**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, and facility policy the facility failed to ensure each resident received the care and supervision necessary to avoid accident hazards for three (#47, #85 and #92) of seven residents reviewed for accident hazards out of 52 sample residents. Specifically, The facility failed to: - Ensure Resident #47, who had severe cognitive impairment, received sufficient supervision to ensure safety while smoking on 2/13/23. Additionally, cigarette butts were not extinguished properly and placed in appropriate receptacles. A smoking blanket and smoking aprons were not readily available in the smoking area. Staff in the vicinity did not take action when a hot ash from the resident's cigarette fell into their lap after the resident burned themselves attempting to light one cigarette off of another; and, - Provide adequate supports and supervision to prevent Resident #92 from eloping through a window on the memory care unit (MCU) on 10/6/22. The resident was located 17 minutes later approximately 0.68 miles from the facility. The facility responded by ensuring the windows of the MCU could not be opened wide enough to be used as an egress. However, the facility's system for monitoring the wander prevention system failed to identify alarms that were not working. The extent of the facility's failure to provide adequate supports and supervision to avoid accident hazards related to smoking and elopement was likely to cause serious injury, harm, impairment, or death to residents. The Administrator and Director of Nursing (DON) were notified of the immediate jeopardy situation on 2/15/23 at 9:30 a.m. and a plan to remove IJ was requested at that time. The Plan to Remove IJ was accepted by the State Survey Agency on 2/17/23 at 8:32 a.m. The IJ was removed on 2/17/23 at 5:52 p.m. after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance remained at the lower scope and severity of a pattern of no actual harm, with potential for more than minimal harm that was not immediate jeopardy for F689. Findings include: I. Smoking A. Policy A review of a facility policy titled, Smoking Policy, revised 11/2022, revealed, It is the policy of this facility to provide to its' [sic] residents a safe smoking environment. It is also policy to provide those residents who choose to smoke a means in which to do so that does not jeopardize their safety or the safety of other residents residing in the facility. The policy did not indicate whether a Brief Interview for Mental Status (BIMS) score would be considered in the determination of supervision required. B. Observations Observations on 2/13/23 at 10:00 a.m. revealed two residents being supervised while smoking in the designated smoking area outside the MCU. There were cigarette butts on the cement, on the ground, in a salt bucket, in pots with dead plants, in a trash can filled with other trash, and in the two designated ashtrays. The emergency/fire blanket box was empty. Observations on 2/13/23 at 11:05 a.m. of the smoking area located off the Montrose Unit revealed extinguished cigarette butts along the grass next to the sidewalk and fence in the area with posted No Smoking Area signs and in the grass around the patio portion of the designated smoking area. Observation on 2/13/23 at 1:20 p.m. revealed three residents from the MCU (Residents #6, #200, and #42) were smoking with Activity Assistant (AA) #1's supervision. Resident #200 and Resident #42 discarded their cigarette butts in the proper containers, while Resident #6 threw their lit cigarette butt on the ground. Observation on 2/13/23 at 1:55 p.m. revealed four of the six chairs in the smoking area outside the MCU had visible burn holes. Resident #47 was observed on 2/13/23 at 2:10 p.m. sitting in a wheelchair in the designated smoking area attempting to light a cigarette with the butt of a lit cigarette. Resident #47 yelled, Ouch, and dropped the cigarette butt onto their lap. Resident #47 flicked the cigarette butt onto the ground. Cigarette ashes were observed in the fold of resident's pants in the groin area. The Business Office Manager (BOM) was standing by and walked over and picked up the cigarette butt from the ground near Resident #47's wheelchair but stated she was unaware that Resident #47 was trying to light a cigarette with another lit cigarette butt and confirmed there were ashes in the fold of resident's pants in the groin area that she was unaware of. Resident #47 then pulled a lighter from their jacket pocket and lit the remaining cigarette. C. Record Review A review of Resident #47's admission Record revealed Resident #47 had diagnoses including unspecified dementia, altered mental status, cognitive communication deficit, hemiplegia and hemiparesis (paralysis and weakness on one side of the body) following cerebral infarction (stroke) affecting the right dominant side, and unspecified lack of coordination. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #47 had a BIMS score of 7, indicating severe cognitive impairment. The MDS indicated the resident used a wheelchair for mobility and required supervision and one-person physical assistance with locomotion on the unit and only supervision and set-up assistance with locomotion off the unit. Review of Resident #47's care plan revealed a focus area, dated as initiated on 5/11/22, that indicated the resident was at risk for impaired cognitive function/dementia or impaired thought processes and presented with mild cognitive deficits including forgetfulness, confusion, poor impulse control, poor judgment, and short and long term memory loss. Further review revealed a focus area, dated as initiated on 4/21/2020, that indicated Resident #47 had the potential for injury related to smoking and being an independent smoker. The care plan indicated Resident #47 had a history of unsafe smoking habits, such as smoking in their room, but had responded well to education and safe smoking agreements and continued to safely smoke independently. A review of Resident #47's Smoking Evaluation, dated 2/09/23, revealed no indication of cognitive impairment or dexterity problems and no need for adaptive clothing/devices/assistance. The document did not indicate whether the resident could smoke independently or required supervision. A review of Resident #47's Smoking Evaluation, dated 2/13/23, revealed the resident had cognitive impairment and dexterity problems but had no need for adaptive clothing/devices/assistance. The document did not indicate whether the resident could smoke independently or required supervision. D. Interviews During an interview on 2/13/23 at 1:24 p.m., AA #1 revealed all the supervised smoking residents' smoking paraphernalia was kept in separate containers for each resident in a bag that was placed in an unsecured utility room on a shelf. AA #1 stated that during smoke breaks, the residents were provided with a cigarette and staff lit the cigarette for each resident. AA #1 stated when the residents were finished smoking, she told the residents to look for an ashtray in which to discard the cigarette butts. AA #1 stated she made sure to watch each resident discard their cigarette butts into the proper receptacles. AA #1 stated she was unaware that one of the residents smoking during the 1:00 p.m. smoke break threw their cigarette butt into the grass and not into a designated receptacle. She stated she was aware of all the cigarette butts on the ground in and around the patio area because that area was rarely clean. AA #1 stated she had reported this to nursing staff, but it had been a long time and she was unable to remember when or to whom she reported. AA #1 stated there was one resident who required the use of a smoking apron and there used to be an apron located in the smoking area, but it was no longer there, and she was not sure where the aprons were stored now. AA #1 stated all the residents assessed as independent smokers kept their own smoking paraphernalia on their person, and she was not sure if the facility provided locks for the residents to secure them. AA #1 stated staff did not supervise independent residents when they were smoking. During an interview on 2/13/23 at 1:50 p.m., the Director of Life Safety stated he saw a lot of cigarette butts on the ground around the smoking area outside the MCU. He stated the maintenance director position was vacant, and he floated between different buildings, but the maintenance team was responsible for cleaning up the smoking areas weekly. During an interview on 2/13/23 at 1:51 p.m., the Assistant Maintenance Director stated he only went out to the smoking area outside the MCU when the area needed attention from maintenance, which was not very often. During an interview on 2/13/23 at 1:52 p.m., the Administrator stated he did not come out to the smoking area outside of the MCU very often and was unaware of all the cigarette butts on the ground. He indicated he did not know there was no fire blanket in the designated box. During interviews on 2/13/23 at 1:55 p.m., the Administrator, the Director of Life Safety, and the Assistant Director of Maintenance stated they did not know there were burn holes in the chairs in the smoking area outside the MCU. During an interview on 2/14/23 at 9:15 a.m., the Staffing Coordinator/Certified Nurse Aide (CNA) #13 revealed there were set times for smoke breaks for supervised smokers, at 7:00 a.m., 10:00 a.m., 1:00 p.m., and 4:00 p.m. She stated independent smokers could smoke whenever they chose. CNA #13 stated that restorative and activities staff were responsible for supervising the smokers. CNA #13 stated that all the supervised residents' smoking paraphernalia was stored on the units in designated drawers. CNA #13 stated the Kardex indicated which residents required supervision, and there was a list located on each unit at each nurses' station that indicated which residents were supervised and independent. CNA #13 was unable to state how many residents were supervised smokers and was only able to name three residents. CNA #13 stated during supervised smoking times, staff took the residents' smoking paraphernalia to the smoking areas. CNA #13 stated staff handed residents their cigarettes and would light the cigarette for the resident and remain outside with the residents while they smoked, to ensure the butts were disposed of properly. CNA #13 stated there were no residents that required the use of a smoking apron, but she was unable to state where the aprons were located if a resident did require the use of one. CNA #13 stated she had seen them in the past, located on other units, but was not sure if they were there now. CNA #13 stated there were some staff that smoked in the smoking areas, but staff should notify maintenance if they observed discarded butts on the ground. CNA #13 stated she was familiar with Resident #47, and in her opinion, the resident was not a safe smoker. CNA #13 stated Resident #47 would light cigarettes in the facility and was not safe holding a cigarette when agitated. CNA #13 stated Resident #47 would wave the lit cigarette around. CNA #13 stated she was aware Resident #47 was evaluated as a safe independent smoker, but she thought the resident should be supervised. CNA #13 stated she thought staff kept the residents' smoking paraphernalia in a drawer at the nurses' station. During an interview on 2/14/23 at 9:35 a.m., Registered Nurse (RN) #18 revealed he did not think Resident #47 should be an independent smoker because the resident was noncompliant, and the resident's dexterity was not good. RN #18 stated staff kept Resident #47's cigarettes, but the resident was allowed to keep their lighter. RN #18 stated that Resident #47 was very sneaky and would get cigarettes from other residents and family. RN #18 stated staff tried to keep an eye on Resident #47 but unfortunately, the resident was not assessed to require supervision and had been assessed to be an independent smoker. During an interview on 2/14/23 at 9:46 a.m., AA #26 revealed the interdisciplinary team (IDT) completed the smoking assessments that identified which residents required supervision when smoking, and there was a list located at each nurses' station and on the wall in the activities room. AA #26 stated the list indicated which residents were independent and which required supervision, along with the smoking times. AA #26 stated the activities department was responsible for supervising at 10:00 a.m., 1:00 p.m., and 4:00 p.m., but AA #26 was unsure if there was an actual list that stated which staff were responsible for supervising smoking. AA #26 stated Resident #47 was an independent smoker, and she had never observed anything concerning but she did not observe Resident #47 smoking since the resident was independent. AA #26 indicated staff kept Resident #47's cigarettes, but she was unsure about the lighter. AA #26 stated cigarette butts were monitored when staff were outside, and that staff should be ensuring the cigarette butts were picked up. AA #26 stated the reason there were so many butts on the ground was because it was hard to keep it up and that the residents were noncompliant. AA #26 stated she thought the residents needed to be reeducated all the time about properly disposing of the cigarette butts and that no staff were required to be present when the independent smokers were smoking. During an interview on 2/14/23 at 10:52 a.m., the Admissions Coordinator revealed he had completed training related to smoking on 2/13/23. He stated the training went over the expectation that staff should monitor residents and ensure they were safe while smoking. The admission Coordinator stated he received an email that morning notifying him that he would be required to monitor smoking from 10:00 a.m. until 12:00 p.m. that day. The Admissions Coordinator stated he was supposed to remain outside for the entire two-hour period and that the Business Office Manager was there before him from 8:00 a.m. until 10:00 a.m. The Admissions Coordinator stated another staff would be there from 12:00 p.m. until 2:00 p.m. The admission Coordinator stated during the training staff were provided with a list that identified which residents were to be supervised while smoking and which were independent. The Admissions Coordinator stated he would not be able to identify all residents by their face so he would need to look in the electronic health record to determine who they were. He was unable to state how he would know their name to look them up if he did not recognize their face, then stated he would ask another staff. The Admissions Coordinator stated supervised smokers' cigarettes were kept at the nurses' station, but he was not sure about the lighters. The admission Coordinator indicated he observed Resident #79 light their own cigarette and asked the resident about that. He stated the resident told him they had their own lighter. The admission Coordinator stated he was not aware that the resident was not supposed to have their own lighter. He indicated he never asked the resident to provide the lighter to him and he did not report that to anyone. During an interview on 2/14/23 at 1:56 p.m., the Director of Nursing (DON) revealed that upon admission and quarterly, nursing staff completed the admission Smoking Assessment and that the activities staff and social services helped make sure the residents had cigarettes. The DON stated the activities staff would let nursing staff know if they observed anything during smoke breaks that would require another assessment to be completed. The DON stated that staff would make one smoking observation of the resident to complete the smoking assessment. The DON stated she observed Resident #47 smoke yesterday evening and had never observed the resident doing anything unsafe during smoking. The DON stated she had spoken with other staff about Resident #47 but none of them identified any concerns. The DON stated there was no documentation of where or how the information was obtained to complete the smoking assessments. The DON stated she had heard that something had occurred the previous day when Resident #47 was smoking but she was unsure of what specifically occurred and that she was unaware that several staff interviewed stated they did not think Resident #47 was a safe smoker. The DON stated another smoking assessment would be completed on Resident #47. The DON also stated the smoking list had been updated and that Resident #79 was moved to supervised smoking, with staff to have possession of the resident's cigarettes and lighter. During a follow-up interview on 2/17/23 at 9:57 a.m., the BOM revealed there was training related to smoking anytime there was a change in policy, or a change in the number of smokers, and the last update was on 2/15/23. The BOM stated the last training prior to that was a couple months previously in 2022 but she was unsure of the date. The BOM stated there were supervised and independent smokers and there was a list that identified which residents were to be supervised, which was located at each nurses' station and was updated anytime there was a change. The BOM stated the independent smokers were allowed to smoke whenever they wanted and were allowed to keep their own cigarettes and lighters, but the supervised smokers would go out at 7:00 a.m., 10:00 a.m., 1:00 p.m., 4:00 p.m., 7:00 p.m., and 10:00 p.m., but that was changed to 10:45 p.m The BOM stated that all the supervised smokers' paraphernalia was kept by staff and that the nurses would get the residents' cigarettes and take them out and staff would light the residents' cigarettes for them. The BOM also stated that staff should take the cigarette butts from the residents and dispose of them properly in the ashtrays. She indicated if staff observed a resident discard their cigarette butt on the ground, they should pick it up and dispose of it in the ashtray. The BOM stated maintenance completed weekly ground checks and was responsible for keeping the ashtrays clean and the grounds cleared, but she was not sure who was responsible for checking to ensure the emergency fire blanket and aprons were available at each of the smoking areas. The BOM indicated she was unable to show the surveyor where the aprons were located because she was not sure. The BOM also stated she was not sure if staff ever made random observations of the independent smokers to ensure they were still smoking safely. During an interview on 2/17/23 at 12:25 p.m., the Maintenance Aide (MA) revealed it was his responsibility to ensure the smoking areas were free of cigarette butts on the ground, that the emergency fire blankets were stored at each smoking area, and to empty the ashtrays and trash cans. The MA stated that was completed on Wednesday or Friday of each week. He stated he had completed the task in the main smoking area on 2/13/23 (a Monday) but forgot to check the smoking area located outside the MCU. The MA stated the last time the MCU smoking area checks were completed was on Wednesday, 2/01/23, but there was no documentation of the check that day or of any of the weekly checks. The MA stated residents should not be discarding lit cigarette butts on the ground, that the residents on the MCU were supposed to be supervised, and that staff should have been disposing of the residents' cigarette butts. The MA stated he had been informed by staff that this was an issue, but only on one occasion. The MA indicated he did not know what happened to the missing emergency/fire blanket outside the MCU, but he had not been checking to ensure it was there prior to the survey. During an interview on 2/17/23 at 1:44 p.m., the DON revealed the nurses were trained on completing the initial smoking assessment and should complete at least one observation of a resident smoking as part of the assessment, but this was not documented. The DON stated nursing, activities, and social services staff were responsible for completing these assessments. The DON stated nursing staff did the initial assessment, and activities staff or social services staff would complete the assessment post-admission. The DON indicated staff should ensure all residents who required supervision during smoking were alert and that all their smoking paraphernalia was held by staff. The DON stated there was a list of supervised and independent smokers located at each nurses' station and the activities staff should have their own list. The DON stated staff would provide each supervised resident a cigarette and light it for them. The DON indicated staff should observe residents smoking and assist those residents with properly disposing of the cigarette butts as needed. The DON stated staff observing the supervised smokers should ensure the proper disposal of the cigarette butts. The DON stated that if staff were supervising appropriately, there should not have been any discarded cigarette butts on the ground and that maintenance should ensure there was no accumulation of cigarette butts. The DON stated probably a lot of staff had been smoking and discarding their butts on the ground. The DON stated staff would make random observations of the independent smokers, or if there were concerns, but otherwise staff were not observing independent smokers. She stated there should have been another observation of each resident when their quarterly smoking assessment was completed. The DON stated that staff redirected supervised residents when they tried to get cigarettes from other residents and should have been going into the independent smoking area to ensure there were no supervised smokers out there without supervision, The DON stated she would have expected the BOM to intervene when Resident #47 dropped the cigarette on themselves. During an interview on 2/17/23 at 3:45 p.m., the Administrator revealed he expected all smoking assessments to be completed as accurately as possible. He indicated staff were supervising residents who required supervision, based on what was in the smoking policy and according to their training. The Administrator stated ideally, there should not have been residents discarding cigarette butts on the ground, and staff who were present should have been picking them up. The Administrator indicated discarded lit cigarette butts were not sanitary and were not safe due to being a possible fire hazard. The Administrator stated maintenance should have been completing routine rounds, cleaning up any discarded cigarette butts, and disposing of them properly. He revealed he would have expected staff to intervene if any resident had visible ashes on their clothing or when a resident dropped a lit cigarette on themselves. He also stated he expected maintenance to complete their weekly rounds to ensure fire safety blankets were located at each smoking area and that staff were making rounds of smoking areas throughout the day to ensure resident safety and well-being. II. Elopement A. Policy Review of a facility policy titled, Elopement, dated 11/2022, indicated, It is the policy of this facility to investigate and report all cases of missing residents. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or DON [Director of Nursing] or designee. If resident not located, notify the Administrator and DON, the resident's legal representative, and law enforcement officials. Provide search teams with resident information. When a departing individual returns to the facility, the Charge Nurse shall examine the resident for injuries and to notify attending physician. B. Record review 1. Resident 92 A review of Resident #92's admission Record revealed the facility admitted the resident with diagnoses that included dementia with behavioral disturbance and agitation, cognitive impairment, and encephalopathy (a disease that affects brain structure or function and causes an altered mental state and confusion). A review of Progress Notes, dated 10/3/22, revealed Resident #92 was admitted to a room on an unsecured hall with the diagnosis of dementia and was identified to be at risk for elopement. A review of an Elopement/Wandering Evaluation, dated 10/3/22, revealed Resident #92 had dementia, ambulated independently, was disoriented, and had the potential to go outside with active exit-seeking behavior. An admission Minimum Data Set (MDS), dated [DATE], revealed Resident #92 had a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident was severely cognitively impaired. The MDS indicated the resident did not exhibit wandering behaviors. According to the MDS, the resident required only supervision and set-up assistance with locomotion on and off the unit and did not use a mobility device. A review of Resident #92's Care Plan, dated as initiated on 10/04/22 and revised on 10/6/22, revealed Resident #92 was an elopement risk related to wandering aimlessly with exit seeking. The care plan indicated the resident had failed attempts with a wandering alert bracelet and was transitioned to the secured unit. Interventions included to assess for fall risk, disguise exits, distract the resident from wandering by offering music, juggling, nutrition, and exercise, document wandering behaviors and attempted diversional interventions, and identify wandering patterns. A review of Progress Notes, dated 10/4/22, revealed Resident #92 was placed on a wandering alert bracelet on 10/3/22 due to signs of exit seeking. The notes indicated on 10/4/22, Resident #92 attempted to leave the facility through a fire door in the dining room. Staff were alerted and redirected Resident #92 back into the facility. A review of Resident #92's Progress Notes, dated 10/5/22, revealed Resident #92 was transferred to the MCU due to exit-seeking behavior with attempts to get out of the facility. The wandering alert bracelet proved to be ineffective, so the facility transitioned Resident #92 to the MCU per their family member's request, to avoid Resident #92 going to the hospital for behaviors. A review of Resident #92's Secure Neighborhood Placement Evaluations, dated 10/5/22, revealed Resident #92 wandered throughout the facility with a wandering alert bracelet and attempted to climb the fence in the smoking areas. A review of Resident #92's Progress Notes, dated 10/6/22, revealed Resident #92 climbed through a window of another resident's room on the MCU at 3:49 p.m. and went over the fence of a courtyard. At 3:50 p.m., staff were directed on the elopement and separated in different directions in order to search for Resident #92. Resident #92 was found ambulating on the street at 4:01 p.m. and was transported back to the facility, with no injuries noted. Resident #92's family member was notified of the incident and preferred medication adjustments, refusing to have Resident #92 sent to the emergency room. A review of the Initial Report for Facility, dated 10/6/22, revealed Resident #92 climbed through a window of another resident's room on the MCU at 3:49 p.m. and jumped the fence. A Code Pink was called to the MCU at 3:50 p.m., and all staff were directed on elopement and where to search. The interdisciplinary team (IDT) members separated and went in different directions away from the facility. Resident #92 was oriented to self only, confused, had impaired memory, wandered, and was admitted within the last 72 hours. Facility staff found Resident #92 down the street at approximately 4:01 p.m. A review of the facility's Missing Person incident investigation, dated 10/6/22, revealed Resident #92 climbed through a window of another resident's room on the MCU at 3:49 p.m. and jumped the fence. Facility staff found Resident #92 on the street, 0.68 miles from the facility, at approximately 4:01 p.m. with no injuries noted. Resident #92 was missing from the facility for approximately 17 minutes. The police, ombudsman, physician, and responsible party were notified. The facility placed Resident #92 on frequent checks and continued placement on the MCU per the family, physician, and facility recommendation. 2. Resident #85 A review of Resident #85's care plan, initiated on 01/11/23, revealed the resident was a high risk for elopement/wanderer related to impaired safety awareness and dementia. A review of Resident #85's Elopement Risk Assessment, dated 11/26/22, revealed Resident #85 scored 24, indicating a high risk for elopement. 3. Monitoring records A review of a list dated 2/13/23, of residents with wandering alert bracelets, revealed two residents who were not on the MCU had the bracelets, one of whom was Resident #85. Multiple observations during the survey conducted from 2/13/23 to 2/17/23 revealed Resident #85 walking up and down unsecured hallways and standing close to exit doors, talking about going on a trip to the mountains without direct staff supervision. A review of the Resident Monitoring Systems: Check operation of door monitors and patient wandering system, dated October 2022 to February 2023, revealed: - 10/13/22: five doors were checked, all passed. - 10/16/22: two doors were checked, both passed. - 10/26/22: five doors were checked, all passed. - 11/7/22: six doors were checked, all passed. - 12/1/22: six doors were checked, all passed. - 12//22: four doors were checked, all passed. - 01/10/23: all seven doors were checked, all passed. - 01/17/23: all seven doors were checked, all passed. - 2/3/23: four doors were checked, all passed. C. Observations Observation on 2/13/23 at 1:20 p.m. revealed Resident #92 asking to get out the exit door to the MCU courtyard and pushing buttons on the keypad next to the door. Observation on 2/14/23 at 12:11 p.m. revealed the Assistant Maintenance Director testing the facility's wandering alert system at six of the seven exit doors. The exit door to the side smoking area did not lock when the Assistant Maintenance Director opened the door with a wandering alert device in hand. D. Interviews During an interview on 2/14/23 at 9:53 a.m., Certified Nursing Assistant (CNA) #2 stated she was doing her routine rounds on 10/06/22 when she noticed Resident #92 was no longer in the MCU's common area. CNA #2 then stated she checked each room and noticed a window open in another resident's room. CNA #2 immediately notified Licensed Practical Nurse (LPN) #3, who then initiated a search for Resident #92. During an interview on 2/14/22 at 10:04 a.m., LPN #3 stated Resident #92 climbed out of another resident's room window on the MCU. LPN #3 immediately notified the DON, the facility called a Code Pink, and staff immediately started searching for Resident #92. During an interview on 2/14/23 at 10:18 a.m., the DON stated Resident #92 started exit-seeking once admitted to the facility, so staff placed a wandering alert bracelet on the resident. Resident #92 continued to exhibit exit-seeking behaviors, so in coordination with the provider and Resident #92's family member, it was determined to place Resident #92 on the MCU. In October 2022, Resident #92 climbed out a window and jumped the fence of a secured outdoor area. Once LPN #3 notified her that Resident #92 had eloped, a Code Pink was called, and facility staff went in different directions from the facility to search. The DON indicated staff found Resident #92 down the street from the facility. The DON stated maintenance put stoppers on the windows of the MCU to prevent them from completely opening to prevent future elopements. During an interview on 2/14/23 at 10:50 a.m., LPN #3 stated Resident #92 had dementia with confusion and was not safe on the street on their own. During an interview on 2/14/23 at 12:04 p.m., the Physician's Assistant (PA) stated he had followed Re[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** VI. Failure to ensure staff wore proper personal protective equipment (PPE) when entering resident isolation rooms A. Professional reference According to the CDC Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes updated 9/10/21, retrieved on 1/25/22 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, in pertinent part: Health care providers who enter the room of a patient suspected or confirmed to be infected with SARS-CoV-2, should adhere to standard precautions and use NIOSH (National Institute for Occupational Safety & Health)-approved N95 or equivalent or higher-level respirator, gown, gloves and eye protection (goggles or a face shield that cover the front and sides of the face). B. Observations Certified nurse aide (CNA) #1 was observed on 1/12/22 at 8:37 a.m. CNA #1 entered the isolation room of Resident #65 without wearing a gown or gloves. Resident #65 was on COVID-19 isolation precautions. Resident #65's room had isolation droplet precaution signage posted on the door and on the wall outside the room. In addition there was a sign posted on the resident's door regarding appropriate PPE to be worn prior to entering the room. The room had a purple bin placed outside the room which stored the personal protective equipment (PPE) for staff to utilize. CNA #1 was observed on 1/12/22 at 12:10 p.m. CNA #1 entered the isolation room of Resident #293 without wearing a gown or gloves. Resident #293's room had isolation droplet precaution signage posted on the door and on the wall outside the room. In addition there was a sign posted on the resident's door regarding appropriate PPE to be worn prior to entering the room. The room had a purple bin placed outside the room which stored the personal protective equipment (PPE) for staff to utilize. C. Staff interviews CNA #3 was interviewed on 1/13/22 at 9:33 a.m. She said all staff should put on the personal protective equipment (PPE) from the isolation carts outside the isolation room. She said the PPE included a gown, gloves, an N95 (face respirator) mask and goggles or a face shield. She said regardless of whether the staff were providing care or dropping something off in the room they should put on the appropriate PPE before entering a resident isolation room. Licensed practical nurse (LPN) #2 was interviewed on 1/13/22 at 9:33 a.m. She said all staff should put on the proper PPE before entering a resident isolation room regardless of what care they were providing. She said the proper PPE included a gown, gloves, an N95 mask and a face shield. She said she would remind the staff to utilize the proper PPE before entering resident isolation rooms. The director of nursing (DON) was interviewed on 1/13/22 at 10:35 a.m. She said all staff should wear a gown, gloves, N95 and face shield or goggles when entering a resident isolation room regardless of what type of care was being provided. She said all staff were wearing the N95 mask and face shield at all times because of the current COVID-19 outbreak status. She said all certified nursing aides were trained on appropriate PPE utilization when entering a resident isolation room (she did not give a specific time frame of training). She said she would provide additional training to the staff observed entering the isolation rooms without the proper PPE (after issues were identified in infection control with the immediate jeopardy). Based on observations, record review and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: -Ensure an unvaccinated resident (Resident #11) was socially distanced (six feet apart) from a confirmed COVID-19 positive resident (Resident #14) and Resident #2 (who was not COVID-19 positive) while consuming their lunch meal; -Ensure staff wore proper personal protective equipment (PPE) when entering Resident #65's and Resident #293's isolation rooms for COVID-19; and, -Ensure staff wore PPE (N95 mask) correctly to ensure secure fit. On 1/12/22 at 12:10 p.m. staff were observed to seat Resident #11 at a dining table for lunch with a positive COVID-19 resident. The observation also revealed there was space available to allow the residents to socially distance (see observation below). On 1/12/22 at 8:37 a.m. and 12:15 p.m. certified nurse aide (CNA) #1 was observed to enter Resident #65's and #293's rooms, who were on isolation for COVID-19, with appropriate PPE (gown and gloves, see observation below). On 1/12/22 at 3:32 p.m. CNA #2 was observed wearing his N95 mask incorrectly, failing to ensure a secure fit. The back/bottom strap of the mask was observed hanging in front of his face (see observation below). Record review revealed the facility had been in a COVID -19 outbreak status since 12/26/21, which included positive cases for both residents and staff. The facility's failures beginning 1/12/22 created an immediate jeopardy situation; a situation that was preceded by the facility's outbreak status where four staff members and four residents had tested positive for COVID-19 just days earlier on 1/10/22 and 1/11/22. Furthermore, Resident #11 started experiencing signs and symptoms of COVID-19 on 12/13/21 and was confirmed COVID-19 positive on 1/15/22 which placed residents at risk for harm. Cross-reference F886, the facility failed to follow infection control measures to prevent the potential cross- contamination of SARS-CoV-2 COVID-19, during testing procedures on staff and residents. Findings include: I. Facility status SARS-CoV-2 COVID-19 According to the facility's line list report, updated on 1/17/22, the facility outbreak status confirmed by the local County Health Department (CHD) on 12/26/21 was as follows: -As of 12/26/21, one facility staff had tested positive for SARS-CoV-2 COVID-19 with a polymerase chain reaction (PCR) test. -As of 12/27/21, one resident had tested positive for SARS-CoV-2 COVID-19 with a PCR test and 10 more facility staff had tested positive for SARS-CoV-2 COVID-19 (seven with a PCR test and three with an antigen test). -As of 12/26/21 and 12/27/21 the resident and all staff who were positive according to the line list had one major symptom of COVID-19. The facility remained in outbreak status during survey 1/12/22 to 1/18/22 with a total of 34 residents (nine confirmed with PCR test and 25 with an antigen test); and a total of 32 staff (14 confirmed with PCR test and 18 with an antigen test) who were COVID-19 positive. The facility had five unvaccinated residents refusing the vaccine and two unvaccinated staff who had medical exemptions. II. Immediate Jeopardy A. Findings of immediate jeopardy Observations, record review and interviews revealed the facility failed to follow infection prevention measures to prevent cross-contamination and spread of SARS-CoV-2 COVID-19. There were multiple observations during survey 1/12/22 to 1/18/22 which revealed multiple failures in the facility's infection control program, including failure to ensure COVID-19 testing of staff and residents was conducted properly to prevent the spread of an infectious disease, failure to properly and appropriately use PPE, and failure to properly and effectively socially distance staff during testing and residents with known positive COVID-19 cases. The facility's failure to follow proper infection control practices created an immediate jeopardy situation due to the likelihood the facility's failures would lead to the transmission of SARS-CoV-2 COVID-19. B. Facility notice of immediate jeopardy On 1/13/22 at 12:30 p.m., the nursing home administrator (NHA), clinical resource nurse (RCN) #1 and director of nursing (DON) were notified that the failures in the facility's infection control program created an immediate jeopardy situation that placed all residents in the facility at risk for serious harm related to the transmission of SARS-CoV-2 COVID-19. C. Plan to remove immediate jeopardy On 1/13/22 at 6:00 p.m., RCN #1 presented the following plan to address the immediate jeopardy situation. The following was implemented: 1. Resident #65 is COVID positive but is asymptomatic at this time. CNA #1 to be educated over the phone on 1/13/22 in regards to proper PPE usage in isolation rooms and skilled checklist completed. 2. Resident #293 is COVID positive and not symptomatic at this time. CNA #1 to be educated over the phone on 1/13/22 in regards to proper PPE usage in isolation rooms. 3. Resident #3 (however, this resident number was incorrect as it was Resident #2) was assessed by RN (registered nurse) today and has tested negative on Antigen test on 1/13/22. 4. Resident #11 and Resident #14 were placed at a table together by staff, IP (infection preventionist) educated CNA #3 on 1/13/22 in regards to proper social distancing and keeping COVID positive Residents away from COVID negative Residents. a. IP initiated full house education to all staff on 1/13/22 in regards to which residents were COVID positive, proper PPE usage and isolation, social distancing on the secured unit, and proper wearing of mask. b. The full house education will be completed by 1/17/22, any employee unable to come in and complete in person education will be called and educated or educated prior to start of next scheduled shift. c. Facility completed 1:1 (one-to-one) education with van driver (certified nurse aide #2) in regards to proper usage of N95 mask and offered a different mask on 1/13/22. d. Facility arranged tables in the secured unit to be six feet apart on 1/13/22 at 1300 (1:00 p.m.), two tables were moved on the secured unit away from other residents to encourage the COVID positive residents to socially distance on secured units. e. Staff will continue to encourage residents to wear masks, if residents require redirection or become agitated, staff will utilize the trigger/behavior cards available for the residents to assist them in redirection of those residents as part of the education stated above, this education will be provided to all staff who work the secured unit, education to be completed by 1/17/22. f. Facility will initiate audits of the secured unit for seven meal times throughout the week to monitor staff redirecting residents with COVID to socially distance, and that no COVID positive and COVID negative residents are seated at the same table. g. Facility will also initiate an audit to monitor 10 employees weekly for proper donning and doffing of PPE in and out of isolation rooms, and for staff appropriately wearing masks, these audits will continue until 12 weeks of compliance has been achieved; the audit will start on 1/14/22 (sic) and go until 12 weeks of compliance is achieved. h. This will be reviewed in QAPI (quality assurance performance improvement) for the areas of the (sic) system that are improved and any issues identified. D. Removal of the immediate jeopardy On 1/13/22 at 6:00 p.m. the NHA, RCN and DON were notified the immediate jeopardy was lifted based on evidence of the facility's implementation of the above plan. However, deficient practice remained at an E scope, a pattern for more than minimal harm. III. Failure to ensure an unvaccinated resident (Resident #11) was socially distanced (six feet apart) from confirmed COVID-19 positive resident (Resident #14) and Resident #2 (who was not COVID-19 positive) while consuming their lunch meal. A. Professional reference The Centers for Medicare & Medicaid Services Nursing Home Visitation Frequently Asked Questions (FAQs) updated 1/6/22, retrieved 1/19/22 from https://www.cms.gov/files/document/nursing-home-visitation-faq-1223.pdf revealed in pertinent part: If the facility is using a contact tracing approach for an outbreak investigation, those residents who are identified as potentially being a close contact of the individual who tested positive for COVID-19, are considered to have had close contact and should not participate in communal dining or activities. Residents who have not received a COVID-19 vaccine and have had close contact with someone with COVID-19 infection should be placed in quarantine for 14 days after the close contact, even if viral testing is negative. A resident who is unable to wear a mask due to a disability or medical condition may attend communal activities, however they should physically distance from others. If possible, facilities should educate the resident on the core principles of infection prevention, such as hand hygiene, physical distancing, cough etiquette, etc. and staff should provide frequent reminders to adhere to infection prevention principles. A resident who is unable to wear a mask and whom staff cannot prevent having close contact with others should not attend communal activities. To help residents prevent having close contact, such as in the case of a memory care unit, the staff should limit the size of group activities. They should also encourage frequent hand hygiene, assist with maintaining physical distancing as much as possible, and frequently cleaning high-touch surfaces. If a resident refuses to wear a mask and physically distance from others, the facility should educate the resident on the importance of masking and physical distancing, document the education in the resident's medical record, and the resident should not participate in communal activities. B. Facility policy The Infection Control and Prevention policy, updated 6/28/21, was provided midday by RCN #1 and NHA on 1/12/22. It documented in pertinent part, It is the policy of this facility to include preparatory plans and actions to respond to the threat of the COVID-19, including but not limited to infection prevention and control practices in order to prevent transmission. Infection Prevention Control: Supplies and Practices Hand Hygiene Supplies: -Place FDA (Food and Drug Administration)-approved alcohol-based hand sanitizer with 60-90% alcohol in every resident room (ideally inside and outside of the room) and in other resident care and common areas. -Perform hand hygiene according to the CDC (Centers for Disease Control) guidance. CDC Performing Hand Hygiene using an alcohol-based hand sanitizer or soap and water as identified by CDC. Personal Protective Equipment: Facilities should have policies and procedures addressing: -Under what circumstances and what type(s) of PPE are to be used; -Proper donning/doffing sequence and technique; -Process for appropriate disposal; and, -Proper cleaning, decontamination and storage of any reusable equipment or supplies. Select, maintain inventory, and supply appropriate PPE, where needed, to HCP (healthcare personnel) according to Occupation Safety and Health Administration (OSHA) PPE standards and CDC Standard and Transmission-based Precautions. Include containers for disposal of PPE supplies where needed. -PPE may include facemasks, N95 or higher-level respirators, gowns, gloves, and eye protection (i.e. face shield or goggles). Environmental Cleaning and Disinfection: -Develop a schedule for regular cleaning and disinfection of shared equipment, frequently touched surfaces in resident rooms and common areas. -Ensure availability of and use EPA (Environmental Protection Agency)-registered, hospital-grade disinfectants from list N-disinfectants for coronavirus (COVID-19) -Ensure HCP (healthcare personnel) are appropriately trained to use and manufacturer's instructions for all cleaning and disinfection products (e.g., concentration, application method, and contact time). Education: Prevention Practices -Educate residents, healthcare personnel, and visitors about SARS-CoV-2, current precautions being taken in the facility, and action they should take to protect themselves. Testing Plan for Testing Residents and HCP Guidance addressing when to test resident HCP for SARS-CoV-2 and how to interpret results of antigen test is available at the following links: -Testing Guidelines for Nursing Homes -Interim Guidance on Testing Healthcare Personnel for SARS-CoV-2 -SARS-CoV-2 Antigen Testing in Long Term Care Facilities. Source Control and Distancing Implement Source Control Measures Use of well-fitting cloth masks, facemasks, or respirators to cover a person's mouth and nose. -Residents, if tolerated, should wear a well-fitting form of source control upon arrival and throughout their stay in the facility. Residents may remove their source control when in their rooms but should put it back on when around others (e.g., HCP or visitors enter the room) and whenever they leave their room or go outside of the facility. CDC-Options to improve fit or masks. Implement Physical Distancing Measures -Maintain physical distance between people (at least 6 feet), except when closer distance is required for the provision of care. -HCP are to practice physical distancing and wear source control when in break rooms or common areas. -The following activities can be considered for residents who do not have current suspected or confirmed SARS-CoV-2 infection, are recovered, and have had close contact with a person with SARS-CoV-2 infection: -Communal dining and group activities at the facility with social distancing, source control and frequent hand hygiene. C. Resident #14 1. Resident status Resident #14, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), the diagnoses included Alzheimer's disease, dementia with behavioral disturbances, hypertension (high blood pressure), and cognitive communication deficit. The 10/20/21 quarterly minimum data set (MDS) assessment revealed the resident was unable to complete an interview for a brief interview for mental status (BIMS). The resident had short and long term memory problems, and had moderate impairment with cognitive skills for daily decision making. The resident had disorganized thinking, inattention, and did not reject any cares from staff. The resident required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident required supervision with locomotion on the unit, and with eating. Resident #14 was confirmed COVID-19 positive via Antigen test on 1/10/22. 2. Record review The 1/10/22 nursing progress note documented the resident had a positive COVID-19 diagnosis. The 12/16/21 care plan revealed the resident would decline to wear a mask in the common areas even when staff requested her to wear a mask. The resident was to be encouraged to maintain a six foot distance between others when out of their room. D. Resident #11 1. Resident status Resident #11, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), the diagnoses included Alzheimer's disease, dementia, hypertension (high blood pressure), and muscle weakness. The 10/28/21 quarterly minimum data set (MDS) assessment revealed the resident was unable to complete an interview for a mental status score (BIMS). The resident had short and long term memory problems, and had severe impairment with cognitive skills for daily decision making. The resident required extensive assistance with bed mobility, transfers, dressing, toilet use, personal hygiene, and did not reject any cares from staff. The resident required supervision with locomotion on the unit, and with eating. The resident used a front wheel walker and a wheelchair. Resident #11 was not vaccinated. 2. Record review The 7/21/2020 care plan revised on 10/31/21 revealed Resident #11 declined the COVID-19 vaccine. The 11/8/21 care plan revealed, Resident is at risk for COVID-19. Resident does not maintain her mask in open spaces. Encourage resident to maintain 6 ft distances between others when out of the room. The 12/26/21 CPO revealed the resident was to be encouraged to socially distance from others of six feet or greater, and to redirect as needed to keep a six feet distance, and to document if the resident was non-compliant. The 1/15/22 nursing progress note revealed the resident had a positive COVID-19 test result (three days after eating lunch with a COVID-19 positive resident, see below). E. Resident #2 1. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), the diagnoses included dementia with behavioral disturbances, acute kidney failure, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), type one diabetes mellitus, and unspecified glaucoma. The 1/6/22 quarterly minimum data set (MDS) assessment revealed the resident was unable to complete a brief interview for mental status score (BIMS). She had highly impaired vision. She did not reject cares from staff. She required extensive assistance with bed mobility, transfers, toilet use, personal hygiene, locomotion on the unit, and eating. The resident was totally dependent upon staff for bathing. 2. Record review The 1/2/22 care plan revealed the resident was at risk for COVID-19. -The care plan did not reveal the resident was to maintain six ft social distance from others in the common areas. F. Observations On 1/12/22 from 12:10 p.m. to 12:50 p.m. lunch was observed in the secured unit. At 12:10 p.m. Residents #11 and #2 were escorted in their wheelchairs by certified nurse aide (CNA) #4 to a table in the common area on the secured unit which was an approximately three feet square table. Resident #14 (COVID-19 positive) walked to the same table and sat down with Resident #11 (unvaccinated for COVID-19) and Resident #2 (vaccinated). CNA #4 told Resident #14 it was okay to sit at the table where Residents #11 and #2 were seated. CNA #4 did not encourage Resident #14 or Resident #11 to sit at other available tables in the dining area. To the left of Resident #14 sat Resident #2. Resident #14 (COVID-19 positive) sat across the three foot table from Resident #11 (unvaccinated for COVID-19). The three residents were not socially distanced six feet apart from one another. The residents were not wearing masks. Residents #11, #14, and #2 ate lunch and drank liquids while being seated together. At 12:16 p.m., registered nurse (RN) #1 pulled up a chair and sat in between Residents #14 and Resident #2. RN #1 did not wear gloves as she assisted Resident #11 and #2 with their meals. RN #1 did not sanitize her hands in between assisting the two residents with eating. During the meal, the residents fed themselves and RN #1 assisted with bites of food to Resident #14 and Resident #2. -RN #1 used each resident's own silverware but she did not wear gloves or sanitize her hands in between assisting Resident #14 and Resident #2 with eating. RN #1 used both her right and left hands to assist Resident #14 and Resident #2. RN #1 took her ungloved right hand to pick up the spoon from Resident 14's plate, scooped some food onto it, brought the food to Resident 14's mouth, and sat the spoon back down onto the plate. RN #1 did not sanitize her hands and used her ungloved right hand to assist Resident #2 in the same manner. RN #1 repeated this for 10 minutes with both her ungloved left and right hands for both Resident #14 and Resident #2. RN #1 did not sanitize her hands in between assisting each resident with eating. At 12:45 p.m. RN #1 stood up and walked away from the table. The three residents continued to sit together. Resident #14 (COVID-19 positive) put her spoon that was in her mouth into the pudding of Resident #2. Then Resident #2 put her spoon in the same pudding that Resident #14 ate from. At 12:50 p.m. Resident #14 stood up and walked away from the table. G. Staff interviews Activity assistant (AA) #1 was interviewed on 1/13/22 at 9:49 a.m. She said she was the resident assistant for the memory care unit. She said the staff did not wear gloves while working on the memory care unit. She said the staff sanitized their hands between residents when the staff were assisting residents with eating. She said the staff did not wear gloves but the staff did sanitize their hands in between every resident they provided care to. She said the staff should not have seated a COVID-19 positive resident with the only resident on the unit who was not vaccinated against COVID-19. She said the staff could easily have seated the COVID-19 positive residents at a table that was isolated and six feet away from others. She said the memory care residents did not stay in their rooms to eat. She said the staff could rearrange the tables to be six feet apart. She said the staff should encourage any COVID-19 positive residents to sit together. She said the tables the residents sat at in the dining room were about three feet square tables. AA #1 said to certified nurse aide (CNA) #4, You should never seat an unvaccinated resident with a COVID-19 positive resident. She said, We need to make sure the unvaccinated resident would be safe and socially distanced from others. CNA #4 was interviewed on 1/13/22 at 9:55 a.m. She said, It was me who sat the COVID-19 positive resident with the unvaccinated resident yesterday for lunch. I did not know we should not do that. She said the residents in the memory care unit usually ate in the dining room not in their rooms. She said Resident #11 had a fever today (the unvaccinated resident) and was in bed. The director of nursing (DON) was interviewed on 1/13/22 at 9:50 a.m. She said the staff should not have seated the COVID-19 positive resident with the unvaccinated for COVID-19 resident. She said the nurse should have washed her hands in between assisting each resident with eating. She said it was not good that a COVID-19 positive resident (#14) put her contaminated spoon in Resident #2's pudding and then Resident #2 ate her own pudding. She said the residents should be six feet socially distanced from each other. She said in the memory care unit it was difficult to keep residents socially distanced but the staff should always encourage the residents to socially distance. She said she had talked to Resident #11's family and they did not want the resident to get her COVID-19 vaccination. The DON said, I can't believe the staff put the COVID-19 positive resident with other residents. I will fix this right away. She said she would educate the staff on the memory care unit to seat the COVID-19 positive residents at one table by themselves. She said the staff would be educated to not put COVID-19 positive residents with the residents who were not vaccinated or those who tested negative with COVID-19. The medical director was interviewed on 1/18/22 at 5:08 p.m. He said he was the medical director for a number of years. He said he routinely visited the facility to attend the facility's QAPI. He said he was notified of the facility's immediate jeopardy in infection control. He said it was unfortunate that staff were performing testing while residents were present and were not socially distancing or wearing appropriate PPE. He said it was difficult to keep residents socially distanced in the secure unit, but agreed if staff knowingly sat residents together (not six feet apart) that was a problem. He said he planned to review the facility's infection control and testing policy and procedures in their next QAPI. H. Facility follow-up The regional clinical nurse (RCN) #2 was interviewed on 1/18/22 at 12:20 p.m. She said staff would be provided training to not seat COVID-19 positive residents with those who did not have COVID-19. She said moving forward the COVID-19 positive residents would be placed at a table together to eat in the memory care unit. She said staff on the memory care unit were educated after the IJ on how to seat COVID-19 positive residents. She said she requested the staff to perform a return demonstration of how and where to seat the residents. She said she called any staff that were not working to educate them concerning the matter. The DON was interviewed on 1/18/22 at 1:00 p.m. She said the tables in memory care were moved six feet apart to enable six feet social distancing. She said a separate table was set up in a separate area for residents who were COVID-19 positive. She said the residents who did not have COVID-19 would be seated away from the table with the COVID-19 positive residents. She said the staff had been educated beginning on 1/14/22 to encourage and seat the residents in their appropriate sections. The DON said she misunderstood who had assisted residents with eating on 1/12/22. She said she thought CNA #4 had assisted the residents She said she would speak with RN #1 who had assisted the COVID-19 positive resident at a table with the resident who did not haveCOVID-19. She said it was sad Resident #11 was now positive for COVID-19. -The facility did not provide any additional follow-up concerning further trainings for COVID-19 positive residents in the dining room before the exit of the survey on 1/19/21. IV. Failure to ensure staff wore PPE appropriately A. Observation and interview On 1/12/22 at 3:32 p.m. CNA #2 was observed wearing his N95 mask incorrectly which would not ensure a secure fit. The back strap was observed hanging in front of his face. He said it was ill fitting. I don't like having the straps rubbing on my head. He said he did not ask the IP about being fitted for a new N95 mask. B. Administrative interview On 1/13/22 at 12:00 p.m. the DON and RCN #1 were interviewed. The DON said she was not aware CNA #2 had problems with his mask fitting. She said CNA #2 would be educated on how to properly wear an N95 mask. Today he is wearing his N95 mask appropriately. She said she would schedule CNA #2 for fit testing of a new N95 mask as soon as possible if it was truely ill fitting.