**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff, resident and resident responsible party interviews, the facility failed to ensure the environment remained free of hazards, and failed to ensure employees reported hazards that posed an immediate threat to the safety of all residents when at least 3 employees failed to report an employee had a loaded handgun in her purse that she brought into the facility stored at the Nurse's Station, unsecured, where a cognitively impaired resident gained access to the purse (Resident #1). The facility reported a census of 79 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 7/3/24 at 1:15 p.m. The IJ began on May 5, 2024. Facility staff removed the Immediate Jeopardy on 7/6/24 by implementing the following actions; a. All Nursing Staff educated between 6/26/24 and 7/6/24 on: 1.) Firearms and weapons are not allowed on the premises, this includes in a vehicle in the parking lot. 2.) If you see or hear of a firearm or weapon being on property. 3.) Keep your personal belongings in your vehicle or the breakroom, not in public areas accessible to residents. 4.) If the person being reported is your supervisor, please go to the next person in charge. 5.) If a person or staff member enters facility carrying a weapon, who is not required to carry a weapon (i.e., a law enforcement officer) they will be asked to remove the weapon from the premises. If they refuse to do so, police will be contacted. Staff will move residents and other staff away from situation. Staff will notify manager on duty. 6.) Education will be completed with new staff or contracted staff prior to the start of their next shift. Based on the corrective measures taken by the facility, the scope and severity was from a J level to a G level. Findings include: The Annual Minimum Data Set (MDS) for Resident#1 dated 4/18/24 documented the resident had diagnoses including non-Alzheimer's Dementia, altered mental status, right hip pain. The MDS revealed that the resident scored a 4 out 15 for Brief Interview of Mental Status (BIMS), which indicated severe cognitive loss. The MDS documented that the resident used a manual wheelchair for mobility. The Residents Care Plan identified a focus area as follows; the resident had impaired cognitive function or impaired thought processes related to dementia. Resident continues to fidget with things and seeks things out activities to occupy her time, and sometimes this causes her to get into others things an invade other peoples personal space. The facility's self-reported incident dated 6/27/24 stated: Management notified of potential staff member with concealed carry within facility. Employee suspended pending investigation. Police notified. Further Investigation to follow. The facility's investigative summary completed by the Administrator stated she received a phone call around 7 p.m. on 6/26/24 from an employee (Staff D, Licensed Practical Nurse, LPN) who informed her that Staff B, Registered Nurse (RN) had just told her that a while back, Staff A, LPN, told Staff B that she forgot to take her gun out of her purse, brought it into the facility, and Resident #1 got a hold of it, Staff A was able to get it away from the resident and there were no injuries. The facility's investigation estimated the alleged incident occurred on May 5, 2024. The facility's daily nursing schedule/assignments revealed Staff A, Licensed Practical Nurse (LPN) was assigned to the 200 and 300 halls on the day shift (6 a.m. to 2 p.m.), and the first half of the evening shift (2 p.m. to 6 p.m.) The facility's Violence in the Workplace policy, dated effective 3/2015, directed that guns were prohibited from the premises, anyone that had a gun that was not someone that required it for their job, such as a law enforcement officer, was to be asked to remove the gun from the premises, and if the gun was not removed, staff were directed to call the police. The policy also directed if staff believed someone had brought a gun to work they were to notify the Administrator or immediate supervisor immediately. Observation at the Nurse's Station on 7/3/24 at 9:40 a.m. revealed the desk surfaces at the Nurse's Station were 60 inches wide, with open area under them, and the medication/treatment carts were 33 inches wide at the widest portion that included a waste receptacle. Observation on 7/6/24 at 1:25 p.m. revealed Resident #1 seated in a wheelchair, inside the Nurse's Station, and held a blood pressure cuff that was in a portable upright cart that staff used to take resident vital signs. A CNA near the resident asked if she could have it and was able to return the blood pressure cuff to the cart. Staff interviews revealed: On 7/2/24 at 2:46 p.m. Staff C, Certified Nursing Assistant (CNA) stated she heard Staff A, LPN, talking out loud about she was happy the resident didn't get into her purse because she would have got a hold of her gun, it wasn't the first time she'd made the comments, she thought it had been discussed before based on how Staff A was talking about it at the time. Staff C didn't know who all might have heard Staff A as she talked about it, but others had to know, and thought she'd heard her talking about it a month or so ago. Staff A always kept her purse at the Nurse's Station, usually on top of the desk and not below it. The resident fidgets, she likes to hold on to things, she gets a hold of things and sometimes it's hard to get them away if she shouldn't have them or they belong to someone else, and is often in the Nurse's Station opening drawers and grabbing papers if she sees them. Staff A said she was glad she got Resident #1 before she got her gun. On 7/2/24 at 4:52 p.m., Staff B, Registered Nurse (RN), stated she was at work one day in May, Staff A said that she forgot her gun was in her purse when she came to work one day, Resident #1 got her purse, but she got to the resident before she got the gun. Staff B stated she told Staff A at that time that she needed to report it to management and she said she was going to. Some time had passed since then and she thought it had been dealt with. When she gave report to Staff D, LPN last week, they started talking about the resident going through purses, the subject of the gun came up and Staff D didn't know anything about it and said she was calling the Administrator, and did. The resident likes to be busy, she likes to rummage through things, will go through drawers at the Nurse's Station, she loves purses and is always looking for her purse. On 7/2/24 at 2:48 p.m. Staff D, LPN, stated on the evening shift on 6/26/24, Staff B told her about an incident where Resident #1 got a gun out of Staff A's purse and she had a gun in her purse. She called the Administrator on the phone and told her about it. Staff D knew staff could not bring a gun to work, and all staff have since been educated that if anyone brought a gun into the facility the were supposed to call the Administrator. There are lockers here for staff to use to store their belongings while they work. On 7/2/24 at 3:01 p.m. Staff A, LPN, stated she'd been out late the day before it happened and didn't think to take the gun out of her purse. She kept her purse under the Nurse's Station, and when she went to the office around 2 p.m. to talk about the scheduler, she blocked the area where her purse was with the treatment cart, she positioned it the long way in front of the desk and locked the wheels. She hadn't been gone even 5 minutes and realized she needed her calendar from her purse, went to the Nurse's Station to get the calendar and the resident had her purse sitting on top of the desk at the Nurse's Station, the resident had moved the treatment cart, with wheels still locked, out of the way and was able to get to her purse. The resident was seated in her wheel chair, she'd been going through the center part of her purse and said she was looking for her hairbrush, she hadn't taken anything out of her purse. She got to the resident as she started to unzip the side pocket, she'd unzipped it about 4 to 5 inches and Staff A was standing above her and could see the case for the gun and that was when she realized the gun was in her purse. She didn't think the resident saw it because she was seated and couldn't see into the purse like Staff A who stood above her. She got the purse away from the resident and normally didn't bring her gun to work. Staff A said nobody else saw or witnessed it, and the resident didn't get a hold of her gun. She didn't want to get in trouble so she didn't tell management. She said something about it to one of the aides around that time, and somebody turned it in quite a bit later. During another interview on 7/8/24 at 9:04 a.m., Staff A stated her gun was a 22 caliber [NAME]. On 7/2/24 at 2:10 p.m., the facility Administrator stated all staff have been educated to notify her if staff brought a gun to work, have completed education about work safety and resident safety, they continued to educate staff as they came to work before they started their shift, and guns were not permitted on the property, it was addressed in the facility's Violence in the Workplace policy, and the Gun with the Null sign (guns not permitted sign) is posted outside the facility. During an interview on 7/2/24 at 3:57 p.m., the resident's Power of Attorney (POA) stated the facility told them that they needed to find a Memory Care unit for her, that she wasn't appropriate for their facility, she was getting into the staff's purses, but never said anything about a gun in one of the purses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record and document review, staff interviews, and facility policy review, it was determined the facility failed to maintain an infection prevention and control program to prevent the transmission of Coronavirus Disease 2019 (COVID-19). Specifically, 1. The facility failed to implement and monitor an effective screening process for staff to prevent a COVID-19 outbreak. The failure to follow facility policy resulted in a staff member being able to work on 07/11/2022 while having signs and symptoms of COVID-19 after having direct exposure to a COVID-19 positive staff member. 2. The facility failed to ensure Resident #38, who tested positive for COVID-19 on 07/05/2022, maintained isolation precautions to ensure staff, residents, and visitors were not exposed to COVID-19. 3. The facility failed to ensure staff working during a COVID-19 outbreak wore N95 masks in accordance with the Centers for Disease Control and Prevention (CDC) guidelines. 4. The facility failed to ensure N95 masks were fit tested before use. The facility reported a census of 64 residents. The first COVID-19 positive resident in the facility had been identified on 07/05/2022. Ten residents had tested positive for COVID-19 from 07/05/2022 through 07/15/2022. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.80 (Infection Control) at a scope and severity of K. The IJ began on 07/11/2022 at 5:30 AM, when Staff A, Dietary Aide, came on duty and worked while having COVID-19 symptoms. The Administrator was notified of the IJ on 07/11/2022 at 6:00 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 07/12/2022 at 4:52 PM. The IJ was removed on 07/15/2022 at 3:15 PM, after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance for F880 remained at the lower scope and severity of a pattern, with no actual harm and a potential for more than minimal harm that was not immediate jeopardy. Findings included: A review of the facility's policy titled, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, revised July 2020, revealed the screening process included, 2. Anyone entering the facility (including staff) is screened and triaged for signs and symptoms of and exposure to others with SARS-CoV-2 [severe acute respiratory syndrome coronavirus 2] infection including: a. fever (measured temperature > [greater than] 100 degrees F [Fahrenheit] or subjective fever; b. cough; c. shortness of breath or difficulty breathing; d. fatigue; e. muscle or body aches; f. headache; g. new loss of taste or smell; h. sore throat; i. congestion or runny nose; j. nausea or vomiting; and/or k. diarrhea. 3. Anyone with a fever, signs/symptoms of illness, or who has been advised to self-quarantine due to exposure is not allowed to enter the facility. 4. Residents are screened daily for fever and symptoms of COVID-19. Residents with fever or symptoms of COVID-19 are provided a facemask, immediately isolated, and placed on appropriate transmission-based precautions. Further review of the policy revealed, For a resident with known or suspected COVID-19: b. Resident is placed in a private room with a dedicated bathroom (if available) and closed door; OR c. Resident is cohorted per national, state, or local public health authority recommendations. 4. If there is a moderate to substantial COVID-19 transmission in the surrounding community: a. Staff wear all recommended PPE [personal protective equipment] (ie. [such as], gloves, gown, eye protection and respirator or facemask) for the care of all residents on the unit (or facility-wide based on the location of affected residents), regardless of symptoms (based on availability). b. Residents are restricted to their rooms except for medically necessary purposes. c. When residents have to leave their room, they wear a face mask, perform hand hygiene, limit their movement in the facility, and practice social distancing. A review of the facility's policy titled, Personal Protective Equipment Program, revised on 03/12/2004, revealed, The use of Health Care N95 Particulate Respirator and Surgical Masks will be required to control exposure to contaminated airborne pathogen. Any worker who is required to wear any personal protective equipment (PPE) shall receive training in the proper use and care of the personal protective equipment (PPE). The policy also indicated, The training shall include, but not necessarily be limited to, the following subjects: 1. When PPE is necessary to be worn. 2. What PPE is necessary. 3. How to properly put on, take off, adjust, and wear PPE. 1. During an interview on 07/11/2022 at 8:30 AM (the first day of the survey), the Administrator (ADM) stated the facility had three COVID-19 positive residents who were located at the end of 200 Hall. The ADM stated they had positive staff members but was unaware of the exact number. During an interview on 07/11/2022 at 9:36 AM, Staff A, Dietary Aide, stated he was having signs and symptoms of COVID-19, sore throat, cough, and fever and chills the day before. Staff A stated he checked with the facility the night before and was told if he had no fever and tested negative, even with symptoms, he had to come to work. During an interview and observation on 07/11/2022 at 9:47 AM, Staff A was walking down the 300 Hall, pushing a meal tray cart, and coughed into his right elbow. Staff A was wearing a KN95 mask and had facial hair that was approximately 1 inch long. Staff A stated, I'm dying, and that his significant other was at home due to testing positive for COVID-19. Staff A stated he had direct contact with the significant other due to living together and provided meals to them. Staff A stated he woke up on Sunday, 07/10/2022, with a sore throat, cough, and fever. Staff A stated he took Tylenol for the fever and did not currently have a high temperature. Staff A stated the last time they had COVID-19, they tested negative on a rapid test, but tested positive on the PCR test. Staff A stated when they screened in the morning of 07/11/2022 on the screening kiosk, he answered the questions honestly about having symptoms of COVID-19, and the kiosk flagged him for answering yes to some of the symptoms. He stated there had to be an override code in order for him to continue checking in but nobody in the facility knew the override code. He stated his current symptoms were a sore throat, coughing up green stuff, chills, and body aches. He stated that he was having the same symptoms as the first time he had COVID-19. He stated that he had tried to get the dietary assistant manager to come in to complete his shift. He stated he notified the Interim Administrator (IADM) of his symptoms, who told him he had to stay until there was a replacement. He stated that he called the facility the previous night, 07/10/2022, and spoke to the Minimum Data Set (MDS) Coordinator/Charge Nurse, advising her that he had symptoms of COVID-19. The MDS nurse told him that he had to come to work and wear a mask. During an interview on 07/11/2022 at 9:56 AM, the Interim Administrator (IADM) and the Administrator (ADM) were interviewed together due to the ADM only being at the facility for one week. The IADM stated that all staff had to ring a doorbell at the front of the facility to enter the facility. Upon entrance, they had to go to the screening kiosk to answer the screening questions, and the staff member who opened the door for the staff member had to take their temperature. At that time, the ADM removed her N95 mask and coughed. The IADM stated that if a staff member had symptoms, the screening kiosk would not let them continue to check in, and the staff had to complete a COVID-19 rapid test. If they were negative, they contacted their regional representative to see if the staff member needed to go home or continue working. The IADM stated they did not know who screened in Staff A but were aware that the staff member was flagged for answering yes to one or more of the screening questions. The IADM stated nobody in the facility had the override code for the screening kiosk. The IADM stated Staff A notified the IADM that he was not feeling well that morning. The IADM stated he was unaware who Staff A's significant other was or that they were positive for COVID-19. The IADM stated Staff A was waiting for the kitchen assistant manager to call Staff A back, so Staff A could go home. The IADM stated that Staff A should be wearing an N95 mask, not a KN95 mask, and an N95 mask would not fit properly if the staff member had facial hair. The IADM stated Interim Director of Nursing (IDON) A worked the previous night, so the Assistant Director of Nursing (ADON) would answer any questions related to infection control. At 07/11/2022 at 10:34 AM, the facility sent Staff A home. During an interview on 07/11/2022 at 10:42 AM, Interim Director of Nursing (IDON) B, who at the time of the interview had not been assigned the title of IDON and was a floor charge nurse, stated that when staff screened in at the kiosk and answered yes to any of the questions, It will pop up that you can't complete it, so you have to have a nurse come look at it. IDON B stated the facility would probably test the staff member and send them home. During an interview on 07/11/2022 at 10:47 AM, Staff K, Certified Nursing Assistant, stated that when staff screened in at the kiosk and answered yes to any of the questions, they had to call one of the nurses or the Administrator. She thought they would be tested but had never been in that situation. During an interview on 07/11/2022 at 10:57 AM, Staff I, Occupational Therapist, stated if she had symptoms while working, she would notify her boss and go home if the symptoms were beyond her normal symptoms. Staff I stated when staff screened in at the kiosk and answered yes to any of the questions, it would flag them. There would be extra screening involved, but Staff I was unsure what type of additional screening would be completed. During an interview on 07/11/2022 at 11:04 AM, the IADM stated if a staff member tested positive on a rapid test, they would be sent home. The IADM stated if the staff member tested negative and was vaccinated but still had symptoms, he would have to look at the facility policy. The IADM was unable to answer what the facility policy was. The IADM stated if staff had signs and symptoms and tested negative on a rapid test, the facility would monitor them, and they were still allowed to work. The IADM stated the charge nurse monitored staff who screened in, but the IADM was unsure if there was a way to actually monitor the screening process. The IADM stated that staff could not enter the building unless another staff member let them in, and that staff member then assisted with the screening of the staff entering the building. The IADM stated if a staff member answered yes to one of the screening questions on the kiosk, it sent the IADM an email notification, and the kiosk would not allow the staff to continue with the screening process. The IADM stated again that nobody in the facility had the override code if a staff member answered yes to a screening question. During an interview on 07/11/2022 at 11:13 AM, the Assistant Director of Nursing (ADON) stated if a staff member had symptoms of COVID-19, they should be sent home, even if the rapid test was negative. The ADON stated when staff screened in at the kiosk and answered yes to any of the questions, it would send an email to management, and the staff member would be rapid tested. During an interview on 07/11/2022 at 11:29 AM, the MDS Coordinator stated when staff screened in at the kiosk and answered yes to any of the questions, a nurse had to evaluate them, and they were rapid tested. If the staff member tested negative, they were allowed to work, and if they were positive, they would be sent home. The MDS Coordinator stated she understood that if the staff member was negative with symptoms, they had to wear a mask and go to work. The MDS Coordinator stated that Staff A did not call her on 07/10/2022, but his significant other did, and she was aware the significant other was positive for COVID-19. The MDS Coordinator stated the significant other advised the MDS Coordinator that Staff A was having signs and symptoms of COVID-19, and the MDS Coordinator advised Staff A that he needed to be rapid tested and, if he was negative, he needed to work. If he was positive, he did not need to come into work. The MDS stated she did not notify anyone that Staff A had signs and symptoms of COVID-19. The MDS Coordinator stated if the staff member had obvious signs of COVID-19, then they should stay home. The MDS Coordinator stated she was not aware who was notified if a staff member answered yes to one of the screening questions on the kiosk. During an interview on 07/11/2022 at 11:40 AM, the ADM and IADM stated they had not received a notification that an employee had answered yes to one of the questions on the kiosk. The IADM stated that an email should be sent to the ADM and the DON. During an interview on 07/11/2022 at 11:45 AM, Staff A, who had been sent home, stated he screened in around 5:30 AM on 07/11/2022 and that Staff AA, housekeeper, had screened him in. He stated neither he, nor Staff AA, were aware of what to do when the kiosk would not let him continue screening in, so they both went to work. He stated he was not advised that a nurse had to screen him in. He stated that when the IADM came into work around 8:00 AM, he notified the IADM of his symptoms and that he had tested negative on a rapid test. During an interview on 07/11/2022 at 3:20 PM, the ADM and IADM stated they were not aware that Staff A was taking Tylenol to decrease his temperature. The IADM stated that after a staff member answered yes to one of the screening questions, the kiosk would still allow other staff members to screen in. The IADM stated that at approximately 2:00 PM, the system notified the IADM that a staff member answered yes to body aches due to working in the garden during the weekend and was sore. The staff member came to the IADM to let them know the system flagged the staff member. The IADM was asked to provide a copy of the screening report. However, the IADM stated they were not aware of how to access it. The IADM stated that the outbreak started when a newly admitted resident, who was vaccinated, was tested 72 hours after being admitted and tested positive. Two staff members then tested positive, and several days later, another resident tested positive. Subsequently, Resident #38 and his/her roommate tested positive for COVID-19. During an interview on 07/11/2022 at 3:30 PM, Staff D, Registered Nurse, stated that another staff member had to assist with the screening process by taking the staff's temperature. Staff D stated that if staff had COVID-19 symptoms at work and tested negative, it just depended on how severe the symptoms were if the facility sent the staff member home or not. During an interview on 07/11/2022 at 4:48 PM, Staff A stated that he had a polymerase chain reaction (PCR) COVID-19 test completed, and the clinic had notified him that he was positive for COVID-19. During an interview on 07/11/2022 at 5:04 PM, the IADM stated the facility was not in contingency or crisis mode staffing. During an interview and observation on 07/12/2022 at 8:29 AM, the Maintenance Director stated two more residents tested positive that morning. On 07/15/2022, a copy of the Accushield-Health-Screening-Log dated 07/11/2022 was received and reviewed. The log revealed Staff A screened at 5:36 AM on 07/11/2022 and answered yes to the following questions: - Do you have a cough? - New Shortness of Breath or Difficulty Breathing - Fever greater than or equal to 100.0 or Chills> - Muscle or Body Aches? - Sore Throat? - In the last 14 days, outside of work, have you closely interacted with someone for 15 minutes or more, who is now COVID-19 positive? - Do you live with someone who has NEW symptoms of COVID-19 or has had a NEW positive test? The Screening Question Status indicated Staff A was Not Cleared. Further review revealed a housekeeper documented Staff A's temperature. During an interview on 07/13/2022 at 8:41 AM, Interim Director of Nursing (IDON) A stated if a staff member was experiencing signs and symptoms of COVID-19, they should be sent home regardless of whether they tested negative. During an interview on 07/16/2022 at 10:05 AM, IDON B stated staff who were exhibiting signs and symptoms of COVID-19 were not allowed to work. During an interview on 07/16/2022 at 4:14 PM, the IADM and ADM stated staff who were exhibiting signs and symptoms of COVID-19 were not allowed to work. Review of an untitled list of COVID-19 positive residents revealed five residents tested positive for COVID-19 from 07/13/2022 through 07/15/2022. 2. A review of Resident #38's admission Record revealed the resident had diagnoses including recurrent depressive disorders, anxiety disorder, and type 2 diabetes. A review of Resident #38's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident was moderately cognitively impaired. According to the MDS, the resident also had an active diagnosis of non-Alzheimer's dementia. A review of an untitled list of COVID-19 positive residents indicated Resident #38 tested positive for COVID-19 on 07/05/2022. A review of Resident #38's Progress Notes dated 07/05/2022 at 1:10 PM (late entry) revealed the resident tested positive for COVID-19. According to Progress Notes dated 07/05/2022 at 4:00 PM, Resident #38 was sitting at the entry way. Staff members attempted to get the resident to quarantine in the isolation hall and to wear a mask and face shield, and the resident stated he/she was not sick and would not wear a face shield/mask and would not go to a room. The note stated the resident became irritated and threw the face shield and mask in the trash. A review of Progress Notes dated 07/06/2022 at 7:30 AM, revealed when the nurse entered the facility, Resident #38 was sitting at the front door. The nurse attempted to direct the resident to the room and to wear a face mask and shield. Resident #38 yelled, No, I'm not sick and leave me alone. During an interview on 07/11/2022 at 8:30 AM, the Administrator (ADM) stated the facility had three COVID-19 positive residents who were located at the end of 200 Hall. Resident #38 was observed sitting in the front lobby and was not wearing a mask. The ADM did not identify the resident as being COVID-19 positive at that time. Further review of Progress Notes dated 07/11/2022 at 8:46 AM, revealed staff attempted to get Resident #38 to wear a mask and face shield, and the resident threw them away. Staff then tried to get the resident to go to his/her room, and the resident stated he/she could not leave and was waiting for military command and the police. During an interview on 07/11/2022 at 2:16 PM, Staff F, Certified Nursing Assistant (CNA), and Staff G, CNA, were asked where Resident #38 was located. Due to a room change, the surveyor was unable to locate the resident during the initial screening process. Both staff stated Resident #38's room was on 100 Hall and was moved to the COVID-19 unit on 200 Hall, but the resident refused to stay in the room. Both staff stated the resident tested positive for COVID-19. During an interview on 07/11/2022 at 2:40 PM, Staff E, Licensed Practical Nurse (LPN), stated Resident #38 was supposed to be on the COVID-19 unit at the end of 200 Hall, but the resident refused to go behind the plastic barrier. Staff E stated the resident had told her, That's where sick people go, and I'm not sick. Staff E stated the resident tested positive for COVID-19 on 07/05/2022. Staff E stated the facility was not allowing other residents out of their rooms, because Resident #38 refused to stay on the COVID-19 unit. Staff E stated the resident was previously in the military and had post-traumatic stress disorder (PTSD), and the resident refused to stay on the unit. Staff E stated Resident #38 sat in the front lobby all day and all night, and the only time the resident moved was to go to use the bathroom in their bedroom on 100 Hall. Staff E stated Resident #38's roommate also tested positive. During an interview on 07/11/2022 at 3:01 PM, the ADON stated the COVID-19 outbreak started with a resident who left the facility three times a week for dialysis. The ADON stated Resident #8 then tested positive, followed by positive staff members. The ADON stated there were more positive staff than there were residents. The ADON stated they did not have any other residents test positive until a week later, which was Resident #38, followed by Resident #38's roommate. The ADON stated the facility currently had three residents who were COVID-19 positive. The ADON stated they moved Resident #38's belongings to the COVID-19 unit, but the resident refused to move, and the facility stopped communal dining due to Resident #38's refusal to isolate. The ADON stated that Resident #38 ambulated down the 100 Hall, where the resident's room was located, and staff could not direct the resident to the COVID-19 unit. The ADON stated she re-tested the resident to prove to the resident that he/she was positive for COVID-19, but the resident did not believe the results. The ADON stated she offered the resident a face shield and face mask when the resident would sit in the front lobby, but the resident refused to wear them. The ADON stated the resident yelled at her and threw the items in the trash. The ADON stated she had verbally told staff to keep an eye on the resident and to keep the resident away from other residents. The ADON stated the facility put the resident's roommate on warm isolation, which meant the resident was on isolation, just not on the COVID-19 unit, until the roommate tested positive and was moved. During an interview on 07/11/2022 at 3:20 PM, the IADM stated the COVID-19 outbreak started when a newly admitted resident, who was vaccinated, was tested 72 hours after being admitted and tested positive. Two staff members then tested positive; several days later, another resident tested positive, then Resident #38 and his/her roommate tested positive for COVID-19. The IADM stated that when a resident tested positive, they were moved to the COVID-19 unit, and the facility tried to keep them in a room by themselves. The IADM stated that Resident #38 would not stay in the room. They kept Resident #38 in an area where there was not a lot of resident contact and stopped communal dining. The IADM stated, The front area is the best we can do. They could not tell the resident he/she was not allowed to move about the building and could not tell the resident he/she had to stay in the room. The IADM stated that instead, they requested all other residents to stay in their rooms. The IADM stated Resident #38 had the potential to get violent, and there was no choice, other than to reduce the resident's exposure to other residents and staff. During an interview on 07/11/2022 at 3:30 PM, Staff D, Registered Nurse, stated Resident #38 was noncompliant with staying isolated in his/her room and could become aggressive. Staff D stated all other residents were made to stay in their rooms. Staff D stated he was not aware if Resident #38 was positive for COVID-19. During an interview on 07/11/2022 at 4:22 PM, Resident #38's family member stated he/she was unaware the resident was positive for COVID-19. The family member stated that within the past three months, the resident started sitting at the front entrance because the resident thought someone was coming to pick him/her up. The family member stated the resident occasionally became aggressive, and the facility had called before when the resident had a bad day. The family member stated the last time the facility contacted him/her regarding the resident's behavior was at the end of April 2022. The family member stated the facility had not contacted him/her regarding the resident's refusal to isolate. During an interview on 07/11/2022 at 5:04 PM, the IADM stated he tried to redirect Resident #38 to his/her room. The resident had threatened to kill the IADM and also attempted to hit the IADM over the head with a fire extinguisher. The IADM stated the facility had not reached out to their public health contact for guidance and had only contacted their corporate office. During an interview on 07/12/2022 at 11:09 AM, the IADM stated the facility had not had a Social Service Director (SSD) for a month and a half, and they had someone coming in from another building. The IADM stated that whatever the resident concerns were, the department heads worked on those issues. During an interview on 07/12/2022 at 11:26 AM, the Medical Director (MD) stated the facility reached out to her last Tuesday (07/05/2022) about the outbreak. The MD stated the facility tried to make a plan for Resident #38, but the resident refused to isolate. The MD stated it was not ideal to allow the resident to wander while COVID-19 positive. The MD stated the resident kept coming out of his/her room and would not wear a mask and became aggressive and tried to hit a nurse. The MD stated the lobby became the resident's room, and every activity, dining, or therapy session was one-on-one with residents. According to the MD, it was interesting, because they had not had a spread of COVID-19 and had stopped it from going everywhere. However, the MD stated she was not aware of the recent positive resident cases. She stated the facility should have notified her, but they may have notified the nurse practitioner instead. The MD stated the facility tried to move Resident #38 to another facility, and the MD felt like the resident needed a facility with a secure unit due to being an elopement risk. The MD stated the previous SSD was working on getting the resident to move to another facility; however, the facility no longer had an SSD and was utilizing one from another facility. The MD stated she did not think the resident had been assessed for psychiatric care but felt the resident should be on a secure dementia unit. The MD stated allowing the resident to sit in the front lobby could possibly affect the other residents, and the best option was to keep the other residents isolated. The MD further stated that keeping the other residents isolated could lead to depression. The MD stated she believed the facility was violating the residents' rights, but they were trying to keep the residents healthy. During an interview on 07/13/2022 at 2:37 PM, the Director of Clinical Operations for Nurse Practitioners (DCONP) stated she did not feel it was appropriate for Resident #38 to be able to ambulate freely throughout the facility while COVID-19 positive. She stated she called her Chief Medical Officer, who stated the facility should transfer the resident to a locked facility due to the resident's behaviors. The DCONP stated she notified the Regional Director of Clinical Services (RDCS) of the recommendation, but the two nearby facilities were full. She stated the facility could send the resident to a local psychiatric facility, but they probably would not take the resident when he/she was COVID-19 positive. She stated she had worked with three different SSDs, and the facility was trying to find the resident another facility. She stated two SSDs had quit because there were no resources around the area. Further review of an untitled list of COVID-19 positive residents revealed 10 additional residents tested positive for COVID-19 from 07/08/2022 through 07/15/2022. 3. An observation on 07/11/2022 at 9:47 AM, revealed Staff A was walking down the 300 Hall, pushing a meal tray cart, and coughed into his right elbow. Staff A was wearing a KN95 mask and had facial hair that was approximately 1 inch long. During an interview on 07/11/2022 at 9:56 AM, the Interim Administrator (IADM) and the Administrator (ADM) were interviewed together due to the ADM only being at the facility a week. The IADM stated that Staff A should be wearing an N95 mask, not a KN95 mask, and an N95 mask would not fit properly if the staff member had facial hair. The IADM stated the loops on the N95 mask should fit around the back of the head. During an interview on 07/11/2022 at 10:51 AM, Staff G, Certified Nursing Assistant, was observed wearing an N95 mask with the top band over the front of the mask and not behind her head. Staff G stated she was, not sure how to exactly wear it. During an interview on 07/11/2022 at 10:55 AM, the Maintenance Supervisor (MS) was wearing an N95 mask with the bottom strap underneath his chin and not behind his head. The MS stated, I'm supposed to wear it over my head. Sometimes I wear it right. I'm used to the KN95, but we can't wear those. During an interview and observation on 07/11/2022 at 1:53 PM, Staff H, Certified Nursing Assistant, was in room [ROOM NUMBER] talking to a resident. Staff H was wearing a face shield and an N95 mask that was below her chin. Staff H placed the mask back on her face and stated the mask should be worn above the nose. During an interview and observation on 07/12/2022 at 8:29 AM, the MS was again wearing the bottom strap of the N95 mask underneath his chin. When asked why the strap was below the chin, the MS responded, Ugh. I'm working on it. 4. During an interview on 07/11/2022 at 10:42 AM, Interim Director of Nursing (IDON) B, who at the time of the interview had not been assigned the title of IDON and was a floor charge nurse, stated she had not been fit tested for the N95 mask she was wearing. During an interview on 07/11/2022 at 10:42 AM, Staff R, Registered Nurse, stated she had not been fit tested for the N95 mask she was wearing. During an interview on 07/11/2022 at 10:47 AM, Staff K, Certified Nursing Assistant, stated they had not been fit tested for the N95 mask they were wearing. During an interview on 07/11/2022 at 10:51 AM, Staff G, Certified Nursing Assistant, stated she had not been fit tested for the N95 mask she was wearing. During an interview on 07/11/2022 10:53 AM, Staff S, Housekeeper, stated she had not been fit tested for the N95 mask she was wearing. During an interview on 07/11/2022 at 10:55 AM, the Maintenance Supervisor (MS) stated he had not been fit tested for the N95 mask he was wearing. During an interview on 07/11/2022 at 10:57 AM, Staff I, Occupational Therapist, stated she had not been fit tested for the N95 mask she was wearing. During an interview on 07/11/2022 at 10:59 AM, Staff N, Physical Therapy Assistant, stated she had not been fit tested for the N95 mask she was wearing. During an interview on 07/11/2022 10:59 AM, Interim Director of Nursing (IDON) C stated he had not been fit tested for the N95 mask he was wearing. During an interview on 07/11/2022 at 11:04 AM, the IADM and ADM both stated they had not been fit tested for the N95 mask they were wearing. The IADM stated they had contacted the local health department to complete fit testing; however, the health department would not come to the facility, and the staff members would have to make an appointment and go to the health department to be fit tested for the N95 masks. During an interview on 07/11/2022 at 11:13 AM, the Assistant Director of Nursing (ADON) stated she had not been fit tested for the N95 mask she was w[TRUNCATED]