a mechanism available for all Members to communicate thoughts, concerns, and issues and discuss issues with the staff of the Home . WHO DOES WHAT: Department Heads 11. Upon receipt of the Minutes, provides immediate corrective action to any concerns addressed for their department. This action is to be documented and forwarded to the Member Services Secretary for reading at the next Council Meeting . During an interview on 6/30/21 at 3:55 p.m., when asked why the Resident Council was not reinstated when communal dining and group activities began in May 2021, SW B stated, I guess we were just going to take baby steps and see how things went. Our next meeting is in July. Review of the July, 2021 Resident's News newsletter revealed the following information for all facility residents: We encourage all members to participate in filling out the Member Council questionnaire . ATTENTION: We will have the next in-person Member council meeting on Tuesday, August 17, 2021 at 10:00 a.m. in the Recreation Room .and we encourage all members to attend.

Based on observation, interview and record review, the facility failed to prevent a medication error rate of less than 5% for medication errors in five Residents (#5, #38, #42, #62 and #413) of eight residents reviewed. This deficient practice resulted in the potential for altered therapeutic effects and undesirable side effects of medications not being administered as ordered. Findings include: On 6/29/21 at 1:10 PM, medication administration was observed performed for Resident #5 by Licensed Practical Nurse (LPN) M. LPN M began by taking a Novolog (insulin) vial for Resident #5 and inverting the vial to inject the amount of air into the vial equivalent to the dose before drawing it up. This action caused bubbles to enter the solution in the vial. LPN M then prepared the dose. An approximate 2 unit air bubble at the top of the syringe was observed by this Surveyor. LPN M then proceeded to the room with the syringe and was stopped just prior to entry to look at the syringe. LPN M was asked to acknowledge the bubble at the top of the syringe and LPN M confirmed the finding. LPN M then returned to the cart to correct the dose. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] NOVOLOG 100 UNIT/ML (milliliter) VIAL Inject 10 unit subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9) After lunch -Start Date- 05/21/2021 1130 On 6/30/21 at 7:45 AM, medication administration was observed performed for Resident #62 by LPN L. LPN L utilized an 'unit' measuring insulin syringe to draw up, measure and administer [MEDICATION(S)] (controlled injectable opioid pain medication) 2 mg (milligram) from a 4 mg/ml [MEDICATION(S)] (specialized injection system) vial. LPN L then placed the unused [MEDICATION(S)] back in the cart and stated she would waste the medication later during shift change with the oncoming nurse. This Surveyor returned to the medication cart for 2 North to perform medication storage observation of the cart on 6/30/21 at 10:10 AM with LPN L. The [MEDICATION(S)] [MEDICATION(S)] vial which needed to be wasted was still in the cart with approximately half of the solution remaining. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Solution 4 MG (milligram)/ML Inject 2 mg subcutaneously every 4 hours as needed for Pain - Moderate ;Pain - Severe related to TACHYPNEA (rapid respirations), NOT ELSEWHERE CLASSIFIED (R06.82) -Start Date- 02/11/2021 1100 On 6/30/21 at 9:05 AM, medication administration was observed performed for Resident #38 by LPN L. LPN L began by taking a [MEDICATION(S)] vial for Resident #38 and inverting the vial to inject the amount of air into the vial equivalent to the dose before drawing it up. This action caused bubbles to enter the solution in the vial. LPN L then prepared the dose and this Surveyor viewed the syringe. An approximate 2 unit air bubble was observed at the top of the syringe. LPN L then proceeded to the room with the syringe and was stopped just prior to entry to look at the syringe. LPN L was asked to acknowledge this Surveyor's observation of a bubble at the top of the syringe and confirmed the finding. LPN L then returned to the cart to correct the dose. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 100 UNIT/ML VIAL Inject 25 unit subcutaneously after meals related to TYPE 2 DIABETES MELLITUS WITH UNSPECIFIED COMPLICATIONS (E11.8) -Start Date- 04/22/2021 0830 On 6/30/21 at 9:05 AM, medication administration was observed performed for Resident #413 by LPN L. LPN L prepared an injection of [MEDICATION(S)] (anti-diabetic injectable medication) via an injection pen by attaching the needle and then primed the pen sideways. LPN L then went to the room and administered the dose of [MEDICATION(S)] by depressing the injection plunger and then immediately withdrew the needle without any time lapse between depressing the plunger and withdraw of the needle. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Solution Pen injector 18 MG/3 ML (Liraglutide) Inject 0.3 milliliter subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS WITH DIABETIC [CONDITION(S)], UNSPECIFIED (E11.40) (0.3 ml = 1.8 mg) -Start Date- 06/22/2021 0645 On 6/30/21 at 9:13 AM, medication administration was observed performed for Resident #42 by LPN N. LPN N began by taking a [MEDICATION(S)] (insulin) vial for Resident #42 and inverting the vial to inject the amount of air into the vial equivalent to the dose before drawing it up. This action caused bubbles to enter the solution in the vial. LPN N then prepared the dose and this Surveyor viewed the syringe. An approximate 2 unit air bubble was observed at the top of the syringe. LPN N then proceeded to the room with the syringe and was stopped just prior to entry to look at the syringe. LPN N was asked to acknowledge this Surveyor's observation of a bubble at the top of the syringe and confirmed the finding. LPN N then proceeded to tap the syringe to remove the bubble and pushed the air out of the syringe in the presence of this Surveyor. LPN N acknowledged this action altered the dose of insulin by two units. LPN N then returned to the cart to correct the dose. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 100 UNIT/ML VIAL Inject 26 unit subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS WITH DIABETIC [CONDITION(S)] (E11.21) -Start Date- 04/11/2020 0645 On 6/30/21 at 11:00 AM, during an interview, Registered Nurse (RN) K Unit Manager was asked about the use of an insulin syringe to measure and administer a medication measured in cubic centimeters (cc's). When asked if the [MEDICATION(S)] [MEDICATION(S)] should have been drawn up, measured and administered from an insulin unit measuring syringe, RN K stated an insulin syringe should not have been used to measure the [MEDICATION(S)]. When asked if it was the practice to hold a syringe in place following administration of insulin through a syringe and pen injectors for a period of time, RN K stated the syringe should be held in place for at least 5 seconds to minimize escape of insulin injected and assure full dose was administered. On 6/30/21 at 11:55 AM, during an interview with the Director of Nursing (DON), the concerns were reviewed regarding medication pass related to insulin injection and time to hold during injection before withdrawing needle, position in which to inject air in an insulin vial before drawing up, assuring no bubbles present in syringe for accurate dosing, and using appropriate syringe for drawing up specific types of medications. The DON agreed all observations were valid concerns. A review of the facility provided [MEDICATION(S)] Manufacturer Information, dated 12/2020, read in part: .Step D. Prepare the Pen · Hold pen with needle pointing up. · Tap the cartridge gently with your finger a few times to bring any air bubbles to the top of the cartridge . · Keep needle pointing up and press dose button until 0 mg lines up with pointer .until a drop of [MEDICATION(S)] appears at the needle tip . .Step H. Injecting the Dose · Insert needle into your skin in the stomach (abdomen), thigh or upper arm . · Press down on the center of the dose button to inject until 0 mg lines up with the pointer . · Be careful not to touch the dose display with your other fingers. This may block the injection. · Keep dose button pressed down and make sure that you keep the needle under the skin for a full count of 6 (six) seconds to make sure the full dose is injected. Keep your thumb on the injection button until you remove the needle from your skin . A review of the facility provided [MEDICATION(S)] Manufacturer Information, Revised December 2020, read in part: .Step 3: Draw air into the syringe equal to your insulin dose. Put the needle through the rubber top of the vial and push the plunger to inject the air into the vial. Step 4: Leave the syringe in the vial and turn both upside down. Hold the syringe and vial firmly in one hand. Make sure the tip of the needle is in the insulin. With your free hand, pull the plunger to withdraw the correct dose into the syringe. Step 5: Before you take the needle out of the vial, check for air bubbles. If bubbles are in the syringe, hold the syringe straight up and tap the side of the syringe until the bubbles float to the top. Push the bubbles out with the plunger and draw insulin back in until you have the correct dose . Step 8: · Pinch the skin. · Insert the needle in the way your health care provider showed you. · Release the skin. · Slowly push in the plunger of the syringe all the way, making sure you have injected all the insulin. · leave the needle in the skin for about 10 (ten) seconds. A review of the facility provided Novolog Manufacturer Information, revised 3/2021, read in part: .Step 3: Hold the syringe with the needle pointing up. Pull down on the plunger until the black tip reaches the line for the number of units for your prescribed dose . Step 4: Push the needle through the rubber stopper of the Novolog vial (See figure D [vial is held with solution not touching the needle tip]). Step 5: Push the plunger all the way in. This puts air into the Novolog vial (See figure E [vial is held with solution not touching the needle tip]). Step 6: Turn the Novolog vial and syringe upside down and slowly pull the plunger down until the black tip is a few units past the line for your dose . · If there are air bubbles, tap the syringe gently a few times to let any air bubbles rise to the top . Step 7: Slowly push the plunger up until the black line reaches the line for your Novolog dose . Step 8: Check the syringe to make sure you have the right dose of Novolog . Step 11: Insert the needle into your skin. Push down on the plunger to inject your dose . The needle should remain in the skin for at least 6 (six) seconds to make sure you have injected all the insulin. There was a total of 5 errors out of 28 opportunities for error which resulted in a 17.86% medication error rate.

Based on interview and record review, the facility failed to ensure the resident's right to receive visitors at the time of his or her choosing and failed to implement written policies and procedures regarding resident visitation rights for two Residents (#24 and #33) of 16 residents reviewed for resident's visitation rights. This deficient practice resulted in delayed visitation, a limited number of daily visits permitted, loneliness, and isolation for facility residents. Findings include: During an interview on 6/29/21 at 8:04 a.m., when asked about visitation with family, Resident #33 stated, I had a window visit when I was on the first floor, and last time we had an outdoor visit, and I went to the chapel a couple of times .We have been on lock down for quite a while. When asked about the frequency of visits, Resident #33 said he had no idea, but said he could get on the list (for a visit). Resident #33 said Licensed Practical Nurse (LPN) C oversaw scheduling the visits and could provide more information. During an interview on 06/29/21 at 9:53 a.m., LPN C confirmed resident visitations were limited to four per day for the total resident population of 113 residents and limited to 30 minutes per visit. During an interview on 06/29/21 at 10:49 a.m., Infection Preventionist (IP) A confirmed resident visitation was scheduled for three days a week in April, 2021 because those were days COVID-19 testing was not being performed. When twice a week testing was reduced the facility added that day to do resident visits. When asked about how the day and time of visits was determined, IP A said when family members called they would get the next time slot that was open, unless they ask for something specific. When asked about the lack of scheduled visits on weekends, IP A stated, They (family/friends) do want to visit on the weekend. IP A acknowledged the facility had talked about increasing the number of visits per day and talked about evening and weekend visitation. IP A stated, We are trying to figure (it) out. A copy of the guidance the facility was using related to the availability of only four visitation appointments daily, Monday through Friday, with no regularly scheduled weekend or evening visits was requested. IP A provided additional documentation of dementia unit visits for May and June 2021 that showed one to three scheduled visits on 14 of 30 days in May 2021, with visits on one of four weekends. In June, 2021, in person visits in the dementia unit were documented on seven of 27 days with two individual visits on weekend days. The dementia unit visitations were scheduled independently from the rest of the facility and not documented in the electronic visitation schedule. Review of the facility Member Bill of Rights and Responsibilities provided by Social Worker (SW) B on 7/1/21 at 7:30 a.m., revealed the following, in part: Each Home member may associate and communicate privately with persons of his or her choice. Reasonable regular visiting hours shall be not less than 8 hours per day . immediate access shall also be available for immediate family members, other relatives, and any other person visiting with the member's consent . During an interview with confidential visitors on 06/29/21 at 03:05 p.m., when asked about visitation, Family Members (FMs) I and J said they had not been able to visit as much as they would like to. In the last 15 months they reported they had approximately five visits with their loved one. They said if they could visit more - they would, and that any increase in visitation would be an improvement. During an interview on 06/29/21 at 10:07 a.m., the Director of Nursing (DON) said the facility resident population included 113 total residents, with 63 occupied beds which were certified by the State. The DON confirmed four visits were scheduled per day, to include scheduled visits for all 113 residents living in the facility. The DON said [IP A] set the number of visits conducted daily. When asked how long it would take for each resident to have one visit, with four visits set per day, the DON acknowledged it would be approximately one month. When asked if he felt that families may wish to see their loved one more than once a month, the DON said [IP A] set the number (of scheduled daily visits). During an interview on 6/30/21 at 9:06 a.m., IP A confirmed as of May 24, 2021 the facility was opened for communal dining and group activities (with mingling between floors) and confirmed the facility had no positive COVID-19 staff or residents, and no residents were in quarantine for COVID-19. During a telephone interview on 06/30/21 at 10:15 a.m., when asked about visitation between family/friends and the residents, Executive Assistant (Staff) H said in May, 2021 the facility was scheduling family visits by priority. When asked what the priority basis was, Staff H stated, They were trying to get everyone a visit before they rescheduled repeat visits. During a telephone interview on 7/1/21 at 9:00 a.m., when queried regarding facility visitation procedures, Family Member (FM) G stated, I had to call and make appointments to see [Resident #24]. It was not satisfactory to me .The last time I called they said they were only scheduling certain days for visitation and only up to four visits a day. I backed off of my visits so other people could have their turn for a visit. I would like to visit more if it weren't so restricted . I think if people are coming from a long distance there should be weekend visit times provided . Observation on 6/30/21 at 2:40 p.m., found a STOP sign posted on the double glass door entrance used by scheduled visitors. The sign read: [Facility Name] is not open to visitors due to risk of COVID-19. Anyone who does not live in, is not employed in or is not providing medically necessary services to the Home are asked not to visit at this time. If you have questions or concerns call [telephone number] . We are setting up remote visits through a variety of ways. Please call the Home if we can set up a virtual visit for you. Review of the facility Visitor Guideline Sheet, dated March 15, 2021, revealed the following, in part: Appointments will be scheduled with the home prior to visitation .Visits will be scheduled M - F (Monday through Friday) between 9am and 3pm unless specific arrangements are made to ensure that the home can maintain infection control standards . Review of April, May, and June 2021 electronic visitation schedule revealed the following: 1. In April, 2021 four facility visits were documented daily on 4/2, 4/6, 4/7, 4/9, 4/13, 4/14, 4/16, 4/21, and 4/23. One visit was scheduled on 4/18/21. Visitations were scheduled on 10 out of 30 days during the month of April. 2. In May, 2021, one to four resident visitations were scheduled Tuesday through Friday at 9:00 a.m., 10:00 a.m., 1:00 p.m., and 2:00 p.m., except for one visit on Monday 5/23 at 10:00 a.m., Visits were scheduled on 17 of 31 days in May 2021. 3. In June, 2021, resident visitation was scheduled 25 of 30 days, with the times of visits remaining nearly the same between 9:00 a.m. and 3:00 p.m., and one late visit at 4:30 p.m. Review of the May 18, 2021 Member Council Minutes revealed the following DON response published in the June 2021 Resident's News (newsletter) .As of this writing, the Home (facility) is starting to open restrictions and as mentioned, guidance is becoming less restrictive. The driving force that has allowed restrictions to be lifted is the tremendous vaccination rates at the Home. Over 95% of both staff and members have been vaccinated for COVID. During an interview on 06/29/21 at 11:57 a.m., the Nursing Home Administrator (NHA) and DON were asked about the current restriction of visitation for facility residents. The NHA expressed concern with increased visitation and the potential for increased risk of COVID-19. The NHA stated, COVID (19) is not gone. The NHA acknowledged a schedule of four -30-minute visits per day would require approximately a month's rotation before all 113 residents (including certified and uncertified beds) could receive one scheduled weekday visit. Review of the [State Agency] Residential Care Facilities May 21, 2021 Order Guidance, received from IP A on 6/29/21, as evidence of guidance being followed to support restricted facility visitation, revealed the following, in part: .Facilities shall comply with the Center for Medicare and Medicaid Services (CMS) guidance included in QSO-20-30-NH (issued September 17, 2020 and updated April 27, 2021). Per this guidance, the facilities should allow indoor visitation at all times and for all residents (regardless of vaccination status), except for a few circumstances when visitation should be limited due to a high risk of COVID-19 transmission. These scenarios include limiting indoor visitation for: · Unvaccinated residents, if the nursing home's COVID-19 county positivity rate is > 10% (greater than 10 percent), and <70% (less than 70 percent) of residents in the facility are fully vaccinated; · Residents with confirmed COVID-19 infection, whether vaccinated or unvaccinated until they have met the criteria to discontinue Transmission-Based Precautions; or · Residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria for release from quarantine.

Based on observation, interview, and record review, the facility failed to perform/obtain the following for two Residents (#30 and #163) of 16 residents reviewed for bed rails: 1. Perform a resident assessment that included an evaluation of alternatives to bed rails. 2. Obtain a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] 3. Obtain informed consent for bed rails. This deficient practice resulted in the installation of bed rails without proper assessment and authorization, and the potential for resident injury. Findings include: Resident #30 Observations on 6/28/21 and 6/30/21 at 4:02 p.m. and 8:18 a.m., respectively, found Resident #30's bed with a bed rail (mobility bar) installed on the Residents left (exit) side of Resident #30's bed. Review of Resident #30's Minimum Data Set (MDS) assessment, dated 5/14/21, revealed a score of 3 of 15 on the Brief Interview for Mental Status (BIMS) reflective of severe cognitive impairment. Resident #30 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 06/30/21 at 9:18 a.m., when the bed rail assessment for Resident #30 was requested from the Director of Nursing (DON), the DON said the facility had gotten rid of all bed rails. The DON questioned if Resident #30 had bed rails, and after discussion agreed that enabler (mobility/grab) bars were considered bed rails. The DON confirmed the expectation that bed rails would be included in the individual resident care plan interventions. The DON stated, Bed rail assessments are not being done on a regular basis to evaluate the continued need for the bed rails, or a resident change in condition that would signify the bed rails were no longer appropriate. Resident #163 Observation on 6/28/21 at 4:06 p.m., found Resident #163's bed with bilateral bed rails (mobility bars) installed. Review of Resident #163's Face Sheet revealed Resident #163 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . following cerebral infarction affecting left non-dominant side. Review of the complete Electronic Medical Record (EMR) for Resident #30 and Resident #163, including physician orders, care plans, progress notes, and miscellaneous documents, found no evidence of signed consents, a physician order, or care plan interventions for either Resident #30's or Resident #163's installed bed rails. During an interview on 6/30/21 at 10:30 a.m., and 11:56 a.m., Registered Nurse (RN)/Unit Manager K confirmed no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN K also provided copies of both Resident Care Plans and acknowledged no interventions related to bed rails were included in either Resident's care plan. Review of the facility's undated, Side Rails policy, revealed the following, in part: It is the policy of the [Facility] to make side rails available for members only after an individualized member assessment, evaluation, and care planning by an interdisciplinary team to determine if it is beneficial and appropriate for use to treat the member's medical condition, assist the member in attaining or maintaining the highest level of physical and psychosocial well-being, and after attempts at using other alternatives have proven inadequate or inappropriate .All side rails require written consent from the member/responsible party and shall include education regarding the potential risks and alternatives to using side rails. A physician order is also required . During an interview on 7/01/21 at 7:00 a.m., the DON confirmed no physician orders, care plans, or signed consents were available for Resident #30's and Resident #163's bed rails.

Based on observation, interview, and record review, the facility failed to administer eye drops using professional standards of practice for one Resident (#28) of eight residents reviewed for standards of practice related to medication administration. This deficient practice had the potential to cause potential eye irritation and eye damage. Findings include: On 6/30/21 at 8:15 AM, eye drop administration was observed performed for Resident #28 by Licensed Practical Nurse (LPN) L. Prior to administration of eye drops, LPN L retrieved a Personal Cleansing Wipe from a container and ran running water over the wipe. LPN L then wrung out the cleansing wipe and applied baby shampoo to the wipe. LPN L then used the cleansing wipe to wash over the right eye of Resident #28. LPN L stated this was what she normally did prior to administering the eye drop for Resident #28. LPN L stated Resident #28's right eye was always red, and the conjunctival sac(internal part of lower eye lid) appeared red and inflamed. A review of the order section of the Electronic Medical Record (EMR) for Resident #28 revealed the following: [MEDICATION(S)] 1%-0.2% EYE DROPS Instill 1 drop in right eye three times a day related to PRIMARY OPEN-ANGLE [CONDITION(S)] (eye disease causing damage to the optic nerve), BILATERAL, STAGE UNSPECIFIED (H40.1130) -Start Date- 04/01/2021 1600 (4:00 PM) On 7/1/21 at 10:06 AM, during an interview, the Director of Nursing (DON) was informed of the concern with using a personal cleansing wipe to clean a resident's eyes. The DON agreed the personal cleansing wipe should not have been used to clean a resident's eyes. The DON was asked to provide the manufacturer's information on the product and stated they would most likely have a Safety Data Sheet (SDS) for the product the facility could provide. A review of the SDS provided by the facility for FitRight Personal Cleansing Wipes with a revised date of 12/2/2019 read in part: .Section 2. Hazards Identification .Potential Health Effects: Routes of Exposure: Eyes, Skin, Inhalation, Ingestion. Target Organs: None known. Eye Contact: May cause mild irritation . .Section 4. First Aid Measures Eye Contact: If in eyes: Immediately flush eyes thoroughly with plenty of water. Tilt head to avoid contaminating unaffected eye. If irritation occurs, get medical attention .

Based on observation, interview, and record review, the facility failed to properly maintain infection control practices during a COVID-19 Infection Control Survey for three Residents (Residents #1, #2, & #3) of three residents reviewed for infection control. This deficient practice resulted in the potential transmission of COVID-19 which had the ability to affect all 71 residents residing in the facility. This citation has five noted deficiencies: 1. The facility failed to perform proper staff/visitor entrance screening for COVID-19, including social distancing, and cleaning/disinfection of medical equipment. 2. The facility failed to cohort presumptive, identified COVID-19 residents. 3. The facility failed to eliminate group dining and group activities to prevent potential transmission of COVID-19. 4. The facility failed to provide consistent staffing assignments for residents to prevent transmission of suspected COVID-19. 5. The facility failed to identify and maintain a safe environment for reprocessing and disposal of contaminated medical equipment. Findings include: On 3/31/2020 at 9:00 a.m., during visitor entrance COVID-19 screening, Staff I placed a thermal thermometer directly on an entering Surveyor's left temple. Staff I took a disinfectant wipe and passed it quickly (approximately 2 seconds) over the contact end of the thermometer. Staff I instructed the next visitor to move forward to complete their temperature screening. When asked the kill time of the disinfectant wipe, Staff I responded, I don't know. When asked again, Staff I looked at the canister and stated, 10 seconds. During the Entrance Conference on 3/31/2020 at 9:33 a.m., the Nursing Home Administrator (NHA) and Registered Nurse (RN)/Infection Control Practitioner A confirmed five residents were under investigation for potential COVID-19 infections. RN A confirmed all five residents were in contact/droplet isolation pending lab results. When asked if residents were in private rooms, RN A responded, There are a couple of residents that do have roommates (not under investigation for COVID-19). Upon discussion of contact/droplet isolation, RN A said the room doors were kept closed. When asked if the disinfectant wipe used by Staff I during facility entrance screening met the Environmental Protection Agency (EPA) standards, RN A was uncertain. On 3/31/2020 at 10:00 a.m., a Surveyor along with RN A observed the yellow-topped canister of generic Disinfectant Wipes, in the presence of Staff I. RN A read the canister label silently, and said they were not the appropriate wipes. RN A removed the wipes from the table. Upon return from the observation, RN A stated, We will see where they (disinfecting wipes) came from. They are bleach free, and I don't know what the (kill) claim is for those wipes. When asked about training provided to the facility screening staff regarding cleaning/disinfecting of the thermometer after use, RN A stated, The point of the laser one (thermometer) is that they are not supposed to touch people. RN A was asked for a list of facility staff, visitors, and/or vendors that had been screened by Staff I from the beginning of the shift, prior to the Surveyors' entrance on 3/31/2020. RN A provided a list which indicated 104 individuals had been screened. Review of the facility provided Disinfecting Wipes Directions for Use, provided no kill claim for Coronavirus, and revealed the following: TO CLEAN AND DISINFECT/VIRUCIDAL DIRECTIONS: Wipe hard, nonporous surface with wipe until surface is visibly wet. Use enough wipes to keep surfaces visibly wet for 4 minutes. Allow surface to remain wet for 4 minutes. Let air dry . Review of facility provided Products with Emerging [MEDICAL CONDITION] Pathogens and Human Coronavirus claims for use against [DIAGNOSES REDACTED] (Severe Acute Respiratory Syndrome) - CoV2, dated 3/24/20, did not list the disinfectant wipes used during the visitor screening process. Review of the facility provided undated (Name Brand) Non-Contact Thermometer User Guide, revealed the following: .4. While holding the MEASURE button, aim the infrared lens at the patient's forehead, holding the thermometer approximately 1.5 (inches) - 2.5 away (from forehead) . During an observation on 3/31/2020 at 11:05 a.m., Vendors J and K were screened by Staff I for facility entrance. During an interview following acceptance into the facility, both Vendor J and K confirmed the thermal thermometer made contact with their skin while being screened. Review of Centers for Disease Control and Prevention (CDC), 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, p. 26, revealed the following regarding outbreaks in healthcare settings, in part: . undiagnosed , infectious patients and visitors were important initiators of these outbreaks .There is ample evidence for droplet and contact transmission; however, opportunistic airborne transmission cannot be excluded . Review of Resident Minimum Data Set (MDS) assessments revealed the following resident high-risk co-morbidities: Resident #1 - [MEDICAL CONDITION], heart failure, and [MEDICAL CONDITIONS] - who required supplemental oxygen. Resident #2 - [MEDICAL CONDITION] (CAD), heart failure, hypertension, and diabetes. Resident #3 - [MEDICAL CONDITIONS], hypertension, and [MEDICAL CONDITION] - who required supplemental oxygen. Resident #4 (roommate of Resident #2) - CAD, diabetes, [MEDICAL CONDITION], and heart failure - who required supplemental oxygen. Resident #5 (roommate of Resident #3) - urinary tract infection. Review of the facility resident roster confirmed Resident #2's roommate was Resident #4, and Resident #3's roommate was Resident #5. The roommates were not identified as suspect COVID-19 residents. Review of Centers for Disease Control and Prevention (CDC), 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, pgs. 57-58, revealed the following, in part: .Single-patient rooms are always indicated for patients .who require Contact or Droplet precautions .Cohorting is the practice of grouping together patients who are .infected with the same organism to confine their care to one area and prevent contact with other patients .Cohorting has been used extensively for managing outbreaks .Assigning or cohorting healthcare personnel to care only for patients infected .with a single target pathogen limits further transmission of the target pathogen to uninfected patients . During an interview on 3/31/2020 at 9:55 a.m., the NHA and RN A indicated residents testing positive for COVID-19 would be transferred to the third floor, currently not used for resident care. The NHA stated, It (quarantine unit on third floor) is pretty much ready to go - we would just have to move the resident's bed up there. During a follow-up interview on 3/31/2020 at 2:00 p.m., when asked why residents currently under investigation for COVID-19 were not being cohorted together, RN A stated, We are waiting on a positive (culture) before we open up the third floor. RN A confirmed multiple COVID-19 culture were still pending, including Resident #1's COVID-19 culture, collected on 3/19/2020, with inconclusive results forwarded to the CDC (Center for Disease Control). According to the facility-provided Emergency Response Plan and Facility Toolkit Infection Prevention Strategies & Guidance COVID-19, page 57, Revised 3/30/2020, revealed the following, in part: .Isolate symptomatic patients as soon as possible. Set up separate, well-ventilated triage areas, place patients with suspected or confirmed COVID-19 in private rooms with door closed . On 3/31/2020 at 12:05 p.m., observation of the locked Memory Care Unit (MCU), with Certified Nurse Aides (CNAs) B and C, found three residents seated in the dining room at one square table, elbow distance apart. CNA C indicated almost all residents in the MCU eat in the dining room. Empty tables were observed in the vicinity of these residents. During an interview within the MCU unit on 3/31/2020 at approximately 12:10 p.m., when asked how many residents were living in the MCU, Licensed Practical Nurse (LPN) D said there were 19. When asked if staff worked solely on the MCU unit, LPN D said he had worked the previous weekend on every single floor, even with awareness of presumptive COVID-19 residents. On 3/31/2020 at when asked about group activities, LPN D confirmed a group activity was conducted in the day room earlier that morning (3/31/2020), led by Activity/Therapy Aide E. Review of staff schedules for the previous week documented LPN D worked on various units on 3/24, 3/28, and 3/29/2020. On 3/31/2020 at approximately 12:15 p.m., when asked if she worked on various floors, RN F confirmed working on another floor the previous weekend. On 3/31/2020 at approximately 12:18 p.m., the MCU dining room was observed with 13 residents seated near one another. Social distancing (6 feet) was not maintained. On 3/31/2020 at 2:33 p.m., when asked about group activities, group dining, and consistent staff assignments, RN A confirmed group dining was not suspended for residents in the MCU. RN A said residents were being kept six feet apart in the dining room, with consistent staffing. RN A confirmed group activities continued in the MCU. Emergency Response Plan and Facility Toolkit Infection Prevention Strategies & Guidance COVID-19, page 16-17, Revised 3/30/2020, revealed the following, in part: .General communal dining will be suspended at this time .General group activities will be suspended at this time . On 3/31/2020 at 12:29 p.m., and 12:36 p.m., Resident #3's and Resident #1's contact/droplet isolation room doors were observed open. On 3/31/2020 at approximately 12:40 p.m., when asked where contaminated personal protective equipment (PPE) was disposed, following exit from an isolation room, Staff H directed the Surveyors to a Conference Room on the second floor. The Conference Room door was wide open without signage designating the room as soiled utility for disposal of PPE. Staff H said used masks were disposed of in a small waste basket, found lined with a clear plastic bag. Upon inspection of the waste basket, an empty snack chip bag, paper towels, and staff hand-written notes were found with the discarded masks. No signage indicated the garbage was used for specific PPE disposal. A covered, plastic storage bin for reprocessing of face shields and goggles was located on a table to the back left of the room. No signage was present to indicate the purpose and provide instruction for reprocessing of PPE equipment (goggles/face shields). On 3/31/2020 at 2:27 p.m., when asked about the disposal of contaminated PPE in the Second Floor Conference Room, RN A confirmed the room had not been identified for reprocessing of medical equipment and disposal of medical waste. RN A agreed the conference room door should remain closed for separation of clean/dirty environment, and staff were not supposed to be eating in that room. On 3/31/2020 at approximately 1:45 p.m., when asked if group activities and group dining were discontinued due to COVID-19 concerns, the NHA stated, As far as I know they are. The NHA acknowledged the Surveyor infection control concerns with visitor screening and consistent staffing assignments.

This citation pertains to intake # 7. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent the elopement of two Residents (Resident #701 and #704), and the risk for elopement for Resident #709. This deficient practice resulted in elopements from the facility for Resident #701 and Resident #704, with the risk for falls, injury, wandering, psychosocial stress, and exposure to inclement weather and the outdoor, unsupervised environment. Findings include: Resident #701 Review of Resident #701's Minimum Data Set (MDS) assessment, reference date 12/22/19, revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #701 was independent with dressing, toileting, and walking in his room and on his hallway; he required supervision off the unit. The Brief Interview for Mental Status (BI[CONDITION]) revealed a score of 5/15, which indicated severe cognitive impairment. Review of the facility 5-day investigation report, submitted to the State Agency (S.A.) on [DATE], revealed, On January 27th, 2020 at approximately 1515 (3:15 p.m.), Registered Nurse (RN) C was notified that member (Resident #701) of 2 (second floor unit name) was located outside of the facility in the (named) parking lot by a staff member. Apparently, staff member (Facility transporter, Certified Nurse Aide (CNA )B) was sitting in a parked vehicle filling out paperwork when he looked up and (Resident #701) was at his window. (Resident #701) asked the staff member, 'Have you seen my rabbits?'. (Resident #701) was redirected back into the facility . Review of Resident #701's (Facility name) Elopement Investigation Packet, dated [DATE], revealed on Page 2, Describe the weather conditions .Temp (temperature) 30°. Not windy. Not snowing. Member wearing long sleeve flannel, jeans, tennis shoes (light flannel jacket) .Member returned to unit. Code Alert applied to 'R' (right) ankle . Review of Resident #701's progress note, dated [DATE], by Resident #701's nurse, RN C revealed, .It was reported to me by transporter staff (CNA B) that member (Resident #701) had been outside at 1515 (3:15 p.m.) .Staff reported he did not see member come out the door but he was suddenly there (outside the facility), and it appeared he had just come out the door . (Resident #701) did not remember going outside . Review of an investigation witness statement, dated [DATE] at 2:45 p.m., by CNA M, revealed, About 2:45 p.m. I seen (sic) (Resident #701) walking down the 2 (name of second floor unit hall) .He was walking towards the central elevators/or in that direction. Review of Resident #701's Nursing Elopement Risk Assessments, revealed: 10/15/2019: .Does the member have a history of wandering? Yes (checked) .Does the member wander: Yes .Elopement risk CP (Care Plan) and Code Alert (number) initiated with transfer to non-secure unit . 12/12/19: .Does the member have a history of wandering? Yes .No wandering behaviors present. At this time this RN (RN P) does not feel like member is an elopement risk . [DATE]20: [DIAGNOSES REDACTED]., [MEDICAL CONDITION] ., .anxiety disorder ., .restlessness and agitation ., .major [MEDICAL CONDITION] . Does the member have a history of wandering? Yes. Member was previously on a locked unit for safety d/t (due to) wandering behavior .Code alert being placed due to recent attempt to wander off unit .Member recently wandered off unit d/t confusion . Review of Resident #701's progress note, dated 12/12/2019 at 18:25 (6:25 p.m.), by RN O, revealed, .No attempts at exit seeking, able to find way on unit and through facility without getting lost; son ok'd (approved) d/c (discontinue) code alert . Review of Resident #701's Physician N's Physician note, dated 1/31/20, revealed, .(Resident #701) has some confusion. On [DATE], (Resident #701's) code alert was reapplied after he was found outside the building .When (Resident #701) first came to (the facility), he was living on (non-secure hall) for about two days. He was insistent on leaving the building then. He was then moved to the Memory Care Unit (on the ground floor), where he resided up until about two months ago when he came up to the (second floor non-secured unit). It's not unusual for him to be this confused . During an interview on [DATE] at 3:10 p.m., CNA B was asked about Resident #701's elopement on [DATE], and responded, I saw (Resident #701) in front of my vehicle .He said he was looking for his rabbits .I got out (of the facility transport vehicle) and we walked in the door (into the facility). CNA B reported this same door was locked and CNA B unlocked it for Resident #701 to reenter the building. CNA B was asked if staff were looking for Resident #701, or knew he was missing. CNA B responded, There were no staff by him .They did not seem to be looking for him .When I brought him to his room, I told the supervisor on duty. It alerted everyone and they wondered why he was outside. He had a code alert (prior) but they didn't consider him a risk so they took it off .I found him outside .He was clothed, dressed in flannel .The weather that day, it was cool, winter, but not freezing . During an interview on [DATE] at 3:22 pm., RN C was asked about Resident #701's elopement and responded, I came on (the afternoon shift) at 2:30 (p.m.), we got shift report, I got back to the office at 2:45 (p.m.). CNA B came into the office and said he had found (Resident #701) outside .It was around shift change or shortly after. RN C was asked if she knew Resident #701 was missing. RN C acknowledged she was not aware. This Surveyor asked if nurses complete a visual confirmation residents are present at shift change. RN C responded this is not done typically. RN C was asked about Resident #701's assessment upon return from outside. She responded, .He was confused . During an interview with the Director of Nursing (DON) on [DATE] at 3:35 p.m., the DON was asked if the facility nurses complete a visual confirmation of their residents presence at shift change. The DON confirmed this is not a typical practice at shift change. A facility video camera observation of Resident #701's elopement, on 1/13/20 at 3:40 p.m., with the DON, showed Resident #701 opened an outer (first floor side/stairwell) exit door and exited the facility on [DATE] at 3:05:58 p.m. Resident #701 was observed wearing a blue flannel jacket, jeans, shoes, and a red hat. He was walking using his four wheeled walker. He walked towards the parking lot and was out of view until 3:07:18, when he was seen returning to the same exit door at 3:07:18, escorted by CNA B. Resident #701 reentered the building at 3:07:42 p.m. (about 2 minutes later). Surveyor noted there was some snow on the ground. Review of Resident #701's progress notes, from 12/12/20 through [DATE], showed no evidence of any monitoring of Resident #701 for signs of elopement, after the removal of the code alert sensor on 12/12/19, beyond the nurses notes dated 12/12/19. Further review of Resident #701's progress notes, dated 2/01/20 at 11:46 (a.m.), by RN Q, revealed a second elopement attempt, as follows: .(Staff) responded to code alert beepers for this member (Resident #701). Member had walked out the front door of the chapel entrance causing code alert to sound. Member walked out to the front sidewalk when staff did stop him and brought him back into the facility. This RN met member as he was walking back into the facility a moment later. Member stated, I was out there looking for my brother .member is confused and has dementia. Member is currently only oriented to self. Member does know where he is or the date/time . During observations/interview on 2/12/20 at 11:42 a.m. with RN supervisor, RN A, RN A was asked about Resident #701's elopement from the facility, while observing the central elevators, and soon after the side/stairwell doors/exits to the outdoors. RN A responded, Anyone is free to access the elevator .They 'lock' for people (residents) with a code alert. Anybody without a code alert can use our stairs. We think (Resident #701) left by the central elevators .he was seen headed that way; it is usually the elevator he uses .He used the central elevator (to reach the first floor), turned right, and went through the door (outer exit door) on the 1 (name of unit hall); it's the door on the end of this unit. The door has 'locks' (for residents wearing a code alert sensor) but (Resident #701) did not have a code alert on; it was removed on December 12th, 2019. He just had to walk through the door (to the outdoors). RN A confirmed residents can access the facility front door, the side/stairwell exits, the chapel doors, and the various building exits on the first floor without a code alert sensor. During an interview with the Maintenance supervisor/Staff E, on [DATE] at 1:30 p.m., when asked about residents entering and exiting the building who are not wearing a code alert sensor, Staff E responded, If the resident doesn't have a code alert, they can go anywhere; they can go out any door. I don't think (Resident #701) had a code alert, (Resident #701) just went out. There is nothing stopping you . During a tour of facility doors/exits with Staff E beginning at 1:40 p.m., this Surveyor observed the first floor exits, and a few of the ground floor exits, to test the code alert sensors. It was noted that these exits 'locked' with the code alert sensor Staff E was carrying. However, this Surveyor could get in and out of each exit, as this Surveyor was not wearing a code alert sensor, including the first-floor side/stairwell exit used by Resident #701 to exit the building. Staff E acknowledged there are several outer exit doors accessible to residents without a code alert sensor, on two building levels, mainly on the first floor, with a few on the ground floor. During an observation on [DATE] at 8:14 a.m., Resident #701 was observed walking to his room using his four-wheeled walker, with good balance. He was wearing jeans, shoes, and a flannel plaid jacket. He was wearing a code alert sensor on his right ankle, and a second code alert sensor was observed on his walker. During an interview on [DATE] at 8:16 a.m. Resident #701 was unable to tell this Surveyor why he was a resident there, or the time/date, or name of this facility. He was aware it was winter. He stated he was there to do a job but didn't know what that was. He did not seem to recall the elopement, or have any concerns with his stay at the facility. Resident #704 Review of Resident #704's MDS assessment, reference date 12/02/19, revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #704 required supervision for dressing and walking in room, on the unit and in the facility. The BI[CONDITION] revealed a score of 12/15, which indicated moderate cognitive impairment. Review of Resident #704's Care Plan, dated 12/05/20, revealed Resident #704 had a [DIAGNOSES REDACTED]. Review of Resident #704's Nursing Elopement Risk quarterly assessment, dated 12/11/2019, revealed, Does the member have a history of wandering? Yes .Member has wandered outside in the past .At Risk for Elopement at this Time: No (checked). Member/family is not concerned with elopement concern . Review of Resident #704's progress note, dated [DATE], by RN B, revealed, [DATE] at 18:44 (6:44 p.m.).Member (Resident #704) was observed in the chapel entry way (double set of doors) facing the interior of the facility, with the outer doors shutting. Member was escorted back into (the) interior doors and then back up to (Resident #704's second floor unit). Member did express that she was waiting for her son to pick her up .Member is with baseline confusion .members son (name) was contacted and informed of member behavior with request provided to place member with a code alert .(Resident #704's son) expressed that he does not want a code alert placed on at this time . During an interview on [DATE] at 9:20 a.m., the DON was asked for any additional documentation of this incident, such as an incident report or an investigation report. The DON acknowledged there was no incident or investigation report available. The DON stated the resident was outside of the facility 'about 45 seconds', per video footage, and related Resident #704 looked outside briefly, then turned around and went back into the facility. Review of Resident #704's progress note, dated 2/10/20, revealed, .Member at her baseline with confusion . Review of Resident #704's care plan, dated 12/05/19, revealed, 12/06/18, original date .Altered thought processes and confusion related to dementia . An observation of Resident #704 on [DATE] at 8:00 a.m. , showed Resident #704 ambulating on the second floor without a device (walker or cane), heading out of her room. Resident #704 was not wearing a code alert sensor, which the DON confirmed. During an interview on [DATE] at 1:19 p.m. the DON was asked why the elopement of Resident #704 on [DATE] was not reported to the S.A., and confirmed they (the facility staff) didn't do an investigation. During an interview on [DATE] at 2:02 p.m., CNA L was asked about the elopement of Resident #704 on [DATE]. CNA L responded, .We were finishing up in the dining room (1st floor name of dining room) .it was at the end of supper, 5 or 6 (p.m.). We were pushing our members (wheelchairs) to their rooms. I could see her, (Resident #704), in the chapel entrance coming back in (from the outside sliding doors). I told my partner (coworker) I needed to go get (Resident #704). I brought her back upstairs (to the second floor) .She was going to look for her son .she was standing inside the two doors; she was by the sliding (door to outside/outer) door. She could have been coming from the outside .I would say she was confused. Because I was thinking she was looking for somebody who obviously wasn't there. This Surveyor asked what Resident #704 was wearing. Just her clothes, no coat. I think it was cold (outside) . CNA L confirmed there were no staff with Resident #704. Review of the outdoor weather for the local area on [DATE] at approximately 6:44 p.m. revealed an outdoor temperature of about 12-13 °F (range 10-15 °F, for 6 to 7 p.m.), per graph review of temperature from Weather Underground, February 4, 2020, https://www.wunderground.com/, accessed [DATE]. An observation of the facility elevators on [DATE] at 11:35 a.m. revealed there was no locking mechanism or code to prevent residents who are not wearing code alert sensors from accessing these elevators. It was noted the facility has three levels, a ground floor, first floor, and second floor, which are all accessible via this central elevator. An observation of the chapel doors on [DATE] at approximately 11:45 a.m., with Staff J, revealed the chapel doors (two sets of doors) were located on the first floor in the 'near center' of the facility, not far from the elevators. There was an inner double door, which opened by pulling the handle on either side of the double doors, and an outer sliding automatic door, which opened to the outdoors. Staff J accompanied this Surveyor per Surveyor request through both sets of doors. There was no lock or audible alarm on either door, which Staff J confirmed. Staff J added the doors would lock if a resident wearing a code alert sensor was near the chapel doors. Further review of Resident #704's current Care Plan, revealed the only update to the Care Plan after Resident #704's elopement was an intervention dated 2/21/19, which stated, .2/21/19 Monitor for Exit-Seeking Behavior. Resident #709 Review of Resident #709's MDS assessment, reference date 11/25/19, revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED].#709 required one-person assistance for dressing, toileting, and transfers, and supervision for walking on the unit and in the facility, with a walker. The BI[CONDITION] revealed a score of 4/15, which indicated severe cognitive impairment. Review of Resident #709's progress note, dated 1[DATE], by RN revealed, .Members DPOA (named) contacted via phone. Per speaker conversation (permission) obtained for code alert monitoring related to recent member elopement activity . There were no other progress notes found, indicating what occurred. Review of Resident #709's Nursing Elopement Risk, dated 12/20/2019, revealed, [DIAGNOSES REDACTED]. Dementia .with behavioral disturbances.Does the member have a history of elopement or wandering? Yes (checked) .Member has a history of wandering and was located on (the) lower floor expressing to staff wanting to leave .(DPOA name) gave permission for code alert to be placed. Code alert placed on member. An observation on [DATE] at 8:03 a.m. revealed Resident #709 walking in the hallway outside of her room, dressed, wearing shoes, and using a two-wheeled walker. Resident #709 wore a code alert sensor on her right ankle. It was noted that Resident #701, Resident #704, and Resident #709 all resided on the second floor of the facility on non-secured units. None of the residents were wearing code alert sensors at the time of the elopement incidents. Review of the facility policy, Elopement Prevention, revised 1/29/20 (after Resident #701's code alert had been removed then reinstated), revealed, .It is the policy of the (facility) to assess each member's risk for elopement and implement a care plan with appropriate interventions to prevent confused members from elopement from the facility or safe area without authorization or appropriate supervision .Elopement: A resident leaves the premises or safe area without authorization .8. If applicable, (RN) arranges an IDT (Interdisciplinary Team) Meeting to determine if removal of code alert is appropriate. Completes an Elopement UDA (elopement risk assessment) prior to removal of transmitter if deemed appropriate by the IDT team . During an interview on [DATE] at approximately 1:30 p.m., the Director of Nursing (DON) acknowledged the policy in place prior to Resident #701's elopement, Elopement Prevention, dated 6/12/19, did not include the IDT meeting, as prior to this incident a nursing staff member independently completed the assessment and recommended removal of Resident #701's code alert.

Based on interview and record review, the facility failed to provide adequate supervision for a resident with increased physical behaviors during an acute illness (urinary tract infection) for one Resident (# 4) of ten residents reviewed for potential abuse. This deficient practice resulted in a resident to resident altercation involving Resident #4 with Resident #5. Findings include: According to Minimum Data Set (MDS) assessment, Assessment Reference Date 10/6/19, Resident #4 was admitted to the facility on [DATE] and had the following applicable Diagnoses: [REDACTED]. The Brief Interview for Mental Status (BIMS) score was 10/15 which reflected moderately impaired cognition. Resident #4 required two-staff assistance for transfers, hygiene, bathing, and toilet use. Review of Facility Report Incident, 11/22/19, read, .(Resident #4) does have a history of increased behaviors associated with illness and was confirmed to have a urinary tract infection this morning . On (MONTH) 14, 2019 . in .Dining Room .(Resident #4) wheeled over to (Resident #5) and kicked (Resident #5) in the left shin . Review of Resident #4's Interdisciplinary Progress Notes, dated 11/13/19 at 10:59 (a.m.) read, .has been c/o (complaint) of lower abd (abdominal) pain for the last couple of days. Her urine is foul smelling. She has been more aggressive the last couple of days. Trying to kick and hit other members. Orders received for a urine culture. Review of Resident #4's Interdisciplinary Progress Notes, dated 11/15/19 at 12:53 (p.m.) read, .She continues to c/o lower abd pain when being changed. She is also having an increase in aggressive behaviors . Review of Certified Nurse Aide (CNA) W hand-written Witness Statement, 11/13/19, read, At 17:00 (5 p.m.) this evening, I was bringing members (residents) into the (specific day room) for supper when I witnessed (Resident #4) roll over to (Resident #5) in her wheelchair and kick him . There were approx. (approximately) 7 members in the dayroom and no other staff . During an interview on 1/2/20 at 9:30 a.m., Charge Nurse/ Registered Nurse (RN) U confirmed staff awareness of Resident #4's increased physical behaviors via review of Interdisciplinary Progress Notes from 11/13/19 through 11/14/19 during signs/symptoms of an acute urinary tract infection [MEDICAL CONDITION]. When asked what the facility could have done to prevent Resident #4's physical altercation with Resident #5, RN U said, Staff should have been there. During an interview on 1/2/20 at 10:00 a.m., the Interim Director of Nursing (DON) and Infection Control/RN T confirmed Resident #4 had signs and symptoms of a UTI on 11/13/19 and showed increased physical aggression just prior to the resident to resident altercation which occurred on 11/14/19. When this Surveyor explained the concern, that Resident #4 had been left unsupervised in the day room, the DON responded, I understand.

Based on interview and record review, the facility failed to: 1) implement effective surveillance of gastrointestinal signs and symptoms to control the spread of infection; 2) follow the facility policy Infection Surveillance Norovirus (virus that causes vomiting, diarrhea and abdominal cramping) Gastroenteritis to test for the infectious agent upon suspicion of infection/ identification of an outbreak and consult the Medical Director regarding the suspected infection/ identified outreak; 3) establish adequate communication between departments to limit the spread of infection from employees to residents; and 4) follow recommended cleaning to destroy infectious agents. This deficient practice resulted in immediate jeopardy when two Residents who had had GI (gastrointestinal) symptoms (Residents #1000 and #39), of 51 residents on the affected units, were hospitalized during the suspected norovirus outbreak within the facility in (MONTH) and (MONTH) 2019. The deficient practice also resulted in the potential for serious harm for all residents of the Memory Care Unit (MCU), 1 North and 2 North Units, due to continued lack of adequate infection symptom surveillance. Immediate Jeopardy was identified at F880 on 9/10/19 during the recertification survey. The Administrator, Veterans Affairs (VA) Director, Director of Nursing (DON), Clinical Programs Director/ Registered Nurse (RN) K, Infection Preventionist/ RN J, and the VA/State Consultant/ RN G were notified of the immediate jeopardy at 6:05 pm on 9/10/19 and an Abatement Plan was requested at this time. The immediate jeopardy was removed on 9/10/19 following initiation of the approved Abatement plan to implement adequate infection surveillance for all infections per their facility policy and CDC (Center for Disease Control) guidelines, which included: -Immediate surveillance of all potential signs and symptoms, monitoring, and investigations for suspected infection control concerns. -Immediate inservice of all managers in the facility regarding communication of all employee, contract employee, and resident infection control concerns to the Infection Control Preventionist. All managers not currently present will be inserviced on their next scheduled shift. The immediate jeopardy began on 4/3/19 at approximately 20:50 (8:50 p.m.) when Resident #1000 was admitted to the local hospital for dehydration and lethargy. The hospitalization was preceded by a period of GI symptoms (source - Progress notes dated 3/26/19- 4/1/19) during the period of time that the facility was not disinfecting effectively for suspected norovirus outbreak, and a Dietary Staff was allowed to return to work on 3/30/19, less than 48 hours after their GI symptoms were present. The noncompliance remained at a widespread level of potential for more than minimal harm that is not immediate jeopardy due to the continued lack of adequate infection surveillance, until adequate implementation of the Infection Prevention and Control Program is verified. Findings include: 1) Surveillance to control spread of infection During an interview with Infection Preventionist/ RN J on 9/10/19 at 12:30 pm, the following documents were reviewed: [NAME] (MONTH) 2019 Cluster Map B. Infection Control Report (MONTH) 2019 C. Infection Control Summary for the Reporting Period (MONTH) 1, 2019- (MONTH) 30, 2019 D. Facility Wide Norovirus Outbreak (timeline) The review of the Infection Control Report (MONTH) 2019 revealed that a Norovirus Outbreak caused the facility to close to visitors on (MONTH) 5 due to 47 members becoming ill in with Noro symptoms. Review of the cluster map for the MCU, 1 North and 2 North units did not indicate GI infections on those units. RN J was asked to show which areas on the map were affected by the outbreak but RN J was unable to do so. RN J was then asked if she had a line listing (list of residents including the name of the infectious agent, onset and duration of symptoms, course of treatment and resolution of infection) for residents infected with [MEDICAL CONDITION] and RN J stated she did not. When asked how she tracked the outbreak, including identifying those with signs and symptoms, RN J stated she pulls a report showing residents with fevers and receives notification of residents with potential infections every morning during morning meeting with department managers. When asked if she could show this Surveyor a current listing of residents with infections, RN J stated she could not and she did not keep that type of listing. On 9/10/19 at 2:40 pm RN J presented a cluster map with the heading Norovirus across the top. The IP stated she found the map in the investigation file she had created during the outbreak. All documentation regarding the outbreak was requested at this time as well as (MONTH) 2019 surveillance documentation. At 4:53 pm on 9/10/19, RN J delivered to the survey team a file folder which included the following norovirus outbreak documents: [NAME] Outbreak Investigation Tool titled GI, MCU, (MONTH) 2019 B. Outbreak Investigation Tool titled Loose stool/Emesis, MCU, March/April 2019 C. Cluster Map titled Norovirus (undated) The (MONTH) 2019 Outbreak Investigation Tool included last names for eight residents with symptoms listed for all eight; the date of onset of symptoms was documented for five of those listed. The form was missing (columns left blank) for room numbers, admission and conclusion dates, treatment/complications/comments and caregivers (staff) for each of the eight residents listed. The March/April 2019 Outbreak Investigation Tool listed 11 resident last names with one of the 11 listed showing no room number, admission or conclusion dates, symptoms, treatment/complications/comments or caregivers. The cluster map was not dated and showed 51 residents on the MCU, 1 North, and 2 North Units with Norovirus as indicated by an X on the map. In an interview with RN J on 9/10/19 at 3:35 pm, when asked if she had an Outbreak Investigation Tool for the remaining 32 infections indicated as an X on the Norovirus cluster map, RN J reported she did not. On 9/10/19 at 6:02 pm, RN J presented the survey team with (MONTH) 2019 Infection Control Report. Review of the report revealed 15 residents ill as part of the Noro-type outbreak. An undated map identical to the Norovirus cluster map was presented with the (MONTH) 2019 Infection Control Report. When asked if a line listing had been completed other than the Investigation Outbreak Tools, RN J responded there was no other listing. 2) Facilily policy Infection Surveillance Norovirus Gastroenteritis In an interview on 9/10/19 at 3:35 pm, RN J was asked to explain the timeline titled, Facility Wide Norovirus Outbreak. RN J reported the first signs and symptoms of the infection presented in residents of the MCU on (MONTH) 25. Reports being alerted at the Morning Meeting attended by the facility Administrator, DON and the Clinical Programs Director. RN J revealed she was alerted that a resident of the 2 North Unit (#39) began exhibiting signs and symptoms of [MEDICAL CONDITION] on 3/25/19, but that it was not believed to be Norovirus because it was isolated to one resident on that unit. When asked when she first suspected the infection to be Norovirus, RN J stated it occurred to her on (MONTH) 26 and the Local Health Department (LHD) was consulted by phone probably around 3/28/19. RN J stated the LHD advised her to just watch it. Review of the facility policy titled Infection Surveillance revealed: Norovirus Gastroenteritis . in the absence of laboratory confirmation, an outbreak (2) or more cases of acute gastroenteritis due to norovirus may be assumed if all of the following are present: a) Vomiting > 50% affected; b) Mean (or median) incubation period of 24-48 hours; c) Mean (or median) duration of illness of 12-60 hours and; d) No bacterial pathogen cause identified in stool culture. Review of the Norovirus Cluster Map showed 10 Xs marked on the 2 North Unit indicating 10 residents were infected with [MEDICAL CONDITION]. Review of the Outbreak Investigation Tool for the MCU dated (MONTH) 2019 and March/April 2019 revealed 18 residents listed with signs/symptoms of [MEDICAL CONDITION] dating from 3/25/19 to 3/31/19. Of the 18 residents listed, seven listed vomiting as a symptom while 2 residents listed as infected were missing symptom information. One (Resident #1000) was listed as being hosptalized on [DATE] for dehydration. In the interview of 9/10/19 at 3:35 pm, RN J was asked to account for the time lapse between consulting with the LHD by phone on 3/28/19 and sending the first stool samples for testing on 4/9/19. RN J stated she didn't know why they waited. When asked how many residents had contracted [MEDICAL CONDITION] before sending in the samples, RN J did not know. RN J was asked if any residents were hospitalized during the outbreak, to which she replied two residents were hospitalized (Residents #1000 and #39.) 3) During an interview on 9/10/19 at 12:30 RN J was asked when facility staff were alerted to the outbreak of Noro-type illness within the facility. RN J stated on the day she was informed of the illness (3/25/19), she sent an email out to the entire facility alerting staff of the presence of the illness and asking staff to increase infection control practices. Review of emails provided by RN J, the DON and Administrator revealed the earliest email regarding the outbreak sent by RN J was dated Tuesday, (MONTH) 25, 2019 1:00 PM, alerting all staff .2 members (residents) having vomiting while running temps. Members will continue to eat in the dayroom and we will have ill members eat in a separate area or after the rest of the members have eaten in the dayroom. Please remember to use excellent hand hygiene during this outbreak . offer members hand hygiene often. The interview with RN J on 9/10/19 at 12:30 pm also revealed the facility identified the source of infection for the Norovirus to be a kitchen worker. RN J stated the identified employee (Dietary Staff B) had worked on 3/27/19 with no signs or symptoms. RN J stated the facility was informed on 3/28/19 Dietary Staff B had visited the emergency department for gastrointestinal symptoms of nausea, vomiting and diarrhea. Review of the Facility Wide Norovirus Outbreak timeline shows four units in the facility, including MCU and 1 East (1 North), closed due to the outbreak. The MCU was closed on 3/26/19 and 1 North was closed on 4/5/19. The timeline also showed on (MONTH) 16: found that our kitchen's disinfectant did not cover Norovirus. On 9/10/19 at 2:30 pm RN J was asked when she became aware the disinfectant in the kitchen was ineffective on the Norovirus. She replied she became aware after the kitchen was instructed to assess their infection control practices. RN J was asked when the dietary department was asked to assess infection control practices and could not provide an answer. During an interview on 9/11/19 at 1:23 p.m., Medical Director I was asked about the Medical Director role in the facility infection control program, and responded, My role is to collaborate with the team. I review all the policies. We (providers) monitor antibiotics, infections, outbreaks. Norovirus, influenza. When asked when she became aware of the outbreak in (MONTH) 2019, Medical Director I stated, I honestly have no idea. Medical Director I confirmed she was not aware of the daily management of the outbreak. During an interview on 9/12/19 at 11:40 a.m., Infection Preventionist/ RN J was asked to provide the facility line listing of infection symptom tracking, and confirmed it was not yet operationalized. 4) During an interview on 9/10/19 at 5:25 p.m., Certified Dietary Manager (CDM) A was asked for the call in slip for Dietary Staff B and replied, We don't follow the VA (Veterans Administration) policies. I don't have a slip for her call-in. She just calls me and I tell her to go to the doctor and bring me a slip. 4) On 9/10/19 during the infection control interview task, it was determined the facility had experienced an outbreak of Norovirus infections and illnesses in (MONTH) and (MONTH) of 2019. The following is the investigation into the food service operations during that period of time: On 9/10/19 at 3:50 PM, an interview with CDM A was conducted related to the dietary practices following the identification of the suspected presence of norovirus among residents and staff members. After looking through information on her computer, CDM A stated We were notified of Norovirus on (MONTH) 16 (2019) and I immediately went to {Local food supplier} and purchased a product which was effective against the Norovirus. When asked to show when the purchase was made, CDM A again looked at her computer and brought up a picture of a receipt from {local food supplier} which did not have a date indicated anywhere on it. According to the computer file information CDM A stated I guess I got it the following day on (MONTH) 17th (2019). CDM A was requested to produce the product used by dietary staff to sanitize equipment returning from the resident areas. CDM A produced a spray bottle of Purell © food service grade sanitizer. A review of the product's label confirmed the product contained 29.4% ethyl alcohol and had bee certified by the Food and Drug Administration (FDA) for the elimination of [MEDICAL CONDITION] on food contact surfaces. When asked what interventions were implemented to reduce the spread of the infection by way of the food service department, CDM A stated I in-serviced all of the staff, reminding them to wash their hands frequently and to use the sanitizer on equipment. When asked how information is communicated between departments regarding infection control, CDM A stated, There are huddles every morning. I used to attend these, but I have not for months because they (administrative personnel) moved them to 8:00 AM. When asked if she remembered any discussion in a huddle regarding the spread of [MEDICAL CONDITION] in the facility, CDM A stated, No. I don't remember hearing that. On 9/10/19 between 4:10 PM and 4:30 PM another interview with CDM A was conducted related to dietary staff who had been identified as being ill during the period of late (MONTH) 2019 and mid (MONTH) 2019. CDM A stated We had one call in. Dietary Staff B called in and was out for a couple of days. She had diarrhea and was vomiting. A review of timecards for Staff B revealed Staff B worked on 3/26/19 until 6:38 PM and returned to work on 3/30/19 at 11:58 AM. An interview with Staff B was conducted on 9/10/19 at 4:19 PM and requested to describe her illness and absence from work. Staff B stated I went to the emergency room (ER) because I was vomiting. They swabbed my nose. I think it was to test for the flu (influenza). When asked if she had had diarrhea, Staff B stated No. I did not have diarrhea. When asked if she had a follow up visit with her physician, Staff B stated I don't remember. I don't think so. A review of the emergency room Work/School Excuse was conducted. Staff B was seen in theER on [DATE] at 7:58 AM. Staff B was released from theER on [DATE] with the recommendation Follow up with physician 2-3 days. At the bottom of the excuse form, the ER physician wrote: Note to Employer/School Official: The patient named above was seen in our Emergency Department today. Recommended restrictions on activity and recommended follow-up are listed above. At the time of the follow-up visit, the physician may decide that further restrictions are necessary. On 9/11/19 at 8:10 AM an interview with CDM A was conducted. CDM A was asked when she was first notified of the Norovirus outbreak in the building. CDM A stated again that she had been notified on (MONTH) 16, 2019. At this time, an email communication, dated Monday (MONTH) 8, 2019 9:03 AM, was reviewed with CDM [NAME] The email included CDM A in the Cc: line of list of recipients. The communication read: As of this morning we are closing the entire building due to illness (including the 2 North, South and East Units.) The Noro-like illness that is in the Home is spreading very rapidly and we want to attempt to prevent it from encompassing those Units where it has not yet hit Included as an attachment to the email was a document Guidelines for the Control of a Suspected or Confirmed Outbreak of [MEDICAL CONDITION] Gastroenteritis in a Nursing Home. Item #4 of this document read: Ill staff should remain out of work for 2-3 days after symptoms have ended. When asked why it took until (MONTH) 17 (2019) that Noro disinfectant or other means to control the spread of [MEDICAL CONDITION] from the dietary department had been implemented, CDM A stated I don't know. I don't remember that email. When asked why Staff B had not been required to obtain approval from her physician prior to returning to work, CDM A stated, I don't know. When asked why a bleach disinfection process was not implemented immediately, CDM A stated, I don't like the staff mixing chemicals. I would rather just have a spray bottle for them to spray. When asked if she realized the immediacy needed related to implementing infection control measures, CDM A stated, Yes. By all means it is important.