Based on interview and record review, it was determined that the facility failed to ensure that the required committee members attended Quality Assurance Performance Improvement (QAPI) meetings at least quarterly for 3 of the 4 quarterly meetings reviewed for 2024. Findings include: Review on 1/3/25 of the first quarter QAPI meeting attendance sheet, dated 1/26/24, revealed that the Medical Director or designee (required member) was not in attendance. Review on 1/3/25 of the second quarter QAPI meeting attendance sheet, dated 4/26/24, revealed that the Infection Preventionist (required member) was not in attendance. Review on 1/3/25 of the fourth quarter QAPI meeting attendance sheet, dated 10/25/24, revealed that the Infection Preventionist (required member) was not in attendance. Interview on 1/3/25 at approximately 2:00 p.m. with Staff A (Administrator) confirmed the above findings. Interview on 1/3/25 at approximately 11:00 a.m. with Staff B (Infection Preventionist) revealed that he/she did not attend the above mentioned QAPI meetings because they were working as a nurse on the unit during scheduled quarterly QAPI meetings.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that medications were secure and unavailable to unauthorized staff and residents on 1 out of 1 nursing units (Resident identifier is #17). Findings include: Observation on 1/25/23 at approximately 10:00 a.m. of Resident #17's room revealed the following medications unattended (no staff or residents in the room) on the bedside table: 1. Alphagan 0.1 percent (%) ophthalmic drops 2. Dorzolamide hydrochloric acid (HCL) ophthalmic 2% drops 3. Latanoprost 0.005% ophthalmic drops 4. Biofreeze (gel) Observation on 1/25/23 at approximately 11:00 a.m. of Resident #17's room revealed the above medications unattended on the bedside table. Observation on 1/26/23 at approximately 9:00 a.m. of Resident #17's room revealed the above medications unattended on the bedside table. Interview on 1/26/23 at approximately at approximately 12:50 p.m. with Staff A (Director of Nursing) revealed that Resident #17 keeps his/her self-administrated medications on the bedside table. Interview on 1/26/23 at approximately 1:55 p.m. with Staff B (Licensed Nursing Assistant) revealed that there are a few residents that wander on the unit. Review on 1/26/23 of the facility policy titled, Self-Administration of Medications, Revision Date February 2021 revealed: . 2.f The resident is able to safely and securely store the medication. . 8. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. .

Based on interview, and policy review, it was determined that the facility failed to maintain infection control practices according to accepted national standards for 1 of 1 staff member reviewed for returning to work after COVID-19 infection. Findings Include: Review on 1/26/23 of the Centers for Disease Control (CDC) Interim Guidance for Managing Healthcare Personnel with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) . Infection or Exposure to SARS-CoV-2, updated on 9/23/22 and retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Freturn-to-work.html, revealed, . Return to Work Criteria for HCP [Health Care Personnel] with SARS-CoV-2 Infection . HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: - At least 7 days have passed since symptoms first appeared if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and - At least 24 hours have passed since last fever without the use of fever-reducing medications, and - Symptoms (e.g., cough, shortness of breath) have improved. *Either a NAAT [Nucleic Acid Amplification Test] (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later . Review on 1/26/23 of the facility's form titled COVID-19 Positive Staff Members in the Last Four Weeks as of 1/26/23 revealed Staff D [title omitted] had onset of symptoms on 1/12/23 and tested positive for COVID-19 on 1/14/23. Further review revealed that Staff D tested negative for COVID-19 on 1/18/23 and returned to work on 1/19/23. Further review revealed that in the past 4 weeks only 1 other staff member testing positive and had not yet returned to work. Review on 1/26/23 of the facility's form titled COVID-19 Testing January 9-January 15, 2023 revealed that Staff D tested negative for COVID-19 on 1/12/23 and tested positive for COVID-19 on 1/14/23. Review on 1/26/23 of the facility's daily staff assignments for 1/19/23 and 1/20/23 revealed that Staff D worked both days. Review on 1/26/23 of the facility's policy titled COVID-19 Testing and Transmission-Based Precautions/Quarantine Policies and Procedures, updated 9/27/22, revealed, .Quarantine .for staff members . Symptomatic - Positive Test. Symptomatic staff members will be asked to quarantine for 5 days from onset of symptoms or positive COVID-19 test. Day zero is the day in which one test positive or the day of onset of symptoms. The subsequent day is day one . Interview on 1/26/23 at 11:03 a.m. with Staff C (Registered Nurse/Infection Preventionist) revealed that Staff D had a symptom of fatigue on 1/12/23 and tested negative for COVID-19. On 1/14/23 Staff D had an additional symptom of congestion and tested positive for COVID-19. Staff C stated that the facility used CDC guidance for the return to work after COVID-19 and stated it was 5 days if tested and no symptoms. It was requested that Staff C produce the CDC guidance stating this. Review on 1/26/23 of the CDC COVID-19 Ending Isolation and Precaution for People with COVID-19, updated 8/31/22 and provided by Staff C (which was the guidance the facility was using) revealed, . This page is intended for use by healthcare professionals who are caring for people in the community setting . These recommendations do not apply to healthcare personnel in the healthcare setting . For healthcare settings, please see Managing Healthcare Personnel with SARS-CoV-2 infection . Interview on 1/26/23 at 1:50 p.m. with Staff C confirmed that the facility was using the incorrect guidance and confirmed this guidance was not intended for health care personnel. Staff C confirmed that the facility's policy needed to be updated based off the correct guidance of at least 7 days. Staff C confirmed that Staff D should not have returned to work on 1/19/23.

Based on interview and record review, it was determined that the facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, for 6 of 92 days reviewed for Quarter 4 - 2022 (July 1 - September 30, 2022). Findings include: Review on 1/25/23 of the facility's Payroll Based Journal Staffing Data Report for Quarter 4 - 2022 revealed that there were no RN hours for the following days; 7/4/22, 7/9/22, 7/10/22 and 8/20/22. Review on 1/26/23 of the facility's daily staffing for 7/1/22 through 9/30/22 revealed the following; - On 7/4/22, 7/9/22, 7/10/22, 8/20/22, 9/4/22 and 9/5/22 revealed that a RN was not scheduled or documented as worked. - These 6 days fell either on a weekend or a holiday. Interview on 1/26/23 at 1:12 p.m. with Staff A (Director of Nursing), who is an RN, confirmed that there was not an RN working the above days. Staff A confirmed that he/she and Staff C (RN, Infection Perfectionist) work Monday through Friday with holidays off. Staff A confirmed that he/she had worked Monday through Friday from 12/25/22 through 1/26/23. Review on 1/26/23 of the facility's daily staffing for 12/25/22 through 1/27/23 revealed that there was an RN working 8 hours daily (the past 33 days).