Every finding on record at Cardinal Healthcare and Rehabilitation

Based on record reviews and staff interviews, the facility failed to complete a significant change in status Minimum Data Set (MDS) assessment following hospice election for 1 of 1 resident reviewed for hospice (Resident #11).The findings included:Resident #11 was admitted to the facility on [DATE] with diagnoses which included fracture of left femur (thigh bone) with routine healing, disorientation, and atrial fibrillation (an abnormal heart rhythm). A medical record review revealed Resident #11 was admitted to Hospice on 12/09/25 with a primary hospice admission diagnosis of senile degeneration of the brain (a progressive cognitive decline in older adults).A review of Resident #11's MDS assessments revealed significant change in status MDS assessment was not completed during the required 14-day period after Resident #11 was admitted to hospice services. A quarterly MDS assessment was completed on 01/15/26 and Hospice was coded. An interview with the facility MDS Nurse was conducted on 05/28/26 at 12:14 PM. The MDS Nurse stated that when a resident was admitted to hospice services, a significant change in status MDS assessment should be completed within 14 days. The MDS Nurse reported that no significant change in status MDS assessment was completed for Resident #11 within the required 14-day period due to confusion about her payment source. An interview was conducted with the Director of Nursing (DON) on 05/28/26 at 3:34 PM. The DON stated when a resident was admitted to hospice services, that was considered a significant change in status and a significant change MDS assessment should be completed within 14 days of the hospice admission date.

Based on record review and staff interviews, the facility failed to accurately code a significant change Minimum Data Set (MDS) assessment in the area of special treatments, procedures, and programs for 1 of 3 residents reviewed for Dialysis treatments and Hospice care (Resident #13). The findings included: Resident #13 was readmitted to the facility on [DATE] with diagnoses which included cerebral vascular accident, and dementia. Review of the significant change MDS assessment dated [DATE] for Resident #13 revealed she was moderately cognitively impaired. Under the section for Health Conditions/prognosis Resident #13 did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. Under the section for Special Treatments, Programs and Procedures Resident #13 was checked as being on Dialysis treatments while a resident and checked as being on Hospice care while a resident. An interview on 05/05/25 at 11:20 AM with Resident #13 revealed she was not on dialysis and had never had dialysis treatments. Resident #13 stated she was not on hospice care but was on palliative care for pain management. Resident #13 stated she had been on hospice care in the past but it was discontinued in 2022. An interview on 05/08/25 at 12:14 PM with the MDS Coordinator at the facility revealed she had just started at the facility in April of 2025 and was not at the facility when the significant change MDS was completed. The MDS Coordinator stated the resident was under palliative care and should not have been coded as Hospice care. Additionally, the MDS Coordinator stated she did not see any reason Resident #13 would have been coded for Dialysis care and said it must have been a keying error. The MDS Coordinator further stated she would modify the assessment and resubmit. An interview on 05/08/25 at 12:31 PM with the Director of Nursing revealed she expected MDS assessments to be coded correctly to reflect the individual resident. An interview on 05/08/25 at 12:40 PM with the Administrator revealed he expected all MDS assessments to be coded correctly to reflect the residents' conditions.

Based on record review and staff interviews, the facility failed to develop an individualized comprehensive care plan in the area of anticoagulant (blood thinner) medication use for 1 of 2 residents whose comprehensive care plans were reviewed (Resident #8). The findings included: Resident #8 was admitted to the facility on [DATE] with diagnoses that included a left femur fracture with surgical repair and dementia. A review of the active medication orders for Resident #8 revealed an order for Enoxaparin Sodium (an anticoagulant medication) 40 milligrams (mg.) subcutaneously (method of administering medication by injecting a drug into the fatty tissue layer beneath the skin) at bedtime for deep vein thrombosis (blood clot) prophylaxis. The medication had a start date of 04/09/2025. Review of the admission Minimum Data Set (MDS) assessment for Resident #8 dated 04/16/2025 indicated Resident #8 was severely cognitively impaired and was receiving an anticoagulant. A review of Resident #8's comprehensive care plan dated 04/29/2025 did not reveal any care plan focus area or interventions related to Resident #8 receiving an anticoagulant medication. A review of Resident #8's Medication Administration Record from 4/09/2025 through 5/07/2025, revealed Resident #8 received Enoxaparin Sodium 40 mg subcutaneously every night at bedtime. On 05/08/2025 at 12:25 PM an interview with the MDS Coordinator revealed Resident #8's care plan did not address anticoagulant medication. The MDS Coordinator explained the care plan should include the use of an anticoagulant medication. An interview was conducted on 05/08/2025 at 12:30 PM with the Director of Nursing (DON). The DON indicated anticoagulant medications were considered high-risk medications. The DON stated the anticoagulant medication should be addressed in Resident #8's comprehensive care plan so all staff caring for her would be aware she was at risk for side effects like bleeding or bruising. An interview was conducted with the Administrator on 05/08/2025 at 12:45 PM. The Administrator stated he expected all resident care plans to be reflective of their clinical condition including the use of anticoagulant medications.

Based on observation, record review, and staff interviews, the facility failed to follow their Handwashing/Hand Hygiene policy when Nurse #1 did not doff her gloves, perform hand hygiene and don clean gloves prior to applying wound treatment and a clean dressing during wound care to Resident #2. The deficient practice occurred for 1 of 9 staff members observed for infection control practices (Nurse #1). The findings included: Review of the facility's policy entitled Handwashing/Hand Hygiene last updated August 2019 read in part: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; g. Before handling clean or soiled dressings, gauze pads, etc.; j. After contact with blood or body fluids; k. After handling used dressings, contaminated equipment, etc.; m. After removing gloves; An observation of Nurse #1 providing wound care on Resident #2's coccyx wound was made on 05/06/25 at 11:08 AM. Nurse #1 gathered her dressing supplies and placed them on wax paper on the overbed table. The old dressing was removed by Medication Aide #1 who was assigned to the resident. Nurse #1 doffed her gloves and washed her hands with soap and water and donned clean gloves and proceeded to clean the wound inside outward with normal saline-soaked gauze and patted the wound dry with dry gauze. After cleaning the wound and without doffing her gloves, sanitizing her hands, and donning clean gloves, Nurse #1 proceeded to pack the wound with normal saline-soaked gauze and applied bordered foam dressing with date and initials over the wound. Nurse #1 gathered her supplies and trash, doffed her gown and gloves, washed her hands with soap and water, and left the room. An interview on 05/06/25 at 4:55 PM with Nurse #1 revealed she felt like she could have done a better job with the wound care on Resident #2. She stated she should have doffed her gloves, sanitized her hands, and donned clean gloves after cleansing the wound and prior to applying the treatment to Resident #2's wound. She stated she knew that you were supposed to doff, sanitize and don clean gloves after cleansing a wound and before applying the treatment because that was going from a dirty to clean procedure. Nurse #1 further stated it was an oversight on her part because she was nervous about being watched during wound care. An interview on 05/07/25 at 9:16 AM with the Infection Preventionist (IP) revealed all the nurses had been in-serviced on handwashing and dressing changes and said anytime they were going from a dirty procedure to clean procedure they were supposed to doff their gloves, sanitize their hands and don clean gloves. The IP also revealed that anytime they doffed their gloves they were supposed to sanitize their hands before donning clean gloves. An interview on 05/08/25 at 12:29 PM with the Director of Nursing (DON) revealed it was her expectation that Nurse #1 follow the facility's policy and procedure for Handwashing/Hand Hygiene during wound care. An interview on 05/08/25 at 12:36 PM with the Administrator revealed he would have expected Nurse #1 to follow their Handwashing/Hand Hygiene policy and procedure while providing wound care.

Based on record review, resident and staff interview the facility failed to honor resident preference and requests to eat dinner in the dining room (Resident #46, Resident #47, and Resident #39) for 3 of 3 residents reviewed for choices. The findings included: a. Resident #46 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #46 was cognitively intact and was assessed as independent requiring no assistance for eating. An interview conducted with Resident #46 on 03/12/24 at 3:10 PM revealed she has always preferred to eat lunch and dinner in the dining room and staff have been aware of that since her admission. She stated for a minimum of the last four months, she and other residents have not been allowed to eat their dinner in the dining room and have had to eat in their rooms. She revealed when she asked staff why she and other residents were not able to eat their dinner in the dining room, staff would say they didn't have time to take residents to the dining room or they were short staffed although she would see multiple staff on the hall. Resident #46 stated although she participated in facility activities and would sit on the outside porch to read, eating lunch and dinner in the dining room was important to her because it allowed her to socialize with other residents and have a break from being in her room and not being able to eat her dinner in the dining room aggravated her and made her feel isolated. b. Resident #47 was admitted to the facility on [DATE]. Review of annual Minimum Data Set (MDS) dated [DATE] revealed Resident #47 was cognitively intact and required set-up and clean-up assistance for eating. An interview conducted with Resident #47 on 03/14/24 at 11:10 AM revealed she preferred to eat lunch and dinner in the dining room and over the past few months she had been served dinner in her room and was not allowed to eat dinner in the dining room. She stated when she would ask staff why she could not eat her dinner in the dining room they would tell her because she had to eat in her room, or they did not have enough staff to go to the dining room. Resident #47 revealed she participated in facility activities but the reason she preferred eating lunch and dinner in the dining room and why it was important to her was because it allowed her time to socialize with other residents and having to eat dinner in her room made her feel like she was stuck. c. Resident #39 was admitted to the facility on [DATE]. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #39 to be cognitively intact and required supervision for eating. An interview conducted with Resident #39 on 03/14/24 at 2:45 PM revealed he preferred to eat lunch and dinner in the dining room and over the past several months he had not been allowed to eat dinner in the dining room and was made to eat in his room. He stated he when he asked staff about going to the dining room for dinner, they would say they did not have the time to take him. He revealed eating lunch and dinner in the dining room was important to him because it allowed him to be in a different setting besides his room and able to socialize with other residents. Resident #39 stated he also was able to participate in some facility activities but not being able to eat dinner in the dining room bothered him and made him feel left out. An interview conducted with Dietary Aide #1 on 03/13/24 at 8:48 AM revealed she had observed over the past few months they had been sending resident trays to the halls and residents were not being brought into the dining room for dinner. She stated they typically had a big turnout in the dining room for lunch and she had wondered why residents were no longer coming to the dining room for dinner but when she asked staff about it, she never received an answer as to why. An interview conducted on 03/13/24 at 5:11 PM with Nursing Assistant (NA) #1 revealed she had been employed at the facility for the past 6 years and worked both 1st and 2nd shift. She stated she was aware of residents being served their dinner meal in their rooms during the week and on the weekends instead of going to the dining room. When asked why residents were being served their dinner meals in their rooms instead of the dining room, NA #1 stated staff did not always have the time to leave the hall and assist certain residents in the dining room, so it was easier for the residents to be served their dinner meal on the hall. NA #1 stated she had a few residents that would ask her from time to time about eating their dinner in the dining room and she would explain to them about not having the time or staff to assist them to the dining room. An interview conducted on 03/14/24 at 11:17 AM with Nurse #1 revealed she had been employed at the facility for the past [AGE] years and worked 12-hour shifts from 7AM to 7PM. She stated over the past few months she had observed residents being served their dinner meals in their rooms instead of being taken to the dining room. She revealed she was not aware of why staff were not taking residents to the dining room for dinner because there had been no issues with the halls being short-staffed or with staff not being able to complete their tasks. Nurse #1 stated that she had not reported the issue to anyone because she assumed administration was aware. An interview conducted on 03/14/24 at 5:07 PM with the Administrator, Director of Nursing (DON), and Vice-President of Clinical Services revealed they had not been aware of staff not honoring resident mealtime preference of being able to eat their dinner meal in the dining room. When asked why they had not been aware of residents not being served their dinner meals in the dining room, they stated no residents or staff had come to them with any issues or concerns of not eating their dinner meal in the dining room until this week and they had not noticed residents not being in the dining room in the evenings when dinner was being served. They also stated there had been no staffing issues at the facility that would attribute to staff not being able to take residents to the dining room for their meals. They revealed staff should always honor resident's mealtime preference of being able to eat their meals in the dining room.

Based on observations, record reviews, and staff interviews, the facility's Quality Assurrance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation surveys that occurred on 10/28/21. This was for one deficiency in the area of Self Determination that was originally cited on 10/28/21 recertification and complaint investigation survey and cited again during the recertification and complaint investigation survey completed on 3/14/24. The continued failure of the facility during two federal surveys showed a pattern of the facility's inability to sustain an effective QAPI program. The findings included: This tag is cross referred to: F561: Based on record review, resident and staff interview the facility failed to honor resident preference and requests to eat dinner in the dining room for 3 of 3 residents reviewed for choices. During the recertification and complaint investigation survey completed on 10/28/21 the facility failed to provide showers for 1 resident at least 2 times per week as scheduled for 1 of 3 residents reviewed for choices. During an interview on 10/14/24 at 5:30 PM with the Administrator, he revealed the QAPI committee meets monthly with department heads, administrative staff, the Medical Director, and at least quarterly the Pharmacist and Registered Dietician attend and monthly attend by phone. He reported they currently had Process Improvement Plans (PIPs) addressing some of the issues he and the corporate advisors had identified at the facility. Some of the PIPs currently being addressed included grievances, care plan meetings, and he also reported they would be putting PIPs into place to address the current concerns addressed during the current recertification and complaint survey. The Administrator stated the PIPs would be ongoing and monitored to ensure ongoing and future compliance.

Based on record review and resident, resident representative and staff interviews the facility failed to afford the resident and/or resident representative the right to participate in the care plan process for 2 of 3 (Resident #7 and Resident #22) residents reviewed for care plans. The findings included: 1. Resident #7 was admitted to the facility on [DATE]. Review of Resident #7's quarterly Minimum Dat Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired. Review of resident #7's care plan revealed it was last revised on 01/19/24. Review of Resident #7's record review revealed no documentation a care plan meeting had been completed with Resident #7 and resident representative (RR). An interview conducted with Resident #7's RR on 03/11/24 at 10:15 AM revealed they had not been invited to any care plan meetings in several months. The RR further revealed she wanted to be invited to care plan meetings to discuss Resident #7. An interview conducted with the Social Worker (SW) on 03/13/24 at 2:45 PM revealed she was hired as the facility SW in November 2023. It was further revealed she had just recently received training for conducting care plan meetings but only a couple of meetings had been completed since November 2023. The SW stated she was aware Resident #7 did not have a care plan meeting this past quarter and did not notify Resident #7's RR that a care plan meeting would not be completed. 2. Resident #22 was admitted to the facility on [DATE]. Review of Resident #22's annual MDS dated [DATE] revealed the resident was cognitively intact. Review of Resident #22's care plan revealed it was last revised on 02/12/24. Review of Resident #22's record review revealed no documentation that a care plan meeting had been completed with Resident #22 and resident representative (RR). An interview conducted with Resident #22 on 03/11/24 at 3:15 PM revealed she had not been invited to her care plan meetings in several months. Resident #22 further revealed she wanted to attend care plan meetings to discuss her care. Resident #22 indicated she was not aware why she had not been notified. An interview conducted with the Social Worker (SW) on 03/13/24 at 2:45 PM revealed she was hired as the facility SW in November 2023. It was further revealed she had just recently received training for conducting care plan meetings but only a couple of meetings had been completed since November. The SW stated she was aware Resident #22's had not received a care plan meeting due to the SW not being trained. The SW indicated she did not notify Resident #22 that her care plan meeting would not be completed. An interview conducted with the Administrator on 03/14/24 at 5:40 PM revealed he was not aware of Resident #7 and Resident #22 had not received a care plan meeting timely. It was indicated that the Administrator expected care plan meetings to be completed and the resident representative/responsible party notified if changes were made.

Based on record review and staff interviews the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed for resident with mental health diagnosis upon admission and resident with new mental health diagnoses for 2 of 3 residents (Resident #9 and Resident #15) reviewed for PASRR. The findings include: 1. Review of Resident #9's medical record revealed the resident had a PASRR level I completed prior to her admission and was admitted to the facility on [DATE]. The resident had been diagnosed with paranoid schizophrenia as part of her admission. No PASRR level II had been completed per Resident # 9 medical records. During an interview on 03/14/24 at 4:20 PM with the Social Worker (SW) revealed she had been employed as the facility SW since November 2023 and was still receiving training on how to complete PASRR paperwork for residents. She stated she was not aware of Resident #9 mental health diagnosis or that a Level II PASRR had not been completed. The SW revealed that based on the PASRR training she had received a Level II PASRR should be completed upon resident admission with a mental health diagnosis, when there was a change in condition or behavior, and when a resident had received a new mental health diagnosis. She also revealed that based on Resident #9 admission diagnosis of paranoid schizophrenia and the preadmission PASRR level I, paperwork for a PASRR level II should have been completed. During an interview on 03/14/24 at 5:05 PM with the Administrator revealed a PASRR level II should be completed in a timely manner upon admission for a resident with a mental health diagnosis or anytime a resident has had a change of condition or a newly added mental health diagnosis. He stated based on Resident #9 admission diagnosis of paranoid schizophrenia, a PASRR level II should have been completed. 2. Review of Resident #15's medical record revealed the resident had a PASRR level I completed prior to her admission and was admitted to the facility on [DATE]. The resident was diagnosed with bipolar disorder, depressed, with mild or moderate severity on 02/08/23 and major depressive disorder on 12/01/23. No PASRR level II had been completed per Resident #15 medical records. During an interview on 03/14/24 at 4:20 PM with the Social Worker (SW) revealed she had been employed as the facility SW since November 2023 and was still receiving training on how to complete PASRR paperwork for residents. She stated she was not aware of Resident #15 newly added mental health diagnosis or that a Level II PASRR had not been completed. The SW revealed that based on the PASRR training she had received a Level II PASRR should be completed upon resident admission with a mental health diagnosis, when there was a change in condition or behavior, and when a resident had received a new mental health diagnosis. She also revealed that based on Resident #15 new mental health diagnosis of bipolar disorder, depressed with mild or moderate severity and major depressive disorder and the preadmission PASRR level I, paperwork for a PASRR level II should have been completed. During an interview on 03/14/24 at 5:05 PM with the Administrator revealed a PASRR level II should be completed in a timely manner upon admission for a resident with a mental health diagnosis or anytime a resident has had a change of condition or a newly added mental health diagnosis. He stated based on Resident #15 new mental health diagnosis of bipolar disorder, depressed with mild or moderate severity and major depressive disorder, a PASRR level II should have been completed.

Based on record review and resident and staff interviews the facility failed to transport a resident to a scheduled appointment with their vascular physician for 1 of 3 residents reviewed for medically related social services (Resident #45). Findings included: Resident #45 was admitted to the facility on [DATE] with diagnoses which included hypertension and fracture. Resident #45s quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #45 was cognitively intact. An interview was conducted with Resident #45 on 8/29/22 at 11:00 AM, and the resident stated she had missed an appointment on 8/12/22 to see a vascular doctor. Resident #45 further revealed she had told the facility scheduler and transporter the appointment needed to be rescheduled but had no knowledge if it had been. Resident #45 indicated on 8/12/22 the facility transporter had told Resident #45 her vascular appointment had to be missed due to the transportation vehicle breaking down. Resident #45 revealed the facility transporter attended the initial vascular appointment on 7/15/22 and scheduled the appointment for 8/12/22 at the vascular doctor's office with the resident present. An interview conducted with the Unit Manager on 8/30/22 at 10:20 AM revealed she did not recall Resident #45 having an appointment scheduled for 8/12/22 and was not aware it was missed. The Unit Manager further revealed she did not recall transportation breaking down, and the facility had a 24/7 back up transportation in case of emergencies. The Unit Manager indicated there was nothing scanned in Resident #45's medical chart for an appointment on 8/12/22. An interview conducted with the facility scheduler/transporter on 8/31/22 at 8:20 AM revealed Resident #45 had a vascular appointment on 7/15/22 but did not have one scheduled for this month. It was further revealed she had attended the appointment with Resident #45 on 7/15/22 and received the paperwork. She revealed once she receives the paperwork, she gives it to nursing staff or the unit manager. She indicated transportation had not broken down the month of August and could not recall why Resident #45 thought she had an appointment or transportation was broke down. A phone interview conducted with the receptionist from the vascular doctor's office on 8/31/22 at 11:05 AM revealed Resident #45 was a no show for a scheduled appointment on 8/12/22. The receptionist stated a staff member from the facility was present for the initial appointment on 7/15/22 and scheduled the appointment for the Resident to be seen on 8/12/22. The receptionist indicated the facility staff had also received paperwork with the appointment time and information on it. An interview conducted with the Director of Nursing (DON) on 8/31/22 at 4:02 PM revealed Resident #45 was cognitively intact. The DON stated the facility scheduler/transporter went to appointments with residents, receives paperwork, gives it the nurse for review for possible orders, and then scanned into medical records. The DON indicated she was not aware of an appointment on 8/12/22. The DON stated transportation should not have been an issue because the facility had a backup service. An interview conducted with the Administrator on 8/31/22 at 4:50 PM revealed she was not aware that Resident #45's appointment was missed on 8/12/22 and it should have been rescheduled if there was an issue. The Administrator further revealed the facility had 24/7 back up transportation. The Administrator indicated Resident #45's appointment on 8/12/22 should have not been missed.

Based on observations, record reviews, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place. This was for one deficiency in the area of Infection Control originally cited on the 08/20/20 focused infection control and complaint investigation survey and 10/28/21 on the recertification and complaint investigation survey. This areas was cited again on the current recertification survey with an exit date of 08/31/22. The continued failure of the facility during the three federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: This citation is cross referred to: F 880- Based on record reviews, observation and staff interviews, the facility failed to implement their infection control policies and the Centers for Disease Control and Prevention (CDC) recommended practices for COVID-19 when 1 of 1 staff member (Nurse #1) failed to change gloves and perform hand hygiene during wound care for 1 of 3 residents reviewed for infection control (Resident #209). On the 10/28/21 recertification and complaint investigation survey the facility failed to follow CDC guidelines for the use of Personal Protective Equipment (PPE) when 6 out of 6 staff members were observed not wearing eye protection while providing resident care. On the 08/20/20 focused infection control and complaint investigation survey the facility failed to implement the Centers for Disease Control and Prevention (CDC) recommended practices for COVID-19 by not placing enhanced droplet contact precautions signs up and not requiring staff to wear all recommended PPE (Personal Protective Equipment) when caring for 2 of 2 newly admitted residents and 1 of 1 readmitted resident and not cohorting and quarantining on the designated quarantine hall (300 hall) 3 of 15 newly admitted residents and 2 of 3 readmitted residents.

Based on record reviews, observation and staff interviews, the facility failed to implement their infection control policies and the Centers for Disease Control and Prevention (CDC) recommended practices for COVID-19 when 1 of 1 staff member (Nurse #1) failed to change gloves and perform hand hygiene during wound care for 1 of 3 residents reviewed for infection control (Resident #209). The findings included: The Centers for Disease Control and Prevention (CDC) guidance entitled, Hand Hygiene in Healthcare Settings, last reviewed on 1/8/21 indicated the following information: Use an alcohol-based hand sanitizer before moving from work on a soiled body site to a clean body site on the same patient, after contact with blood, body fluids or contaminated surfaces and immediately after glove removal. Change gloves and perform hand hygiene during patient care, if moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs. The facility's policy entitled, Hand Hygiene Policy and Procedures, revised on 2/5/21 indicated the following statement: Hand hygiene should be performed after contact with blood, body fluids, or excretions, mucous membranes, non-intact skin, or wound dressings, when hands are moved from a contaminated body site to a clean body site during patient care and after glove removal. Resident #209 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation of wound care by Nurse #1 for Resident #209 was made on 8/30/22 at 1:46 PM while being assisted by Nurse Aide #2. Nurse #1 washed her hands and put gloves on both hands. She started to remove the compression bandage and gauze wrap off Resident #209's left leg. A foam dressing was observed in place to Resident #209's left heel. Nurse #1 proceeded to remove the compression bandage and gauze wrap off Resident #209's right leg. Resident #209's right heel was also covered with a foam dressing. Nurse #1 took off her gloves and washed her hands. She put new gloves on and removed the foam dressing off Resident #209's right heel. The foam dressing looked saturated with yellowish drainage. Nurse #1 cleaned the right heel wound by spraying wound cleanser directly on the wound and wiping it with a dry gauze. While cleaning the right heel wound, Nurse #1 removed a moderate amount of yellowish debris from the wound bed. Without removing her gloves and doing hand hygiene, Nurse #1 proceeded to remove the foam dressing off Resident #209's left heel wound. Nurse #1 sprayed wound cleanser on the wound bed and wiped the drainage with a dry gauze. Nurse #1 then removed her gloves and washed both hands. She put on new gloves and covered the right heel wound with alginate (dressing made of natural fibers derived from seaweed, absorbs exudates and forms a gel-like covering over the wound), applied a foam dressing and wrapped the whole right leg with a gauze wrap and a compression bandage. Without removing her gloves and performing hand hygiene, Nurse #1 covered the left heel wound with alginate, applied a foam dressing and wrapped the whole left leg with a gauze wrap and a compression bandage. Nurse #1 removed her gloves and washed her hands. An interview with Nurse #1 on 8/30/22 at 3:29 PM revealed she probably should have changed her gloves and washed her hands after cleaning Resident #209's right heel wound and before cleaning his left heel wound. Nurse #1 stated she normally removed Resident #209's dressings to both legs at the same time and cleaned and dressed them simultaneously because it was time-consuming to do one leg at a time. An interview on 8/31/22 at 4:38 PM with the Director of Nursing (DON) who was also the facility's Infection Preventionist revealed Nurse #1 should have provided wound care to Resident #209 by doing one leg at a time and she should have changed her gloves and washed her hands before dressing the other wound to prevent cross-contamination of his wounds. The DON stated she couldn't remember the last time the nurses had been educated on wound care and that she would need to do an in-service on wound care and infection control soon.

Based on record review and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS)- Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) and CMS- Notice of Medicare Non-Coverage letter (NOMNC) prior to discharge from Medicare Part A skilled services for 3 of 3 residents reviewed for beneficiary protection notification (Residents #11, #51 and #210). Findings included: 1. Resident #11 was admitted to the facility on [DATE]. A review of the medical record revealed the facility initiated Resident #11's discharge from Medicare Part A Services when benefit days were not exhausted. Resident #11 should have received both CMS- Notice of Medicare Non-Coverage letter (NOMNC) and CMS- Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) due to resident having skilled benefit days remaining and was being discharged from Medicare Part A Services and continue living in the facility. Neither form was discussed or completed with Resident #11 or her Responsible Party (RP). Medicare Part A coverage for skilled services ended on 03/21/22 and Resident #11 remained in the facility. An interview was conducted with the Social Worker on 08/30/22 at 04:30 PM. She revealed was notified around the second week of August that she would be responsible for completing the NOMNC and SBF ABN forms and received training on how to complete the forms and notifying residents and/or their RP of changes. She stated prior to August, the Business Office Manager was responsible for completing the forms, but he was no longer at the facility. The Social Worker revealed she was not aware of forms not being completed or residents and their RP's not being contacted about changes. An interview was conducted with the Administrator on 08/31/22 at 05:03 PM. The Administrator stated she was not aware the NOMNC and SNF ABN forms had not been completed until yesterday. She stated the former Business Office Manager was responsible for completing the forms and he was no longer at the facility. She stated the Social Worker had received training and would be responsible for completing the forms and the new Business Office Manager will be responsible for the completing the forms if the Social Worker was not available. The Administrator revealed the NOMNC and SBF ABN should have been discussed and issued to the resident and/or the RP. She stated she expected the required forms to be completed timely and correctly. 2. Resident #51 was admitted to the facility on [DATE]. A review of the medical record revealed the facility initiated Resident #51's discharge from Medicare Part A Services when benefit days were not exhausted. Resident #51 should have received both CMS- Notice of Medicare Non-Coverage letter (NOMNC) and CMS- Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) due to resident having skilled benefit days remaining and was being discharged from Medicare Part A Services and continue living in the facility. Neither form was discussed or completed with Resident #51 or her Responsible Party (RP). Medicare Part A coverage for skilled services ended on 03/21/22 and Resident #51 remained in the facility. An interview was conducted with the Social Worker on 08/30/22 at 04:30 PM. She revealed was notified around the second week of August that she would be responsible for completing the NOMNC and SBF ABN forms and received training on how to complete the forms and notifying residents and/or their RP of changes. She stated prior to August, the Business Office Manager was responsible for completing the forms, but he was no longer at the facility. The Social Worker revealed she was not aware of forms not being completed or residents and their RP's not being contacted about changes. An interview was conducted with the Administrator on 08/31/22 at 05:03 PM. The Administrator stated she was not aware the NOMNC and SNF ABN forms had not been completed until yesterday. She stated the former Business Office Manager was responsible for completing the forms and he was no longer at the facility. She stated the Social Worker had received training and would be responsible for completing the forms and the new Business Office Manager will be responsible for the completing the forms if the Social Worker was not available. The Administrator revealed the NOMNC and SBF ABN should have been discussed and issued to the resident and/or the RP. She stated she expected the required forms to be completed timely and correctly. 3. Resident #210 was admitted to the facility on [DATE]. A review of the medical record revealed a CMS- Notice of Medicare Non-Coverage letter (NOMNC) was not discussed with Resident #210 prior to discharge on 03/16/22. The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted and the NOMNC form was not provided to resident. NOMNC form should be completed when resident has skilled benefit days remaining and was being discharged from Medicare Part A services and was leaving the facility immediately following the last covered skilled day. Medicare Part A coverage for skilled services ended on 03/16/22 and Resident #210 was discharged home. An interview was conducted with the Social Worker on 08/30/22 at 04:30 PM. She revealed was notified around the second week of August that she would be responsible for completing the NOMNC form and received training on how to complete the form and notifying residents and/or their RP of changes. She stated prior to August, the Business Office Manager was responsible for completing the form, but he was no longer at the facility. The Social Worker revealed she was not aware of forms not being completed or residents and their RP's not being contacted about changes. An interview was conducted with the Administrator on 08/31/22 at 05:03 PM. The Administrator stated she was not aware the NOMNC and SNF ABN forms had not been completed until yesterday. She stated the former Business Office Manager was responsible for completing the forms and he was no longer at the facility. She stated the Social Worker had received training and would be responsible for completing the forms and the new Business Office Manager will be responsible for the completing the forms if the Social Worker was not available. The Administrator revealed the NOMNC and SBF ABN should have been discussed and issued to the resident and/or the RP. She stated she expected the required forms to be completed timely and correctly.

Based on record review, staff interviews, Nurse Practitioner (NP) and Medical Director interviews, the facility failed to notify the Physician or Nurse Practitioner of Resident #1 being on anticoagulant therapy when he had experienced an unwitnessed fall with a head injury. The facility also failed to notify the Physician or NP when Resident #1 experienced a change of condition after a fall with head injury by becoming increasingly confused, not urinating for the entire day, and having no intake by mouth. This was for 1 of 3 residents reviewed for notification (Resident #1). Resident #1 was transferred to the hospital for an evaluation and found to have a C6 (part of the cervical spinal cord, located in the lowest region of the neck) vertebral fracture. Immediate Jeopardy began on 01/05/22 when the facility failed to notify the Physician or Nurse Practitioner that Resident #1 was on anticoagulant therapy when they reported an unwitnessed fall with head injury. Immediate Jeopardy was removed on 03/18/22 when the facility implemented an acceptable credible allegation on Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D no actual harm with potential for more than minimal harm that is not Immediate Jeopardy to ensure education is completed and monitoring systems put in place are effective. The findings included: Resident #1 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 09/08/21 revealed Resident #1 was taking an anticoagulant (a medication that inhibits the clotting of blood) [MEDICATION(S)] 5 milligrams (mg) 1 tablet by mouth every 12 hours related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #1's Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact. Resident #1 was coded as experiencing no pain during the assessment period and having no falls since the last assessment. Resident #1 was coded as receiving anticoagulant therapy on 6 of the days during the look back period. Resident #1's care plan dated 01/05/22 revealed he was receiving anticoagulant therapy medication related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal was for Resident #1 to remain free from discomfort or adverse reactions related to anticoagulant use through the next review date. Interventions included taking precautions to avoid falls due to an increased risk of bleeding. Review of the facility's on call provider messaging system revealed on 01/05/22 at 4:33 AM a message was sent to the provider stating Resident #1 had been observed on the floor near his bed. The note revealed Resident #1 had a laceration to his middle right finger, abrasion to right knee and a 1-centimeter (cm) skin tear to his right forehead. Nurse #1 wrote in the note that neurological checks (neurological assessment of the resident's level of consciousness) had been started and were within normal limits at that time. The on-call provider acknowledged the note at 4:44 AM with a low priority (non-urgent) message. A nursing progress note dated 01/05/22 at 5:07 AM written by Nurse #1 revealed Resident #1 was found lying on the floor beside his bed in a prone position (lying flat with the chest down and back up). She documented that she performed passive and active range of motion. The note revealed Resident #1 was alert and oriented to his name. He had obtained a 1-centimeter (cm) skin tear to his right forehead, a right knee and shin abrasion 10 cm in length and his right middle finger had a 2 cm skin tear. Resident #1 was lifted back into bed with 3 staff member assist using a mechanical lift. The resident ' s wounds were cleansed with normal saline and dry foam dressings were applied. A smart pager text was sent to notify the on-call physician of the residents fall. The Nurse Practitioner noted the text. Neurological checks were initiated. On 03/16/22 at 2:34 PM an interview was conducted with Nurse #1. She stated she was working during third shift on 01/04/22 on the 100 hall. The interview revealed Nurse #3, an agency nurse, was Resident #1's nurse for the night. She stated Nurse #3 came to her and said he found Resident #1 lying on the floor and asked her for help getting him back into the bed. She stated when she walked in the room Resident #1 was lying to the left side of his bed on the floor with his head facing his heater/air conditioning unit in the room. She stated the resident had some bleeding from his head area and forearm. Nurse #1 stated she and Nurse #3 put the resident back into the bed using a sling and a mechanical lift for the transfer. She stated she then performed active and passive range of motion by asking and moving Resident #1's arms and legs. Nurse #1 stated Resident #1 did not complain of any pain out of the normal for him, she stated he had chronic pain. The interview revealed Nurse #3 then went out of the building so Nurse #1 dressed the resident's wounds to his forehead, right knee and right middle finger and placed a note into the computer. She stated she initiated neurological checks every 15 minutes then when Nurse #3 returned in the building she told him he would need to continue completing the neurological checks. She stated she did not know if he had done so. The interview revealed she sent a note via text to the on call provider. Nurse #1 stated when she saw Resident #1, he did not complain of pain or have any confusion. She stated Resident #1 was not her resident she was just helping Nurse #3 complete the necessary follow-ups to a fall and did not know Resident #1 was on an anticoagulant. On 03/17/22 at 9:20 AM an interview was attempted with Nurse #3 with no return phone call. An interview conducted on 03/16/22 at 12:02 PM with NA #2 revealed she had worked first shift on 01/05/22 taking care of Resident #1. She stated she had received in report from NA #1 that Resident #1 had experienced a fall during the night. She stated when she was completing her rounds during the day, she noticed Resident #1 was making a moaning sound. The interview revealed Resident #1 continued to make the moaning sound on into the day and she notified Nurse #2 around 4:00 PM. She stated Nurse #2 told her the resident was going to be sent out to the hospital. NA #2 stated Resident #1 had not voided and had not eaten his breakfast or lunch meal. She stated she was an agency NA and had only worked in the facility a few times, so she didn't know the resident's baseline status and that was why she hadn't notified Nurse #2 earlier in the day. A nursing progress note dated 01/05/22 at 1:56 PM written by Nurse #2 revealed Resident #1 was alert with confusion. She documented in the note that his neurological check was normal in the note, and that Resident #1 had not complained of pain. A nursing progress note dated 01/05/22 at 4:35 PM revealed Nurse #2 had reported to the Medical Director that Resident #1 had a change in mental status, no intake for the day or output. Resident #1 was documented to have increased confusion during the shift. The note revealed the Medical Director evaluated the resident and gave a new order to send Resident #1 to the hospital for an evaluation and a computed tomography (CT) scan. An interview could not be conducted with Nurse #2. Medical Director #1's evaluation note dated 01/05/22 at 4:08 PM revealed she had seen Resident #1 on this date due to staff reporting to her he had a fall around 3:00 AM and had hit his head. The staff reported to her he had not urinated since the fall. Resident #1 had stated to her he had a headache and staff also reported he had altered mental status. The MD noted he had multiple abrasions. She noted Resident #1 was receiving anticoagulated therapy and that she would send him to the hospital for an evaluation and possible head CT scan. Resident #1's emergency room hospital records revealed on 01/05/22 at 5:23 PM Resident #1 presented in the emergency room after experiencing a fall at 3:00 AM that morning. The hospital staff noticed that the resident started having increased confusion and the resident told the staff where he was experiencing pain. Resident #1 complained of pain in the right side of his head where he told staff he hit when he fell . He also complained of right knee pain where he had an abrasion. Resident #1 was found to have a C6 vertebral fracture and was also complaining of neck numbness between his neck and left shoulder. Resident #1 was instructed to wear a cervical collar and to follow up outpatient with neurosurgery. Resident #1 returned to the facility on [DATE]. On 03/17/22 at 8:27 AM an interview was conducted with the Nurse Practitioner. During the interview she stated Resident #1 had been under her care and staff were supposed to inform her if he experienced a change of condition. She stated regarding the incident with Resident #1 on 01/05/22 she had not been notified Resident #1 had experienced a fall. She stated the nurse who was working notified the on-call physician through a different company via a text instead of notifying her. The Nurse Practitioner stated Resident #1's fall had not been addressed during the morning of 01/05/22 by the provider the nurse notified. The NP stated if she had been notified of the resident's fall, she would have sent him to the emergency room for an evaluation. On 03/17/22 at 12:40 PM an interview conducted with Medical Director #2. He stated he would not have sent Resident #1 to the hospital based on the information Nurse #1 included in the page text sent to the on-call provider that the resident had a skin tear to his forehead. He stated she should have included the resident was on an anticoagulant, but they did not send everyone who hit their head to the emergency room . The MD stated based on the nursing note at 1:30 PM that Resident #1 had a change of condition by increased confusion he or the NP should have been notified. He stated after trauma such as a fall they like to give the residents time to recover so regarding Resident #1 not voiding or having any intake he would have wanted to have been notified within 6-8 hours from the time of the fall. On 03/22/22 at 10:25 an interview was conducted with the Director of Nursing (DON). During the interview she stated the normal process if a nurse had a resident who experienced an unwitnessed fall was to assess the resident and notify the Medical Director or Nurse Practitioner of the fall and if the resident was receiving anticoagulant therapy. The DON stated the nurse should initiate neurological assessments and continue them every 15 minutes for one hour, every hour for 4 hours and every 4 hours for 19 hours. The Administrator was notified of Immediate Jeopardy on 03/17/22 at 4:35 PM. The facility submitted the following corrective action plan. Identify those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident had a fall on 1/05/22 at approximately 3:45am. Resident was observed on the floor in prone position towards the center of the room. Nurse assessed resident. Passive and active range of motion within normal limits. Neurochecks also within normal limits. Resident observed with skin tear to right forehead. MD and RP notified. Nurse did not inform physician at that time, that resident was receiving anticoagulant therapy. Additionally, nursing staff failed to complete timely neurological assessments and ongoing assessment of the resident for change in condition. Physician notified of change of condition at approximately 4:30pm on 01/05/22 and resident sent to the emergency room for further evaluation for failure to void, no po intake, and increased confusion. Residents On 03/17/22, the Unit Coordinator completed a review of current residents receiving anticoagulant therapy that had a fall with head injury in the past 30 days. 11 total residents reviewed and no residents at risk identified. On 03/17/22, the Unit Coordinator completed a review of current residents receiving anticoagulant therapy that had a fall with head injury in the past 30 days to ensure physician was notified timely. 11 total residents reviewed and no residents at risk identified. On 03/17/22, resident assessments were completed by a Licensed Nurse to ensure the following was in place for any active or new change in conditions for residents on anticoagulant therapy identified: 11 total residents reviewed and no residents at risk identified. · Family/Responsible Party Notification · Physician Notification · Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] · Appropriate documentation · Interventions to prevent further changes and /or worsening of condition · Appropriate Care Plan Intervention put in place On 3/17/22, the Director of Clinical Services and Unit Coordinator initiated education to the Licensed Nurses. After 3/17/2022, nurses not educated will receive this education prior to working their next scheduled shift), regarding physician notification of a change of condition related to residents on anticoagulant therapy that have an unwitnessed fall, recognition and response to include the following: · Evidence of a Licensed Nurse assessment · Neurological assessments are initiated and completed · Physician is notified that resident is receiving anticoagulant therapy · physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] · Treatments have been performed per physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] · Physician and responsible party notification of changes · Appropriate care plan is in place · Accurate documentation · Continued monitoring for change of condition s/p fall (to include neuro-checks) Newly Hired Licensed Nurses, medication aides, and certified nursing assistants, will be educated during the Orientation process by the Director of Nursing, going forward. The Direcor of Nursing has been notified of this responsibility. Education is being provided in person and via phone. The Director of Nursing is tracking who has received education. Validation of understanding has been documented via post-test questionnaire. On 3/17/22, the Director of Clinical Services and/or Designee initiated education with Certified Nursing Assistants/Medication Aides regarding licensed nurse notification of a change of condition observation to include the following: · Interact - Stop and Watch Tool After 3/17/2022 Certified Nursing Assistants/Medication Aides not previously educated on change of condition observation and Interact Stop and Watch Tool will be educated prior to working their next scheduled shift. Newly Hired Certified Nursing Assistants/Medication Aides will be educated during the Orientation process going forward. The Director of Nursing has been notified of this responsibility. Education On 3/17/2022, Licensed Nurses were educated that each attending physician has an on call physician when they are not available to take their own calls. Additionally, the education included that the center ' s medical director is the back-up person to the physicians and the physicians ' on call physicians in the event of an issue with contact. Further, in the event of an issue with contact to the attending or the attending's on call physician, the Licensed Nurse will notify the medical director for further orders pertaining to the resident. After 3/17/2022 Licensed Nurses not previously educated will be educated prior to working their next scheduled shift. Newly Hired Licensed Nurses will be educated during the orientation process going forward. The Director of Nursing/Unit Coordinator is responsible for this. Agency staff is included in the credible allegation. After 3/17/2022 the process going forward will be residents who had a fall on anticoagulant therapy will be reviewed during morning meeting to ensure physician notification, neuro checks initiated, and assessment was done for change of condition. The Director of Nursing will bring any residents who had a fall on anticoagulant therapy to the morning meeting to ensure physician notification, neuro checks initiated, and assessments complete for change of condition. Date of IJ Removal: 03/18/2022 On 03/22/22, the facility's credible allegation of immediate jeopardy removal was validated by review of documentation regarding staff training on Physician notification of change of condition related to residents on anticoagulant therapy that experienced an unwitnessed fall, stop and watch forms put in place for all staff related to if a resident experienced a change of condition staff were to fill out the form and give it to a nurse and what to do if a resident experienced a fall in the facility. Staff interviews revealed receipt of training related to change of condition and notification. The facility's date of Immediate Jeopardy removal of 03/18/22 was validated.

Based on record review and staff, Nurse Practitioner (NP) and Medical Director interviews, the facility failed to complete and document on-going thorough assessments of a resident's condition who was prescribed an anticoagulant and had an unwitnessed fall with a head injury. In addition, Nurse Aide #2 observed the resident was moaning, had not eaten breakfast and lunch, and had not voided but did not report this to the nurse until later in the day. This was for 1 of 3 residents reviewed for quality of care (Resident #1). Resident #1 was transferred to the hospital for an evaluation and found to have a C6 (part of the cervical spinal cord, located in the lowest region of the neck) vertebral fracture. Immediate Jeopardy began on 01/05/22 when the facility failed to complete and document on-going thorough assessments of a resident's condition who was prescribed an anticoagulant and had an unwitnessed fall with a head injury. Immediate Jeopardy was removed on 03/18/22 when the facility implemented an acceptable credible allegation on Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D no actual harm with potential for more than minimal harm that is not Immediate Jeopardy to ensure education was completed and monitoring systems put in place are effective. The findings included: Resident #1 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 09/08/21 revealed Resident #1 was taking an anticoagulant (a medication that inhibits the clotting of blood) [MEDICATION(S)] 5 milligrams (mg) 1 tablet by mouth every 12 hours related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #1's Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact. Resident #1 was coded as experiencing no pain during the assessment period and having no falls since the last assessment. Resident #1 was coded as receiving anticoagulant therapy on 6 of the days during the 7 day look back period. Resident #1's care plan dated 01/05/22 revealed he was receiving anticoagulant therapy medication related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal was for Resident #1 to remain free from discomfort or adverse reactions related to anticoagulant use through the next review date. Interventions included administration of the medication as ordered, daily skin inspection and taking precautions to avoid falls due to an increased risk of bleeding. A nursing progress note dated 01/05/22 at 5:07 AM written by Nurse #1 revealed Resident #1 was found lying on the floor beside his bed in a prone position (lying flat with the chest down and back up). She documented that she performed passive and active range of motion. The note revealed Resident #1 was alert and oriented to his name. He had obtained a 1-centimeter (cm) skin tear to his right forehead, a right knee and shin abrasion 10 cm in length and his right middle finger had a 2 cm skin tear. Resident #1 was lifted back into bed with 3 staff member assist using a mechanical lift. The resident ' s wounds were cleansed with normal saline and dry foam dressings were applied. A smart pager text was sent to notify the on-call physician of the residents fall. The Nurse Practitioner noted the text. Neurological checks were initiated. On 03/16/22 at 2:34 PM an interview was conducted with Nurse #1. She stated she was working during third shift on 01/04/22 on the 100-hall and Nurse #3, an agency nurse, was Resident #1's nurse for the night. She stated Nurse #3 came to her and said he found Resident #1 lying on the floor and asked her for help getting him back into the bed. She stated when she walked in the room Resident #1 was lying to the left side of his bed on the floor with his head facing his heater/air conditioning unit in the room. She stated the resident had some bleeding from his head area and forearm. Nurse #1 stated she, and Nurse #3 put the resident back into the bed using a sling and a mechanical lift for the transfer. She stated she then performed active and passive range of motion by asking and moving Resident #1's arms and legs. Nurse #1 stated Resident #1 did not complain of any pain out of the normal for him, she stated he always had chronic pain. The interview revealed Nurse #3 then went out of the building so Nurse #1 dressed the resident ' s wounds to his forehead, right knee and right middle finger and placed a note into the computer. She stated she initiated neurological checks every 15 minutes then when Nurse #3 returned in the building she told him he would need to continue completing the neurological checks. She stated she did not know if he had done so. Nurse #1 stated when she saw Resident #1, he did not complain of pain or have any confusion. She stated Resident #1 was not her resident she was just helping Nurse #3 complete the necessary follow-ups to a fall and did not know Resident #1 was on a anticoagulant. A neurological assessment flow sheet dated 01/05/22 initiated at 3:45 AM revealed Resident #1 was documented as alert with normal pupil response, pain response and motor functions every 15 minutes until 6:45 AM. The neurological assessment data was not documented after 6:45 AM on 01/05/22. The instructions at the top of the sheet stated neurological assessments were to be completed every 15 minutes for one hour, every hour for 4 hours and every 4 hours for 19 hours (a total of 24 hours). On 03/17/22 at 9:20 AM an interview was attempted with Nurse #3 with no return phone call. Review of the facility's on call provider messaging system revealed on 01/05/22 at 4:33 AM a message was sent to the provider stating Resident #1 had been observed on the floor near his bed. The note revealed Resident #1 had a laceration to his middle right finger, abrasion to right knee and a 1 cm skin tear to his right forehead. Nurse #1 wrote in the note that neurological checks (neurological assessment of the resident ' s level of consciousness) had been started and were within normal limits at that time. The on-call provider acknowledged the note at 4:44 AM with a low priority (non-urgent) message. An interview conducted on 03/16/22 at 12:02 PM with NA #2 revealed she had worked first shift on 01/05/22 taking care of Resident #1. She stated she had received in report from NA #1 that Resident #1 had experienced a fall during the night. She stated when she was completing her rounds during the day, she noticed Resident #1 was making a moaning sound. The interview revealed Resident #1 continued to make the moaning sound on into the day and she notified Nurse #2 around 4:00 PM. She stated Nurse #2 told her the resident was going to be sent out to the hospital. NA #2 stated Resident #1 had not voided and had not eaten his breakfast or lunch meal. She stated she was an agency NA and had only worked in the facility a few times, so she didn ' t know the resident's baseline status and that was why she hadn't notified Nurse #2 earlier in the day. A nursing progress note dated 01/05/22 at 1:56 PM written by Nurse #2 revealed Resident #1 was alert with confusion. She documented in the note that his neurological check was normal in the note, and that Resident #1 had not complained of pain. A nursing progress note dated 01/05/22 at 4:35 PM revealed Nurse #2 had reported to the Medical Director that Resident #1 had a change in mental status, no intake for the day or output. Resident #1 was documented to have increased confusion during the shift. The note revealed the Medical Director evaluated the resident and gave a new order to send Resident #1 to the hospital for an evaluation and a computed tomography (CT) scan. An interview could not be conducted with Nurse #2. Medical Director #1's evaluation note dated 01/05/22 at 4:08 PM revealed she had seen Resident #1 on this date due to staff reporting to her he had a fall around 3:00 AM and had hit his head. The staff reported to her he had not urinated since the fall. Resident #1 had stated to her he had a headache and staff also reported he had altered mental status. The MD noted he had multiple abrasions. She noted Resident #1 was receiving anticoagulated therapy and that she would send him to the hospital for an evaluation and possible head CT scan. Resident #1's emergency room hospital records revealed on 01/05/22 at 5:23 PM Resident #1 presented in the emergency room after experiencing a fall at 3:00 AM that morning. The hospital staff noticed that the resident started having increased confusion and the resident told the staff where he was experiencing pain. Resident #1 complained of pain in the right side of his head where he told staff he hit when he fell . He also complained of right knee pain where he had an abrasion. Resident #1 was found to have a C6 vertebral fracture and was also complaining of neck numbness between his neck and left shoulder. Resident #1 was instructed to wear a cervical collar and to follow up outpatient with neurosurgery. Resident #1 returned to the facility on [DATE]. On 03/17/22 at 8:27 AM an interview was conducted with the Nurse Practitioner. During the interview she stated Resident #1 had been under her care and staff were supposed to inform her if he experienced a change of condition. She stated regarding the incident with Resident #1 on 01/05/22 she had not been notified Resident #1 had experienced a fall. She stated the nurse who was working notified the on-call physician through a different company via a text instead of notifying her. The Nurse Practitioner stated Resident #1's fall had not been addressed during the morning of 01/05/22 by the provider the nurse notified. The NP stated if she had been notified of the residents fall, she would have sent him to the emergency room for an evaluation. On 03/17/22 at 12:40 PM an interview conducted with Medical Director #2. He stated he would not have sent Resident #1 to the hospital based on the information Nurse #1 included in the page text sent to the on-call provider that the resident had a skin tear to his forehead. He stated she should have mentioned the resident was on an anticoagulant, but they did not send everyone who hit their head to the emergency room . The MD stated based on the nursing note at 1:30 PM that Resident #1 had a change of condition by increased confusion he or the NP should have been notified. He stated after trauma such as a fall they like to give the residents time to recover so regarding Resident #1 not voiding or having any intake he would have wanted to have been notified within 6-8 hours from the time of the fall. On 03/22/22 at 10:25 an interview was conducted with the Director of Nursing (DON). During the interview she stated the normal process if a nurse had a resident who experienced an unwitnessed fall was to assess the resident and notify the Medical Director or Nurse Practitioner of the fall and if the resident was receiving anticoagulant therapy. The DON stated the nurse should initiate neurological assessments and continue them every 15 minutes for one hour, every hour for 4 hours and every 4 hours for 19 hours. The Administrator was notified of Immediate Jeopardy on 03/17/22 at 4:35 PM. The facility submitted the following corrective action plan. Identify those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident had a fall on 1/05/22 at approximately 3:45am. Resident was observed on the floor in prone position towards the center of the room. Nurse assessed resident. Passive and active range of motion within normal limits. Neurochecks also within normal limits. Resident observed with skin tear to right forehead. MD and RP notified. Nurse did not inform physician at that time, that resident was receiving anticoagulant therapy. Additionally, nursing staff failed to complete timely neurological assessments and ongoing assessment of the resident for change in condition. Physician notified of change of condition at approximately 4:30pm on 01/05/22 and resident sent to the emergency room for further evaluation for failure to void, no po intake, and increased confusion. Residents On 03/17/22, the Unit Coordinator completed a review of current residents receiving anticoagulant therapy that had a fall with head injury in the past 30 days. 11 total residents reviewed and no residents at risk identified. On 03/17/22, the Unit Coordinator completed a review of current residents receiving anticoagulant therapy that had a fall with head injury in the past 30 days to ensure physician was notified timely. 11 total residents reviewed and no residents at risk identified. On 03/17/22, resident assessments were completed by a Licensed Nurse to ensure the following was in place for any active or new change in conditions for residents on anticoagulant therapy identified: 11 total residents reviewed and no residents at risk identified. · Family/Responsible Party Notification · Physician Notification · Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] · Appropriate documentation · Interventions to prevent further changes and /or worsening of condition · Appropriate Care Plan Intervention put in place On 3/17/22, the Director of Clinical Services and Unit Coordinator initiated education to the Licensed Nurses. After 3/17/2022, nurses not educated will receive this education prior to working their next scheduled shift), regarding physician notification of a change of condition related to residents on anticoagulant therapy that have an unwitnessed fall, recognition and response to include the following: · Evidence of a Licensed Nurse assessment · Neurological assessments are initiated and completed · Physician is notified that resident is receiving anticoagulant therapy · physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] · Treatments have been performed per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] · Physician and responsible party notification of changes · Appropriate care plan is in place · Accurate documentation · Continued monitoring for change of condition s/p fall (to include neuro-checks) Newly Hired Licensed Nurses, medication aides, and certified nursing assistants, will be educated during the Orientation process by the Director of Nursing, going forward. The Direcor of Nursing has been notified of this responsibility. Education is being provided in person and via phone. The Director of Nursing is tracking who has received education. Validation of understanding has been documented via post-test questionnaire. On 3/17/22, the Director of Clinical Services and/or Designee initiated education with Certified Nursing Assistants/Medication Aides regarding licensed nurse notification of a change of condition observation to include the following: · Interact - Stop and Watch Tool After 3/17/2022 Certified Nursing Assistants/Medication Aides not previously educated on change of condition observation and Interact Stop and Watch Tool will be educated prior to working their next scheduled shift. Newly Hired Certified Nursing Assistants/Medication Aides will be educated during the Orientation process going forward. The Director of Nursing has been notified of this responsibility. Education On 3/17/2022, Licensed Nurses were educated that each attending physician has an on call physician when they are not available to take their own calls. Additionally, the education included that the center ' s medical director is the back-up person to the physicians and the physicians ' on call physicians in the event of an issue with contact. Further, in the event of an issue with contact to the attending or the attending's on call physician, the Licensed Nurse will notify the medical director for further orders pertaining to the resident. After 3/17/2022 Licensed Nurses not previously educated will be educated prior to working their next scheduled shift. Newly Hired Licensed Nurses will be educated during the orientation process going forward. The Director of Nursing/Unit Coordinator is responsible for this. Agency staff is included in the credible allegation. After 3/17/2022 the process going forward will be residents who had a fall on anticoagulant therapy will be reviewed during morning meeting to ensure physician notification, neuro checks initiated, and assessment was done for change of condition. The Director of Nursing will bring any residents who had a fall on anticoagulant therapy to the morning meeting to ensure physician notification, neuro checks initiated, and assessments complete for change of condition. Date of IJ Removal: 03/18/2022 On 03/22/22, the facility's credible allegation of immediate jeopardy removal was validated by review of documentation regarding staff training on Physician notification of change of condition related to residents on anticoagulant therapy that experienced an unwitnessed fall, stop and watch forms put in place for all staff related to if a resident experienced a change of condition staff were to fill out the form and give it to a nurse and what to do if a resident experienced a fall in the facility. Staff interviews revealed receipt of training related to change of condition and notification. The facility's date of Immediate Jeopardy removal of 03/18/22 was validated.

Based on observation, record reviews, staff interviews, and resident interviews the facility failed to maintain residents' dignity by delaying incontinence care affecting 1 of 1 resident (Resident #26) reviewed for dignity. The resident expressed feelings of being uncomfortable, upset, mad and embarrassed. The findings included: 1.Resident #26 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was cognitively intact and dependent upon staff members for assistance with toilet use and transfers. Resident #26 was coded as being incontinent of bowel and bladder. Resident #26 was coded as having adequate vision. Review of Resident #26's care plan dated 9/28/20 with a target date of 10/27/21 revealed a focus area for bowel incontinence related to immobility. The goal was for Resident #26 to experience less episodes of incontinence through the review date. Interventions included providing peri care after each incontinent episode. An interview and observation conducted with Resident #26 on 10/26/21 at 8:54 AM revealed she was upset stating to the surveyor, I'm having a bad day and you don't want to know why. She stated she had a bowel movement at 7:30 AM and she used her call light for assistance. The interview revealed at 7:45 AM Nurse Aide (NA) #3 entered her room, and she told the NA that she had went to the restroom and needed to be changed. She was told by NA #3 that she would have to wait because she needed to assist residents in the dining room for the breakfast meal. NA #3 turned off her call light and left the room. Resident #26 stated she had since been sitting in a bowel movement and had to eat her breakfast meal without being changed. She stated it made her feel mad, upset and embarrassed that other residents were more important. The interview revealed she knew the exact times of the incidents because she had been looking at the clock. An observation conducted on 10/26/21 at 8:54 AM revealed a foul odor coming from Resident #26's room while the surveyor entered the room with Nurse #1 during her medication pass. The surveyor informed Nurse #1 that Resident #26 needed to be changed. Nurse #2 went down the hall to find NA #3 and asked her to change Resident #26. An observation conducted on 10/26/21 at 8:59 AM revealed NA #3 picking up resident's breakfast meal trays. An interview conducted with Nurse #1 on 10/26/21 at 9:00 AM revealed it was expected for incontinence care to be completed every two hours but took longer due to staffing shortage. Nurse #1 further revealed multiple residents had complained about having to wait for long periods of time for incontinence care. She stated she was not aware Resident #26 had not been changed but could smell the foul odor when she entered the room with the resident's medication. An observation was conducted on 10/26/21 at 9:04 AM with NA #3 providing incontinence care to Resident #26. NA #3 entered the room with a full bed change including top sheet, fitted sheet and bed pad. When NA #3 removed the loose-fitting top bed sheet there was a brown substance noted to be on the resident s top sheet, gown, bed pad and bottom sheet. NA #3 cleaned Resident #26 using wash clothes and soap with water to rinse. When finished removing the soiled items she provided Resident #26 with a clean gown, top sheet, fitted sheet, bed pad and brief. NA #3 was observed scrubbing a brown substance from the resident's mattress which had soaked through the bed sheet. An interview conducted with Nurse Aide (NA) #3 on 10/26/21 at 9:15 AM revealed she had not provided incontinence care to Resident #26 since coming on shift at 7:00 AM. She stated she normally started getting residents up in the mornings for breakfast and took them to the dining room for their breakfast meal. NA #3 stated she was assisting a resident to the dining room when she saw Resident #26's call light on. She entered the room and Resident #26 stated she had a bowel movement and needed to be changed. NA #3 stated she turned off the residents call light and told her she would return after the breakfast meal to change her. She stated she thought Resident #26 was okay with waiting to be changed and did not tell the other NA working on the hall. NA #3 stated she went ahead a brought in bed change linens because she figured she would need them. An interview conducted with NA #4 revealed she was working on the 100 hall with NA #3. She stated when she came onto shift at 7:00 AM her and NA #3 immediately start getting residents up for the breakfast meal because the facility was short staffed, and third shift wasn't getting all of the residents up. NA #4 stated they did not have time to complete an incontinence round until after breakfast because one NA went to the dining room to assist and one stayed on the hall. NA #4 stated she had remained on the 100 hall while NA #3 went to the dining room and didn't know Resident #26 needed to be changed. She stated she had been assisting other residents on the hall with their breakfast meals. An interview conducted on 10/28/21 at 3:34 PM with the Director of Nursing (DON) revealed she had provided education to staff regarding call lights and turning them off without providing care. She stated NA #3 should not have turned off the residents call light until care had been provided. The interview revealed a lot of the NAs in the building thought they did not have to provide incontinence care during meal times. The DON stated she would speak to staff again on the issue and make sure they knew incontinence care still had to be provided. She stated she had residents complain of not being changed during meal times. An interview conducted on 10/28/21 at 5:45 PM with the Administrator revealed he expected for nursing staff to be providing incontinence care as needed to the residents. The interview revealed staff were expected to not turn off a resident call light unless care had been provided.

Based on observations, record reviews, resident, staff, and Physician's Assistant (PA) interviews, the facility failed to manage a resident's complaints of pain for 1 of 2 residents (Resident #46) reviewed for pain management. The findings included: Resident #46 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During the resident's hospitalization from [DATE] to 09/20/21 she had an above the knee amputation (AKA) of the right leg. Resident #46's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired for daily decision making but could make her needs known. The MDS further revealed she had no rejection of care behaviors, and Resident #46 received scheduled and as needed (prn) pain medication for occasional pain at a level of 4 which was assessed prior to her right AKA. Review of Resident #46's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] extended release (ER) 15 milligram (mg) tablet - take 1 tablet by mouth every 12 hours with maximum daily amount 30 mg. (scheduled at 9:00 AM and 9:00 PM) effective 09/20/21. 2. [MEDICATION(S)] (HCl) tablet 10 mg - 1 tablet by mouth every 8 hours as needed for pain effective 09/28/21. 3. [MEDICATION(S)] Capsule delayed release particles (DRP) 60 mg - give 1 capsule by mouth once daily for [CONDITION(S)] effective 09/06/21. Review of Resident #46's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] extended release (ER) 15 milligram (mg) tablet - take 1 tablet by mouth every 12 hours with maximum daily amount 30 mg. (scheduled at 9:00 AM and 9:00 PM) 2. Oxycodone immediate 10 mg tablet - take 1 tablet by mouth every 4 hours as needed for pain. (An increase from every 8 hours as needed for pain) 3. [MEDICATION(S)] Capsule delayed release particles (DRP) 60 mg - give 1 capsule by mouth once daily for [CONDITION(S)] effective 09/06/21. Resident #46's Care Area Assessment (CAA) summary dated 10/03/21 for pain revealed she recently had a right above the knee amputation (AKA) and had increased pain, due to phantom pain of the right leg. The summary further indicated Resident #46 had verbal behaviors directed at staff related to care and was associated with her increased pain. Resident #46's care plan dated 10/04/21 revealed she had a care plan for pain related to right AKA, chronic pain, and decreased mobility among others. The interventions included assessing resident's pain level every shift, utilize pain scale 0-10, medicate resident as ordered and evaluate effectiveness of pain medication, monitor for non-verbal signs of pain, and document/report any changes in pain characteristics to PA or MD. Review of the MAR for September 2021 and October 2021 revealed the resident ' s pain level was being assessed 2 times per day and the documented ranges were 5 to 10 most shifts and when pain medication was administered the ranges were recorded as 7 to 10 on a scale of 0 to 10. Observation and interview on 10/25/21 at 4:13 PM revealed Resident #46 lying in bed crying and stated her pain level was a 10 on a scale of 1-10. Resident #46 was noted to be moving in her bed trying to find a comfortable position. She stated it was unbearable pain as she pointed to her right AKA. Resident #46 further stated she still had staples in her incision to her right stump and said they were very uncomfortable. Interview on 10/25/21 at 4:30 PM was conducted with Nurse #4 who confirmed she was caring for Resident #46. Nurse #4 was made aware of Resident #46's pain in her right AKA stump and that she verbalized pain on a scale of 10. Nurse #4 stated she would check to see what medication she could administer to the resident. Resident #46's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no entry on the MAR by Nurse #4 that she had given the Oxycodone at 2:00 PM. Review of the narcotic sheets revealed Resident #46 received [MEDICATION(S)] ER 15 mg 1 tablet by mouth at 9:08 AM (as ordered), Oxycodone 10 mg by mouth at 2:00 PM and [MEDICATION(S)] ER 15 mg 1 tablet by mouth at 3:00 PM on 10/25/21. The resident received an extra dose of [MEDICATION(S)] 15 mg 1 table by mouth at 3:00 PM. The resident reported at 4:00 PM her pain level was down to a 4 from a 10. Follow up interview on 10/26/21 at 9:30 AM with Nurse #4 revealed when she checked on Resident #46 ' s medication she had given a dose of Oxycodone at 2:00 PM and the resident was not due for another dose until 6:00 PM because it was ordered every 4 hours as needed for pain. Nurse #4 confirmed she had not notified the PA the resident was having severe pain and had not called the doctor to report the resident's pain. Nurse #4 stated Resident #46 was not still crying with pain when she checked on her yesterday at 4:00 PM and stated the [MEDICATION(S)] seemed to have helped with her severe pain. While observing a medication pass on 10/26/21 at 11:19 AM, another surveyor revealed Resident #46 was screaming out in pain and could be heard in the hallway. Nurse #4 heard the resident screaming and asked, what is that noise? The surveyor explained it was Resident #46 screaming for her pain medication. Nurse #4 administered her pain medication at 11:30 AM. Observation and interview on 10/26/21 at 11:42 AM revealed Resident #46 lying in bed crying with tears running down her face and stated her pain was beyond a 10 and she had just received her 9:00 AM pain medication along with her prn pain medication. Resident #46 stated she had been screaming in pain and begging for her medication since 9:30 AM and had just received it. Resident #46 stated the pain was unbearable. Resident #46 indicated NA #9 had been in to see what she needed and went to let the nurse know she needed pain medication. Interview on 10/26/21 at 12:00 PM with NA #9 revealed she had gone to the 300 hall to find Nurse #4 to let her know the resident needed pain medication around 11:00 AM. NA #9 stated the resident had been complaining of pain for over an hour and she had reported it to Nurse #4. Review of Resident #46's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 10/27/21 at 7:31 AM with Nurse #6 who typically cared for Resident #46 on night shift revealed Resident #46 did have pain sometimes at night but not like during the day. Nurse #6 stated the resident took Trazadone at night for sleep and she typically was able to sleep through the night once she was medicated with her prn pain medication and Trazadone. Review on 10/26/21 at 12:00 PM of Resident #46's narcotic sheets for 10/26/21 revealed at 8:00 AM Resident #46 had received [MEDICATION(S)] ER 15 mg 1 tablet by mouth (as ordered), Oxycodone Immediate 10 mg tablet 1 tablet by mouth at 11:30 AM and [MEDICATION(S)] ER 15 mg 1 tablet by mouth at 11:30 AM. The resident received an extra dose of [MEDICATION(S)] 15 mg 1 tablet by mouth at 11:30 AM. Follow up interview on 10/26/21 at 12:15 PM with Nurse #4 revealed she had given Resident #46 an extra dose of [MEDICATION(S)] ER 15 mg 1 tablet by mouth on 10/25/21 and on 10/26/21. She stated she had given the medication because she had misread the order and thought it said prn (as needed). Nurse #4 further stated Resident #46 was in so much pain she administered the medication to help alleviate her pain. Nurse #4 indicated she had consulted with the Unit Manager about giving the resident another dose of the [MEDICATION(S)] and said the Unit Manager told her she thought the order was prn (as needed), but she needed to verify it before she gave an extra dose. Nurse #4 further indicated she misread the order and gave the extra doses. Interview on 10/26/21 at 1:43 PM with the Unit Manager revealed Nurse #4 should have called the NP or the MD regarding the resident's pain and obtained orders for additional medication or a change in medication. Follow up interview on 10/27/28 at 11:45 AM with the Unit Manager revealed she had spoken with the PA over the phone last evening and obtained new orders for Resident #46's pain medication. She stated the new medications would begin today and they would see how well it worked to manage her pain. Interview on 10/28/21 at 4:26 PM with the PA revealed she had been made aware on 10/26/21 around 8:00 PM of Resident #46's unrelieved pain and had made some changes in Resident #46's medication orders to try to better control her pain. She stated it was difficult to manage her pain and find the right combination of medications that worked for her because of her systemic disease. The PA stated it was a matter of finding the right balance of pain control without causing sedation and affecting her function. She further stated she had changed her pain medications and added [MEDICATION(S)] to help with her phantom pain in her right AKA stump. The new orders given on the evening of 10/26/21 for medications were as follows: 1. [MEDICATION(S)] tablet 10 mg - give 1 tablet by mouth every 8 hours as needed for pain. 2. [MEDICATION(S)] 15 mg tablet - give 1 tablet by mouth every 6 hours as needed for pain. 3. [MEDICATION(S)] capsule 300 mg ([MEDICATION(S)]) - give 1 capsule by mouth at bedtime for pain effective 10/27/21. The PA indicated she would be monitoring Resident #46 to determine the effectiveness of the new orders for her pain medication and to see if the [MEDICATION(S)] helped with her phantom pain in her right leg.

Based on observations, record reviews, resident, and staff interviews, the facility failed to provide sufficient nursing staff for the provision of incontinence care to a resident (Resident #26) who had a bowel movement, failed to provide showers as scheduled for 1 resident (Resident #23) and failed to provide showers or complete bed baths for 1 dependent resident (Resident #46). This affected 3 of 7 residents reviewed for sufficient nursing staff. The findings included: This tag is cross referred to: F550: Based on observation, record reviews, staff interviews, and resident interviews the facility failed to maintain residents' dignity by delaying incontinence care affecting 1 of 1 sampled resident (Resident #26). The resident expressed feeling of being uncomfortable, upset, mad and embarrassed. F561: Based on observations, record reviews, resident, and staff interviews, the facility failed to provide showers for one resident at least two times per week as scheduled for 1 of 3 residents reviewed for choices (Resident #23). F677: Based on record reviews, resident, and staff interviews the facility failed to provide showers or complete bed baths for 1 of 3 residents (Resident #46) reviewed for activities of daily living (ADL) for dependent residents. An interview conducted with Nurse #1 on 10/26/21 at 9:00 AM revealed it was expected for incontinence care to be completed every two hours but took longer due to staffing shortage. Nurse #1 further revealed multiple residents had complained about having to wait for long periods of time for incontinence care due to staffing and the showers were not being completed as scheduled. An interview conducted with Nurse Aide (NA) #4 on 10/26/21 at 2:36 PM revealed in the mornings when she came on shift at 7:00 AM she had to immediately start getting residents out of bed and dressed for the morning meal. She stated one NA went to the dining room and one stayed on the hall with the residents. The interview revealed there was no time for incontinence care rounding prior to breakfast. NA #4 stated it was touch and go getting tasks completed during the day with the number of staff members they had working in the facility. She stated she hadn ' t taken a lunch break yet due to trying to get showers completed on the hall. An interview conducted on 10/27/21 at 7:00 AM with Nurse #3 revealed she always worked on third shift with one other nurse. She stated on 10/26/21 the facility had 2 nurses and 3 NAs to provide care to 58 residents. The interview revealed she had been working since 4:30 PM the previous day because the facility could not find anyone else to come in and needed a nurse. Nurse #3 stated the facility sometimes only had 2 NAs working on the hall during third shift which made it hard for them to get their task completed such as incontinence rounding. An interview conducted on 10/27/21 at 7:15 AM with NA#6 she worked the 7:00 PM to 7:00 AM (third) shift during which showers were scheduled from 7:00PM to 11:00 PM. The interview revealed she was unable to complete those showers due to residents wanting to go to bed, residents wanting snacks and not enough staff to complete all of the tasks. An interview on 10/27/21 at 3:45 PM with NA #8, a first shift NA, revealed there was not always enough staff available to give everyone ' s shower on the days scheduled. An interview conducted on 10/28/21 at 3:27 PM with the Director of Nursing revealed the facility was staffed with two licensed practical nurses (LPN) during the day and they sometimes had a Medication Aide. The DON stated she and the facility transporter were in charge of staffing. She stated the goal for Nurse Aides (NA) during the day was 6 however the facility normally had 4-5 NAs for day shift and 3-4 on night shift. The interview revealed the facility was using agency staffing for nurses and NAs since July 2021 however had been experiencing issues with the agency staff calling out or not showing up. She stated the facility had started a program to train their own NAs and pay for their courses, but staff were leaving once they completed the course. The DON stated the facility could not compete with COVID-19 pay offered by other facilities and had lost a lot of staff since COVID-19. She stated she had received a lot of complaints from NAs due to staffing and not being able to get their incontinence rounding or showers completed. She stated the week before she had given 3 showers herself due to the NAs on the hall not being able to do so. The interview revealed the facility had 2 open Registered Nurse positions, 6 open Licensed Practical Nurse positions, 2-unit manager positions open, two medication aide positions open and several Nurse Aide positions open for day and night shift. She stated the facility was offering incentives for new staff and was hoping this would help. An interview conducted with the Administrator on 10/28/21 at 5:30 PM revealed he did not feel the facility had a staffing issue. He stated they were using agency Nurses and Nurse Aides to assist with staffing and felt the NAs had enough time to complete their assigned task if they used their time wisely.

Based on observations, record reviews, resident, staff and Physician's Assistant (PA) interviews, the facility failed to follow a Physicians order for one of one resident reviewed for [CONDITION(S)] (Resident #6) and one of two residents reviewed for wound care (Resident #56). Findings included: 1. Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's admission Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact requiring extensive assistance of one staff member for most activities of daily living. Resident #6 was coded under special treatments as receiving [CONDITION(S)]. Review of a Physicians progress note dated 9/28/21 revealed Resident #6 was evaluated for chronic conditions such as hypertension and [CONDITION(S)] (GERD). Resident#6's blood pressure was within the goal range and her GERD was stable. The Physician stated he would like her [CONDITION(S)] level monitored every 6 months. Review of an active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Hemodialysis on Tuesday, Thursday and Saturday at 9:45 AM. Review of active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Medication not to be given on [CONDITION(S)] days prior to [CONDITION(S)]. The order was not transcribed to the Medication Administration Record. Review of Resident #6's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication received included: · [MEDICATION(S)] Capsule 125 micrograms once daily for [CONDITION(S)] · Tums 500mg tablet for [CONDITION(S)] (GERD) Resident #6 received the following 9:00 AM medication prior to [CONDITION(S)] on 10/5, 10/7, 10/12, 10/14, 10/16, 10/19, 10/21, 10/23, 10/26, 10/28: · [MEDICATION(S)] 100mg for constipation · [MEDICATION(S)] delayed release 30 milligram capsule for depression · [MEDICATION(S)] 40 mg tablet for GERD · [MEDICATION(S)] 100mg 1 tablet for hypertension · Tums 500 mg tablet for GERD Review of a [CONDITION(S)] communication form dated 10/9/21 revealed they had no recommendations to the facility. Resident #6's blood pressure was 133/55. Review of a [CONDITION(S)] communication form dated 10/26/21 revealed their recommendation was to administer Resident #6's medication as scheduled. Resident #6's documented blood pressure was 198/68 after [CONDITION(S)]. Review of Resident #6's most recent [CONDITION(S)] stimulating hormone (TSH) level dated 11/5/21 revealed her TSH level was 1.41 (normal range 0.45- 5.33). An interview could not be conducted with Nurse #9. She no longer worked in the facility An interview conducted on 10/27/21 at 4:18 PM with Resident #6 revealed some of the nurses had given her medication prior to going to [CONDITION(S)]. She stated the Nurse yesterday morning on 10/26/21 had stopped her and administered her 9:00 medication prior to going to [CONDITION(S)]. The interview revealed Resident #6 was not having any negative effects from receiving her medication prior to [CONDITION(S)]. She stated the facility always provided her with breakfast prior to leaving for [CONDITION(S)] and sent her with a snack because the [CONDITION(S)] facility would not allow the residents to eat lunch there. An interview conducted on 10/27/21 at 4:29 PM with Nurse #7 revealed she had administered Resident #6's prior to [CONDITION(S)] on 10/5/21 because she was able to give the resident her medication first on that day. Nurse #7 stated she was not aware of any orders to not administer her medication prior to [CONDITION(S)]. The interview revealed the order should have been transcribed onto the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview conducted with Nurse #1 on 10/28/21 at 8:34 AM revealed she had administered Resident #6's medication prior to [CONDITION(S)] on 10/7/21, 10/12/21 and 10/25/21. She stated she knew there was an order to not administer Resident #6's medication prior to [CONDITION(S)] however she thought she remembered the resident asking for her medicine, so she decided to give it. An interview conducted on 10/28/21 at 9:10 AM with Nurse #8 revealed she had administered Resident #6's medication prior to [CONDITION(S)] on 10/21/21. She stated she was an agency nurse working in the facility and had stopped Resident #6 in the hallway on her way to leave the building for [CONDITION(S)] and administered her medication. Nurse #8 stated she did not know there was an order to not administer the resident's medication prior to [CONDITION(S)] but she had not checked the resident's orders. An interview conducted on 10/28/21 at 9:34 AM with the Director of Nursing (DON) revealed Resident #6 shouldn't have received any medication prior to going to [CONDITION(S)] per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the order had not been transcribed onto the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview conducted on 10/28/21 at 4:25 PM with the facility Physician's Assistant (PA) revealed she had reviewed Resident #6's medication and agreed the nurses should have held her morning medication on [CONDITION(S)] days because she was getting blood pressure medication and taking that prior to [CONDITION(S)] could cause [CONDITION(S)] (low blood pressure) when the resident came back from [CONDITION(S)]. After reviewing Resident #6's vital signs she stated the resident had not experienced a low blood pressure as a result of receiving the medication prior to [CONDITION(S)] however she stated her expectation was for the nursing staff to follow her orders. The interview revealed Resident #6 was in a stable condition and had experienced no negative outcomes from receiving her medication prior to [CONDITION(S)]. 2. Resident #56 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #56's most recent quarterly minimum data set (MDS) dated [DATE] revealed she was cognitively intact and required one person assistance with dressing, toileting, personal hygiene and bathing. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Clean incision with alcohol daily, may shower. This order was never transcribed to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 10/25/21 at 10:34 AM with Resident #56 revealed she had been at the facility for approximately 3 weeks, resident stated that she had a wound on the back of her neck, and she wears a neck collar. Resident #56 stated that she had no wound care done to her neck since she was admitted . She stated that she had complained about this to the nurses, but no one had done any wound care. An observation on 10/25/21 at 10:56 AM revealed Nurse #4 performing wound care to Resident #56 neck. She wiped the area with an alcohol wipe per physician order. Incision to back of neck was covered with a scab, edges were approximated. No signs or symptoms of infection observed. An interview on 10/26/21 at 11:54 AM with Nurse #4 revealed that she remembered transcribing and entering the order to perform daily wound care to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 10/26/21 at 12:23 PM with the Regional Nurse Consultant revealed he was unaware that Nurse #4 was so overwhelmed with the amount of work assigned to her. He stated that he expects all physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/28/21 at 2:20 PM an interview with the Director of Nursing (DON) was conducted. She stated that she expects the Unit Manager and/or the nurses to transcribe and enter all physicians' orders to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted on 10/28/21 at 4:25 PM with the Physician's Assistant (PA) which revealed that she expected the staff to follow the physician orders. She expected the staff to notify the physician if the orders were not followed. She stated she was unaware that wound care had not been performed until 10/21/21, once she was aware, she initiated another order for the wound care.

Based on record reviews, observations and staff interviews the facility failed to follow CDC guidelines for the use of Personal Protective Equipment (PPE) when 6 out of 6 staff members (Nurse #1, NA #6, NA #3, Speech Therapist, Nurse #4 and Laundry Assistant #1) were observed not wearing eye protection while providing resident care. This occurred during a global pandemic. The findings included: A review of the Centers for Disease Control and Prevention (CD*C) COVID-19 Data Tracker on 10/25/21 indicted the county where the facility was located had a high level of community transmission for COVID-19. The CDC guidance entitled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on 09/10/21 indicated the following information under the section Implement Universal Use of Personal Protective Equipment for HCP (Healthcare Personnel): *If [CONDITION(S)]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP working in facilities located in counties with substantial or high transmission should also use PPE (Personal Protective Equipment) as described below including: Eye protection (i.e. goggles or a face shield that covers the front and sides on the face) should be worn during all patient care encounters. A review of the facility policy entitled, Consulate Healthcare Emergency Procedure - Pandemic COVID-19, revised on 10/04/2021 indicated: 16. Initiate Transmission based precautions per the CDC (Standard, Contact and Droplet) including PPE - respirator, eye protection, gown and gloves. 1. a. Observation on 10/25/21 at 10:36 AM revealed Nurse #1 going into room [ROOM NUMBER]-A to administer morning medications to Resident #158 without eye protection. The nurse was observed within 3 feet of the resident assisting her with medications and providing water for the resident to take her medications. Interview on 10/25/21 at 11:39 AM with Nurse #1 revealed she had not been informed by the Director of Nursing or the Unit Manager she needed to wear eye protection on the general unit while providing medication pass. Nurse #1 stated she would have to find some goggles to wear over her glasses or a face shield. Interview on 10/25/21 at 11:41 AM with the Regional Nurse Consultant revealed the staff on the general unit did not need to wear eye protection, only the staff working on the isolation unit for new admissions. The Regional Nurse Consultant stated he was not aware of the guidelines requiring staff to wear eye protection in counties with high or substantial rate of transmission of COVID-19. Interview on 10/28/21 at 3:16 PM with the Director of Nursing (DON) who is also the Infection Preventionist (IP) revealed she was not aware of the guidelines requiring staff to wear eye protection in counties with high or substantial rate of transmission of COVID-19 until informed on Monday by the Regional Nurse Consultant. b. Observation on 10/25/21 at 10:43 AM revealed Nurse Aide (NA) #6 going into room [ROOM NUMBER] passing ice to Resident #33 without eye protection. The NA was observed within 3 feet of the resident adjusting items on his overbed table to get his cup within his reach. Observation on 10/25/21 at 11:29 AM revealed NA #6 coming out of room [ROOM NUMBER] with bagged dirty linen and trash after providing care to Resident #5 without eye protection. Interview on 10/25/21 at 11:33 AM with NA #6 revealed she had not been informed by the nurse or the DON she needed to wear goggles or a face shield while providing resident care on the general unit. Interview on 10/25/21 at 11:41 AM with the Regional Nurse Consultant revealed the staff on the general unit did not need to wear goggles, only the staff working on the isolation unit for new admissions. The Regional Nurse Consultant stated he was not aware of the guidelines requiring staff to wear eye protection in counties with high or substantial rate of transmission of COVID-19. Interview on 10/28/21 at 3:16 PM with the Director of Nursing (DON) who is also the Infection Preventionist (IP) revealed she was not aware of the guidelines requiring staff to wear eye protection in counties with high or substantial rate of transmission of COVID-19 until informed on Monday by the Regional Nurse Consultant. c. Observation on 10/25/21 at 10:45 AM revealed NA #3 coming out of room [ROOM NUMBER] with bagged linen and trash after completing care for Resident #3 without eye protection. Interview on 10/25/21 at 11:33 AM with NA #3 revealed she had not been informed by the nurse or the DON she needed to wear goggles or a face shield while providing resident care on the general unit. Interview on 10/25/21 at 11:41 AM with the Regional Nurse Consultant revealed the staff on the general unit did not need to wear eye protection, only the staff working on the isolation unit for new admissions. The Regional Nurse Consultant stated he was not aware of the guidelines requiring staff to wear eye protection in counties with high or substantial rate of transmission of COVID-19. Interview on 10/28/21 at 3:16 PM with the Director of Nursing (DON) who is also the Infection Preventionist (IP) revealed she was not aware of the guidelines requiring staff to wear eye protection in counties with high or substantial rate of transmission of COVID-19 until informed on Monday by the Regional Nurse Consultant. d. Observation on 10/25/21 at 11:31 AM revealed the Speech Therapist in room [ROOM NUMBER] interviewing and working with Resident #29 within 3 feet of the resident without eye protection. Interview on 10/25/21 at 11:39 AM with the Speech Therapist revealed she had not been informed by the DON she needed to wear goggles or a face shield while providing care to residents on the general unit. She stated it was her understanding she only needed to wear goggles or a face shield on the isolation unit. Interview on 10/25/21 at 11:41 AM with the Regional Nurse Consultant revealed the staff on the general unit did not need to wear eye protection, only the staff working on the isolation unit for new admissions. The Regional Nurse Consultant stated he was not aware of the guidelines requiring staff to wear eye protection in counties with high or substantial rate of transmission of COVID-19. Interview on 10/28/21 at 3:16 PM with the Director of Nursing (DON) who is also the Infection Preventionist (IP) revealed she was not aware of the guidelines requiring staff to wear eye protection in counties with high or substantial rate of transmission of COVID-19 until informed on Monday by the Regional Nurse Consultant. e. On 10/25/2021 at 11:30 AM observed Nurse #4 passing medications on the 200 hall without wearing a face shield and/or goggles. During an interview on 10/25/21 at 11:40 AM Nurse #4 indicated that she was instructed to only wear eye protection on the 300 hall (which is the isolation hall). She further stated that she was instructed that she did not have to wear eye protection anywhere else in the facility because the pandemic for their area was over. f. An observation on 10/25/21 at 11:40 AM revealed Laundry Assistant #1 going in and out of resident rooms on the 200 hall without eye protection. An interview was conducted on 10/25/21 at 11:38 AM with Laundry Assistant #1. When asked what the facility policy was for wearing eye protection, indicated that she was informed to only wear eye protection when on the 300 hall. On 10/25/21 at 11:47 AM the Director of Nursing (DON) indicated staff wearing eye protection in the facility was mandatory at this time. She further stated that all staff had been instructed at the monthly staff meetings.

Based on observations, staff interviews, resident interview, and record review, the facility failed to place a call light within reach for 1 of 1 resident (Resident #208) reviewed for accommodation of needs. Findings included: Resident #208 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most current Minimum Data Set (MDS) dated [DATE] revealed Resident #208 had moderately impaired cognition. Resident #208 was coded as not having behavioral symptoms or refusing care. Resident #208 required one-to-two-person assistance from staff for bed mobility, transfers, and personal hygiene. Review of the care plan dated 10/20/21 revealed Resident #208 had an activity of daily living (ADL) self-care deficit with a goal identified to maintain her current level of function. The interventions included Resident #208 to use her call bell to call for assistance. On 10/26/21 at 10:48 AM Resident #208 was observed in bed wringing her hands. She was calling out for someone to help her. Resident #208's call bell was observed to the left of her bed, on the floor. Resident stated that her call bell had been on the floor for 2 hours and she could not call for the nurse to inform her that she needed her nerve medication. On 10/26/21 at 11:05 AM observed Resident #208's call bell lying on the floor on the left side of the bed. An interview was conducted on 10/26/21 at 11:06 AM with Resident #208, she stated that she needed help with ambulating and her call bell was lying in the floor. Resident #208 stated that she became extremely anxious once she noticed the call bell was on the floor. An interview was completed on 10/26/21 at 11:20 AM with Nurse Aide (NA) #7. She stated when she delivered Resident #208 breakfast tray she was observed resting in bed and the call bell was within reach. On 10/26/21 at 11:15 AM an interview with Nurse #4 was completed. Nurse #4 stated that she had just gotten to the 300 halls (which is also the isolation hall). Nurse #4 further explained she did not observe Resident #208's call bell placement when she worked with her in the room. On 10/26/21 at 12:23 PM an interview with the Regional Nurse Consultant was completed. He stated he went to Resident #208's room and placed the call bell back onto the bed. He further stated that he clipped the call bell closer to the resident so that it was within her reach. On 10/26/21 at 4:00 PM an interview was completed with the Director of Nursing (DON). The DON stated her expectation of staff would be to ensure that the resident's call bells were within reach.

Based on record review, observations, and interviews with staff and two Health Department staff members, the facility failed to implement the Centers for Disease Control and Prevention (CDC) recommended practices for COVID-19 by not placing enhanced droplet contact precautions signs up and not requiring staff to wear all recommended PPE (Personal Protective Equipment) when caring for 2 of 2 newly admitted residents (Resident #11 and Resident #25) and 1 of 1 readmitted resident (Resident #18) and not cohorting and quarantining on the designated quarantine hall (300 hall) 3 of 15 newly admitted residents (Resident #15, Resident #17 and Resident #19) and 2 of 3 readmitted residents (Resident #16 and Resident #18). Immediate jeopardy began on 6/22/20 when the facility failed to place newly admitted and readmitted residents on enhanced droplet contact precautions and failed to quarantine the newly admitted and readmitted residents on the designated quarantine hall (300 hall). Immediate jeopardy was removed on 7/27/20 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. The findings included: The CDC guideline entitled Responding to Coronavirus (COVID-19) in Nursing Homes last reviewed on 4/30/20 indicated the following statements: * Place signage at the entrance to the COVID-19 care unit that instructs HCP (healthcare personnel) they must wear eye protection and an N95 or higher-level respirator (or facemask if a respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms. * All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (goggles or a disposable face shield that covers the front and sides of the face), gloves and gown. * A single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. * New residents could be transferred out of the observation area or from a single to a multi-resident room if they remain afebrile and without symptoms for 14 days after their last exposure (e.g. date of admission). A review of the facility's COVID-19 Pandemic Plan revised on 6/29/20 indicated the following statements: * Infection prevention and control policies require staff to use Standard, Contact and Droplet precautions, including eye protection - unless otherwise directed by local, state health department. * The center will designate an area and cohort new admissions/readmissions for 14 days. a. The patient will then be moved to a different room/area of the center. b. If the resident's COVID-19 status is unknown (no available test) - resident placed in a private room or cohort with another resident whose status is unknown, initiate transmission-based precautions (standard, contact and droplet) for 14 days. During the entrance conference on 7/20/20 at 8:45 AM, the Administrator indicated the 300 hall was the isolation/dedicated hall for COVID-19. A review of the facility's list of Admissions/Readmissions from 6/17/20 to 7/22/20 indicated: 1. Resident #15 was admitted on [DATE] from the hospital to room [ROOM NUMBER] (private room). 2. Resident #16 was readmitted on [DATE] from the hospital to room [ROOM NUMBER] (private room). 3. Resident #17 was admitted on [DATE] from the hospital to room [ROOM NUMBER] (private room). 4. Resident #11 was admitted on [DATE] from the hospital to room [ROOM NUMBER] (private room on quarantine hall). 5. Resident #18 was readmitted on [DATE] from the hospital to room [ROOM NUMBER] (private room). 6. Resident #25 was admitted on [DATE] from the hospital to room [ROOM NUMBER] (private room on quarantine hall). 7. Resident #19 was admitted on [DATE] from the hospital to room [ROOM NUMBER] (private room). Review of the medical records of the above-listed residents revealed all of them had a negative test for COVID-19 prior to coming to the facility. The medical records further revealed that none of the residents listed above were placed on enhanced droplet/contact precautions when they were admitted or readmitted to the facility. Observations made on 7/20/20 at 12:40 PM, 7/21/20 at 10:15 AM, and 7/22/20 at 9:00 AM on the 100 hall revealed no residents were on transmission-based precautions and there were no PPE supplies available for use outside any resident door. Nurse aide (NA) #4 was observed on 7/20/20 at 12:45 PM wearing a mask and gloves while providing care to Resident #6 on the 100 hall. Observations made on 7/20/20 at 12:40 PM, 7/21/20 at 10:15 AM, and 7/22/20 at 9:00 AM on the 200 hall revealed no residents were on transmission-based precautions and there were no PPE supplies available for use outside any resident door. Nurse #6 was observed on 7/20/20 at 4:05 PM wearing a mask and gloves while administering medications to Resident #7 on the 200 hall. Observations made on 7/20/20 at 12:40 PM, 7/21/20 at 10:15 AM, and 7/22/20 at 9:00 AM on the 300 hall revealed no residents were on transmission-based precautions and there were no PPE supplies available for use outside any resident door. NA #3 was observed on 7/21/20 at 3:00 PM going into Resident #25's room on the 300 hall while wearing a mask. On 7/20/20 at 12:50 PM, Nurse #7 was observed on the 200 hall entering Resident #18's room while wearing a mask and gloves. No signage for any transmission-based precautions was on the door and Nurse #7 did not wear a gown prior to entering the room. On 7/20/20 at 4:09 PM, an interview with Nurse #7 revealed she was aware that Resident #18 had recently been readmitted to room [ROOM NUMBER]. She did not know why Resident #18 was not placed on the 300 hall which was considered the facility's quarantine hall. Nurse #7 stated she only wore a mask and gloves when going inside the room and that a gown was not required because she was not on any transmission-based precautions. On 7/20/20 at 4:24 PM, NA #7 was observed entering Resident #18's room on the 200 hall while wearing a mask. After entering the room, she put on gloves and closed the door. After 5 minutes, NA #7 came out of room [ROOM NUMBER] with a mask on and gloves which she removed and disposed of in the trash bin parked outside room [ROOM NUMBER] in the hallway. NA #7 was further observed using hand sanitizer from a dispenser in the hallway. On 7/20/20 at 4:30 PM, an interview with NA #7 revealed Resident #18 was not on any transmission-based precautions so she had not been wearing a gown prior to entering her room. NA #7 stated she only wore a mask and gloves when she provided personal care to Resident #18. On 7/21/20 at 12:04 PM, a phone interview was conducted with NA #8 who usually worked on the 300 hall and helped out on the first half of the 200 hall. NA #8 confirmed that new admissions went to the 300 hall where they were quarantined for 14 days but they were not placed on any transmission-based precautions. NA #8 stated she only wore a mask and gloves when providing personal care to the residents on 300 hall and that a gown was not required. On 7/21/20 at 1:49 PM, an interview with the Assistant Director of Nursing (ADON) revealed the facility quarantined their new admissions and readmissions for 14 days on the 300 hall. The ADON clarified that quarantine meant the residents were kept inside their rooms for 14 days. She stated that none of the currently admitted and readmitted residents were placed on transmission-based precautions unless they came to the facility with certain medical conditions that required it. They did not put up signs for precautions because they did not require all new admissions and readmissions to be placed on any transmission-based precautions. Staff who provided care to the newly admitted and readmitted residents were only required to wear a mask and gloves. She stated the facility's policy did not specify what to do with incoming residents who had tested negative for COVID-19 prior to coming to the facility. She thought having been tested negative once for COVID-19 was enough to prevent possible transmission of COVID-19. She said she was not sure why some of the newly admitted and readmitted residents were not placed on the 300 hall. On 7/21/20 at 3:27 PM, an interview conducted with the Regional Director of Clinical Services (RDCS) revealed she had questioned the Director of Nursing (DON) about new admissions and readmissions not being placed on transmission-based precautions and she said she was told that these residents had tested negative for COVID-19 at the hospital 48 hours prior to coming to the facility. During the interview, she referred to the facility's COVID-19 Pandemic Plan which did not include directions on what to do for incoming residents who were tested negative for COVID-19 prior to entering the facility. She further stated that they should follow the CDC guidelines and state and local health department directives which they tried to incorporate into the facility's policies. On 7/21/20 at 5:22 PM, an interview conducted with the DON revealed they made sure the newly admitted and readmitted residents were tested negative for COVID-19 within 24 to 48 hours prior to coming to the facility. These residents continued to be screened for COVID-19 by the nurses who checked their vital signs including temperatures at least twice a day and none had exhibited any signs or symptoms of COVID-19. On 7/22/20 at 1:57 PM, a phone interview with Health Department staff member #1 revealed new admissions and readmissions should be placed on droplet precautions using all recommended PPE and quarantined for 14 days even though they did not exhibit any signs or symptoms of COVID-19. They should be placed in a separate unit and away from the general facility population until after 14 days of coming to the facility. She also stated having been tested negative one time for COVID-19 did not guarantee that these residents had not been exposed to COVID-19. She stated she had sent the CDC guideline entitled Responding to Coronavirus (COVID-19) in Nursing Homes to the Administrator on 6/30/20. The CDC guideline entitled Responding to Coronavirus (COVID-19) in Nursing Homes last reviewed on 4/30/20 indicated the following statements: * Place signage at the entrance to the COVID-19 care unit that instructs HCP (healthcare personnel) they must wear eye protection and an N95 or higher-level respirator (or facemask if a respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms. * All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (goggles or a disposable face shield that covers the front and sides of the face), gloves and gown. * A single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. * New residents could be transferred out of the observation area or from a single to a multi-resident room if they remain afebrile and without symptoms for 14 days after their last exposure (e.g. date of admission). On 7/22/20 at 2:42 PM, a phone interview conducted with Health Department staff member #2 revealed the local health department had provided guidance to the facility on [DATE] and that he expected them to quarantine their new admissions and readmissions for 14 days and place them on droplet precautions. This information was provided to the facility due to a call to the Health Department on 6/30/20 when the facility had identified their first staff member who tested positive for COVID-19. On 7/22/20 at 3:27 PM, a follow-up interview with the DON revealed the residents who were newly admitted and readmitted to the facility were tested on ly one time at the hospital prior to coming to the facility. These residents were quarantined for 14 days which meant they were not supposed to go outside of their rooms. Staff who provided care to the newly admitted and readmitted residents were supposed to wear either goggles or face shield, mask and gloves. The DON stated gowns were not required to be worn when providing care to these residents as the use of gowns was not specified in the facility's COVID-19 Pandemic Plan. Since they did not require staff to wear gowns prior to entering the rooms of newly admitted and readmitted residents, they were not readily available outside each room. Gloves were located inside each room and each staff member was provided her own face shield or goggles which were reused after disinfection at the end of the day. The DON further stated that the facility had not stopped accepting admissions even with the COVID-19 pandemic. They had designated the 300 hall for newly admitted residents but the readmitted residents went back to their previous rooms. On 7/22/20 at 4:33 PM, an interview was conducted with the Administrator with RDCS present. The Administrator stated he had reviewed the CDC guidelines which were sent to him by the Health Department staff member and admitted that he had misinterpreted the guidance and thought that a single negative test was enough to consider the resident as not exposed to COVID-19. The Administrator further stated that he was trying to conserve his resources for when there was an outbreak of COVID-19 at the facility. The RDCS stated the corporation had experienced a shortage of supplies such as gowns and face shields and had been trying to share their resources with sister facilities. On 7/23/20 at 2:13 PM, a phone interview with the Administrator revealed the new admissions were supposed to go to the 300 hall so they could be quarantined for 14 days. He stated Resident #15 was admitted to room [ROOM NUMBER] because there were no available rooms on the 300 hall on 6/22/20 and 214 was the only private room available. She was not placed on transmission-based precautions. Resident #17 was admitted to room [ROOM NUMBER] because there were no available rooms on the 300 hall on 7/2/20 and 103 was the only private room available. She was not placed on transmission-based precautions. Resident #19 was admitted to room [ROOM NUMBER] on 7/21/20 because they wanted to separate her from another resident with the same name. She was not placed on transmission-based precautions. Resident #16 and Resident #18 were readmitted back to their original rooms, but they were not placed on transmission-based precautions. The Administrator stated he realized he did not follow the facility's COVID-19 Pandemic policy of cohorting new admissions and readmissions by placing them on other halls aside from the 300 hall and not separated from other residents who had remained at the facility. He was also not sure if the staff member assigned to care for the new admissions and readmissions had cared for other residents at the facility at the same time. The Administrator further stated that he did not think about halting admissions due to lack of space. The Administrator was notified of the immediate jeopardy on 8/13/20 at 1:13 PM. On 8/17/20 at 11:46 AM, the facility provided the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Review of medical records revealed the following admissions and readmissions: On 6/22/20, Resident #15 was newly admitted to the facility into room [ROOM NUMBER]-A. Resident #15 was tested for COVID-19 while in hospital on [DATE], the results were negative. Resident #15 was tested on [DATE] and 8/5/20 in-house, test results were negative. On 6/30/20, Resident #16 was newly admitted to the facility into room [ROOM NUMBER]-A. Resident #16 had a rapid COVID-19 test completed the day of discharge from the hospital on [DATE], the results were negative. Resident #16 was tested on [DATE] and 8/5/20 in-house, test results were negative. On 7/2/20, Resident #17 was newly admitted to 103-A. Resident #17 was tested for COVID-19 while in hospital on [DATE], the results were negative. Resident #17 was tested on [DATE] and 8/5/20 in-house, test results were negative. On 7/10/20, Resident #18 was readmitted back into her private room [ROOM NUMBER]-A. Resident #18 had rapid COVID-19 test completed the day of discharge from the hospital on [DATE], the results were negative. Resident #18 was tested on [DATE] and 8/5/20 in-house, test results were negative. Resident #18 was not moved on 7/21/20 but was placed on enhanced droplet precautions. Enhanced droplet precaution sign was posted on resident's door. Resident #18 transferred out to hospital on [DATE] and readmitted on [DATE] to room [ROOM NUMBER] on the quarantine unit. On 7/21/20, Resident #19 was newly admitted to the facility into room [ROOM NUMBER]-A. Resident #19 was tested for COVID-19 while in hospital on [DATE], the results were negative. On 7/21/20, Resident #19 stayed in private room [ROOM NUMBER]-A and was placed on enhanced droplet precautions, until moved to quarantine unit on 7/23/20 into room [ROOM NUMBER]-A. Resident #19 no longer resides in facility. Resident #19 was discharged from facility to the hospital on [DATE]. Admissions and readmissions #15 on 6/22/20, #16 on 6/30/20, #17 on 7/2/20, #18 on 7/10/20 and #19 on 7/21/20 were monitored for COVID-19 symptoms to include: fever, cough, shortness of breath, sore throat, vomiting, diarrhea, muscle pain, headache, new loss of taste or smell, chills and repeated shaking with chills. However, Residents #15, #16, #17, #18 and #19 were not quarantined for a period of 14 days on the 300 hall, which was the designated hall for new admissions and readmissions to the facility. On 7/21/20 and prior to that date, staff members were wearing surgical masks to care for all residents. However, Residents #15, #16, #17, #18 and #19, at the time of their admission/readmission, had not been placed on enhanced droplet contact precautions (to include staff wearing additional Personal Protective Equipment (PPE) of gowns, gloves and face shields/goggles when having encounters with these residents). On 7/21/20 during visit, a surveyor made the Regional Director of Clinical Services (RDCS) aware of an Infection Control issue involving new admissions and readmissions process. The surveyor expressed concern that new admissions and readmissions were not being quarantined on the designated quarantine hall (300 hall); and not placed on enhanced droplet contact precautions. The Regional Director of Clinical Services immediately posted signage on the 300 hall to communicate enhanced droplet contact precautions for residents who needed to be quarantined, along with the need to wear Personal Protective Equipment when caring for these residents to include enhanced droplet precautions. At that time, RDCS ensured gowns, gloves, masks and face shields/goggles were provided to unit, and initiated education with current staff working on the unit. On 7/21/20, Personal Protective Equipment to include gowns, gloves, masks and face shields/goggles were provided to 300 hall. The nurses and nurse aides were educated at that time to utilize this PPE when caring for newly admitted and readmitted residents by the Director of Nursing. On 7/24/20, Regional Director of Clinical Services reeducated the Administrator, Director of Nursing, Assistant Director of Nursing, Admissions Director and Social Worker on the COVID-19 to include the instruction for residents who are admitted or readmitted to the center as follows: The center will designate an area and cohort new admissions/readmissions for 14 days on 300 hall. a. The patient will then be moved to a different room/area of the center. b. If the resident's COVID-19 status is unknown (no available test) - resident placed in a private room or cohort with another resident whose status is unknown, initiate transmission-based precautions (standard, contact and droplet) for 14 days. Specify the action the entity will take to alter the process of system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. New Admissions, Readmissions and current residents have the potential to be affected by this alleged deficient practice. On 7/21/20, the Director of Nursing and Assistant Director of Nursing reviewed Residents #15, #16, #17, #18 and #19 as well as the current residents on 100, 200 and 300 halls to determine if they needed any precautions. Residents #15, #16 and #17 were beyond the 14-day period of requiring quarantine or enhanced droplet contact precautions and showed no signs or symptoms of COVID-19, nor did other current residents on 100 or 200 halls require quarantine or additional enhanced droplet contact precautions. On 7/21/20, six long-term care residents were identified as residing on the 300 hall. On 7/23/20, the six long-term care residents residing on 300 hall were moved off the unit into rooms on other side of facility to accommodate new admissions and readmissions. The six long-term care residents remained on the 300 hall while the Administrative Team worked on bed management and notification to residents and family. On 7/27/20 and 8/5/20, current residents residing at the center on those dates were tested for COVID-19, and all resident test results were negative to include the six long-term care residents that were on the quarantine hall until 7/23/20. On 7/21/20, the Director of Nursing and the Assistant Director of Nursing initiated staff reeducation to include the following staff: Nursing Department, Therapy Department, Housekeeping Department, Dietary Department and Administrative Team (Social Worker, MDS, Business Office Manager, Human Resource Coordinator, Admissions Director, Medical Records, Activities, Maintenance and Administrator) on Infection Control to include the following: * The center will designate a quarantine unit (300 hall) and cohort new admissions/readmissions whose COVID-19 status is known (negative) or who has been removed from transmission-based precautions prior to admission/readmission for 14 days. * Newly admitted or readmitted residents will be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. * After 14 days of quarantine and if resident is not experiencing symptoms, the resident will then be moved to a different room/area of the facility. * The Director of Nursing will decide when residents are ready to be moved off quarantine unit. The Director of Nursing will consult with the Nurse Practitioner and/or Medical Director before moving residents off quarantine unit. * The facility will make every effort to staff unit with dedicated staff. * Wearing (PPE) mask and face shield/goggles, gowns and gloves * Infection Control to include: process for new admissions and readmissions, enhanced droplet precautions and PPE (donning and doffing). Education will be ongoing; no staff could return to work until they had completed the mandatory education. On 7/24/20, the Nursing Management Team (Director of Nursing and Assistant Director of Nursing) initiated reeducation to staff to include: Nursing Department, Therapy Department, Housekeeping Department, Dietary Department and Administrative Team (Social Worker, MDS, Business Office Manager, Human Resource Coordinator, Admissions Director, Medical Records, Activities, Maintenance and Administrator) on proper use of PPE including competency with return demonstration. Staff will not be allowed to work until they received the mandatory education. Additionally, this education will be provided to all new employees as part of new hire orientation, including contract staff and agency staff. As of 7/27/20, the Center's Pandemic Plan for COVID-19 was revised per CDC guidelines to clarify and include the following: The center will designate an area and cohort new admissions/readmissions whose COVID-19 status is known (negative) or who has been removed from transmission-based precautions prior to admission/readmission for 14 days. (The resident will remain in their room during this time). * Newly admitted or readmitted residents will be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. * The patient will then be moved to a different room/area of the center. 1. The Center will designate an area (Person Under Investigation unit) for residents who: * Upon admission the COVID-19 status is unknown or is awaiting test results * Resident with possible exposure and awaiting test results * Resident with possible signs and symptoms awaiting test results * Place resident in a private room or cohort with another resident whose status is unknown, initiate transmission-based precautions (standard, contact and droplet). The Admissions Director will work in conjunction with the Administrator and Director of Nursing to ensure new admits and readmits are placed on the designated quarantine unit. The Administrator and Director of Nursing will ensure that the residents are quarantined for 14 days. The Director of Nursing will decide when residents are ready to be moved off quarantine unit. The Director of Nursing will consult with the Nurse Practitioner and/or Medical Director before moving residents off quarantine unit. The Central Supply person will ensure PPE is stocked and available on all units. The Admissions Director and/or the Director of Nursing will be responsible for checking if new admits/readmits had a negative test in the hospital or if they were quarantined already 14 days in the hospital. The center Executive Director alleges abatement of immediate jeopardy on 07/27/20. On 08/19/20 at 9:00 AM the facility's plan for immediate jeopardy removal was validated by the following. Review of in-service training records revealed staff from all shifts and all disciplines had been inserviced on 7/21/20 and 7/24/20 regarding designated area for residents admitted and readmitted and COVID-19 positive residents on the 300 hall, proper PPE, donning and doffing PPE with return demonstrations, signage for COVID presumptive and positive residents, signage for 300 hall, clean and dirty rooms on designated COVID hall, testing of residents and staff, quarantine of residents for 14 days for unknown COVID status. Observation of the COVID hall revealed residents admitted /readmitted quarantined and signage present on all doors. Observed clean and dirty rooms and dedicated staff to the unit interviewed. The facility's Pandemic Plan was reviewed and revisions were noted. Long term residents previously on the 300 hall were moved to another hallway. The facility's date of immediate jeopardy removal of 07/27/20 was validated.

Based on record review, staff interviews, family interview, emergency medical services (EMS) interview and nurse practitioner interview the facility neglected to provide nursing and medical services to a resident who was unresponsive. This was for 1 of 1 resident reviewed for neglect (Resident #2). The resident was sent to the emergency room (ER) for evaluation and experienced cardiopulmonary arrest on 4 occasions. Resident #2 passed away at the hospital. The facility failed to protect a resident's right to remain free from sexual abuse for 1 of 3 sampled residents reviewed for abuse (Resident #26). Resident #27 who was cognitively intact was observed in bed with Resident #26 who was a cognitively impaired female resident on [DATE]. On [DATE] Resident #26 was observed sitting in her wheelchair with her hand on Resident #27's genitals. Immediate jeopardy began on [DATE] when Nurse #1 assessed Resident #2 as being unresponsive and failed to provide nursing and medical services for the resident. Immediate Jeopardy was removed on [DATE] when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of G (actual harm that is not immediate jeopardy) due to example #2. Findings included: 1. Resident # 2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The initial nursing assessment dated [DATE], noted Resident #2 to be alert and oriented. Resident #2 had a code status of full code on admission into the facility. Resident #2 required extensive, two-person assistance with most activities of daily living (ADL). Review of nursing note dated [DATE] at 9:35 PM revealed Nurse #1 had written a late entry on the events that had occurred earlier in the day. The note stated Resident #2 was alert and verbally responsive and two Nurse Aides (NA) had assisted the resident up to her Geri-chair using a mechanical lift to assist her with the lunch meal. The NA left the room with Resident #2's lunch tray and later checked on the resident again and called for Nurse #1. At that point Resident #2 was noted to be unresponsive to tactile stimuli, unarousable to sternum rub with some facial grimacing and squeezing of her eyes shut. Resident #2's oxygen saturation level was at 84% on room air and oxygen was applied at 3 liters. The note revealed Resident #2 stopped breathing, no pulse was found, and cardiopulmonary resuscitation (CPR) was initiated by Nurse #1 and Nurse #2. Nurse #3 phoned 911 services and chest compressions were continued until emergency medical services (EMS) arrived and took over. EMS intubated Resident #2 started intravenous fluids and transported Resident #2 to the hospital. On [DATE] at 2:30 PM an interview was conducted with NA #1. NA #1 stated on [DATE] she had met Resident #2's family outside of the building when she arrived to work and told them she would keep an eye out for her during the day. She stated at 11:00 AM on [DATE] she was walking down 300 hall and heard a banging on Resident #2's window. When she entered the room Resident #2 had spit up onto her shirt and around her mouth and her family was outside of the window trying to get the staffs attention. NA #1 cleaned Resident #2 up and assisted her to the bed with help from NA #2. She stated Resident #2 was awake and communicating. NA #1 stated she told Nurse #1 the resident was nauseated and had spit up. Nurse #1 told her to sit the resident up and give her some ginger ale in which Resident #2 refused the drink. At lunch time NA #1 went back into the room to assist Resident #2 with her lunch meal. She stated the resident was alert and able to eat, NA #2 came into the room to finish helping the resident and NA #1 left the room. She stated about ,[DATE] minutes later around 1:00 PM she heard a loud sound coming from Resident #2's room. When she entered the resident's room Resident #2 was in her Geri chair with her mouth wide open making a loud noise. She stated she conducted a sternum rub and called the residents name with no response from the resident. She stated she left the resident's room to get Nurse #1 from 200 hall and when she reentered the resident's room, she discovered the resident was unresponsive. She stated Nurse #1 came to Resident #2's room conducted a sternum rub and wiped the residents face with a cold cloth. Nurse #1 asked NA#1 to get Nurse #2. Nurse #2 went back out of the room to get some items Nurse #1 asked for and Nurse #1 asked NA #1 to obtain vital signs. As NA #1 proceeded to gather her vital sign machine Nurse #2 handed her a needle and told her to take it to Nurse #1. NA #1 stated Resident #2's vital signs were blood pressure ,[DATE], pulse 61, oxygen saturation 84% on room air. NA #1 stated Nurse #1 took the needle from her and proceeded to stick the top, bottom and side of Resident #2's foot around ,[DATE] times in an attempt to gain a response. NA #1 stated she had seen red substance coming from the areas on Resident #2's foot in which Nurse #1 had placed the needle and Resident #2 was still unresponsive with no movement. Nurse #1 instructed NA #1 to get oxygen tubing and Nurse #1 placed oxygen at 2 liters on the resident. NA #1 stated that Nurse #1 told her , this is normal for her she ' s had a stroke I will have to go read her chart she also stated Nurse #1 believed Resident #2 did not have feeling in her body because she experienced a stroke. NA#1 stated that she told Nurse #1 that Resident #2 did have feeling because when she moved her earlier, and the resident complained of pain in her feet. NA #1 stated Nurse #1 left the room and went back to the nurse's station and left her alone with Resident #2. NA #1 stated she never left the resident after her oxygen level had dropped. She stated at 2:00 PM she checked Resident #2's vital signs and found her oxygen saturation level wouldn't read, and Resident #2 was still unresponsive. She stated she then left the resident's room to find Nurse #1 to assess Resident #2. NA #1 stated she found Nurse #1 in the breakroom. NA #1 stated Nurse #1 told her, Of course her oxygen level is dropping she's a mouth breather. NA #1 stated Nurse #1 went outside for a smoke break before returning to the hall to assess Resident #2. She stated when Nurse #1 returned she instructed the NAs to place Resident #2 in the bed so she could do an in and out urinary catheterization. NA #1 stated the residents color had changed a pale gray while in the bed and she stopped breathing. Nurse #1 yelled for another nurse to come to the resident's room and Nurse #2 responded. Nurse #2 stated to Nurse #1, Is she a full code. Nurse #1 stated she thought the resident was a do not resuscitate (DNR). Nurse #2 went to the nurse's station to check and yelled back stating the resident was a full code. Nurse #1 then stated to NA #1 to go get the supervisor Nurse #3 to start chest compressions on the resident. NA #1 stated neither Nurse #1 or Nurse #2 started chest compressions and by the time Nurse #3 got to the room to start compressions the resident's daughter had called EMS and they had arrived at the facility. On [DATE] at 10:00 AM a second interview was conducted with NA #1. NA #1 stated when she had found Resident #2 still unresponsive at 2:00 PM she had notified Nurse #1 who was in the breakroom and told her the resident's oxygen saturation level would not read because she was breathing through her mouth. NA #1 stated she then went to the nurse's station and could not find Nurse #2. She stated at that point she felt desperate and had called Resident #2's family to ask if it was normal for the resident to not respond and had asked them to come to the facility. She stated Nurse #1 and Nurse #2 were outside of the building smoking when she called Resident #2's family to come to the facility. She stated she wished she had just called 911 when she knew something was wrong with the resident instead of waiting on Nurse #1. On [DATE] at 7:30 PM an interview was conducted with NA #2. NA #2 stated she was working on Resident #2's hall on [DATE]. She stated during the morning of [DATE] Resident #2 was alert and oriented. She stated NA #1 wasn't assigned to the 300 hall however kept coming to check on the resident to help her. She stated after lunch around 1:00 PM she was picking up the trays and completing her incontinence rounding when NA #1 came and got her and said Resident #2 was unresponsive. NA #2 stated both she and NA #1 went and told Nurse #1 who stated it was fine and that was normal for Resident #2. She stated Nurse #1 had returned from break and entered Resident #2's room to find the resident unresponsive. She stated when Nurse #1 entered the room she saw her do a sternum rub and use a tool or needle to stick the bottom of Resident #2's feet to attempt to get her to respond, she did not see a red substance coming from the areas in which Nurse #1 had placed the object on Resident #2's foot. She stated Nurse #1 then left the room and returned to the nurse's station. NA #2 stated she, and NA #1 told Nurse #1 two times that something was wrong with Resident #2 from 1:00 PM to 2:30 PM however Nurse #1 never came to the room to assess the resident. She stated the resident's daughter was then at the window stating something was wrong with her mother, because she wouldn't respond at 2:30 PM. She stated she ran to get Nurse #1 who didn't know whether the resident was a DNR or full code and Nurse #2 had to check the resident's chart. She said the resident's daughter called 911. She stated Nurse #1 nor Nurse #2 started chest compressions. They asked NA #1 to go get the supervisor Nurse #3 to start compressions, when Nurse #3 arrived, she completed 5 minutes of compressions before the EMS arrived. NA #2 stated they had told Nurse #1 for 2 hours something was wrong with Resident #2, but she did not come down the hall to assess the resident. She stated she was on the hall the entire time and never saw Nurse #1 in the room prior to when the resident was coding. She stated Nurse #1 couldn't even tell the story of what had happened to EMS when they arrived. On [DATE] at 10:23 AM an interview was conducted with Nurse #1. She stated she was responsible for Resident #2 on [DATE]. The interview revealed Resident #2 had stated to her around 11:00 AM she was nauseated, and she instructed NA #1 to get the resident a ginger ale to drink in which the resident refused. She stated after lunch she did not recall the NAs coming to her to tell her the residents vital signs had been obtained and her oxygen level was low. She stated the NAs never came to the break room to get her. Nurse #1 then stated after lunch on [DATE], but could not recall a specific time, she had obtained vital signs herself and noticed Resident #2's oxygen saturation level was low; she asked the NAs to move her to the bed and she applied oxygen but could not recall what the residents oxygen saturation level was. She stated Resident #2's oxygen level dropped quickly, and her objective was to get the resident stable and out of the facility. She stated she then checked the residents blood pressure and pulse in which she was unable to obtain. Nurse #1 stated she ran out of the room to get Nurse #2 to verify code status of the resident and get the crash cart. Nurse #2 verified code status as full code and when the two got back to the room Nurse #3 was in the room checking Resident #2's pulse and began compressions. Nurse #1 stated she was using the ambu bag when EMS arrived after being called by the resident's daughter who was at her window. She stated she could not recall exact times of when the incident occurred however it was only a matter of minutes from the time the resident was unresponsive until action was taken by the two nurses. She stated she never used a needle or any other object to stick or poke the resident's feet when she found her unresponsive. On [DATE] at 10:34 AM a second interview was conducted with Nurse #1. She stated she did recall the NAs coming to her after lunch stating Resident #2's oxygen level was low because she had placed supplemental oxygen on the resident at 2 liters. She stated she did not notify the Physician after placing Resident #2 on supplemental oxygen due to a low oxygen saturation level nor did she notify the residents family of the change in condition. The interview revealed she normally would have but on [DATE] the resident declined so quickly she did not have a chance to call either of them. On [DATE] at 6:00 PM an interview was conducted with Nurse #2. She stated on [DATE] Nurse #1 came down the 100 hall where she was working to get her because Nurse #1 had a resident who was unresponsive. She stated she looked up the resident's code status for Nurse #1 which was full code. When she entered the room Resident #2 was unresponsive with her eyes glazed over. NA #1, NA #2, Nurse #1, and Nurse #3 were in the room. The interview revealed the supervisor Nurse #3 had initiated compressions roughly 5 minutes prior to EMS arriving. She stated she had heard NA #1 tell Nurse #1 the residents oxygen level was low earlier in the day but could not recall a specific time and Nurse #1 had the NAs lay the resident down in the bed. She stated she had not gone into Resident #2's room prior to when the resident was coding and had not seen Nurse #1 sticking the resident's foot with a needle. On [DATE] at 5:31 PM an interview was conducted with Nurse #3. She stated she had just gotten back to the nurse's station from taking the residents who smoke outside of the building. Smoking time was at 1:30 PM. The interview revealed she saw NAs going into Resident #2's room so she walked down the hall to see what was going on. She stated when she walked into the room, she saw Nurse #1 trying to get a blood pressure and pulse on Resident #2. Nurse #2 asked if she would try and find a pulse. Nurse #3 stated she tried to find a pulse but immediately saw Resident #2 was not breathing and could not find a pulse. She stated she heard someone say the resident was a full code and started chest compressions. The interview revealed neither Nurse #1 or Nurse #2 started compressions or used the ambu bag. Nurse #3 stated she performed two rounds of compressions until EMS arrived. Nurse #3 stated she believed Nurse #1 had not started chest compressions because she was waiting on a second opinion. On [DATE] at 10:00 AM an interview was conducted with Resident #2's family member. She stated on [DATE] at 8:00 AM she had called the facility and spoke with Nurse #1 regarding how Resident #2 had faired through the night. She stated Nurse #1 told her she did not know and that she would text the third shift nurse and ask her. She stated the third shift nurse had replied stating the resident had done well but hadn't worn her continuous positive airway pressure ([MEDICAL CONDITION]) much during the night. She stated the family visited Resident #2 around 9:30 AM until 11:00 AM that morning through the window and Resident #2 was alert and talking. Around 11:12 AM she stated they noticed Resident #2 coughing and saying, help me. The resident began gagging, coughing and yelling to help her. The family began beating on the windows of the facility in order to gain staff's attention. NA #1 entered the room and cleaned the resident up wiping her face. The family member stated Nurse #1 entered the room shortly after and they asked Resident #2 if she wanted to get up in her Geri chair for lunch, she stated she left the facility at 12:00 PM before lunch to go home. Around 2:20 PM she received a phone call from another family member stating NA #1 had called them and had asked if Resident #2 was hard to wake up, when the family member replied no NA #1 directed the family to come to the facility quickly. She stated at 2:28 PM she arrived at the facility to find Resident #2 lying in bed with supplemental oxygen on, unresponsive and no staff members in the room. She stated she picked up her phone to dial 911 then saw NA #1 run into Resident #2's room, open the window and stated to her to call 911 at 2:34 PM. She stated Nurse #1 entered the room and attempted to pull the blinds down to block her view of Resident #2 however the family member told her to stop. The interview revealed she did not see any nurses performing CPR or a crash cart in the room. She stated once EMS arrived Nurse #1 pulled the blinds down so she could no longer see into the room and Resident #2 was taken to the hospital shortly after. She stated she felt Resident #2 had experienced a change of condition after lunch and the family wasn't notified by Nurse #1 nor had the Nurse called 911 in a critical situation. Review of the 911 communications call log dated [DATE] revealed one phone call was placed at 2:34 PM requesting assistance at the facilities location. The 911 communications log confirmed the one call was placed by the residents family member. On [DATE] at 1:00 PM an interview was conducted with EMS responder #1. He stated when he arrived at the facility on [DATE] at 2:40 PM he observed an upset woman standing outside of the facility which he later learned was Resident #2's family member. The interview revealed when entering Resident #2's room he observed 2 staff members doing chest compressions and nobody using an ambu bag to ventilate the resident. He stated he grabbed a ventilation mask and threw it to the two staff members and asked them to put it on the resident immediately. EMS found a femoral pulse however Resident #2 was not breathing so they intubated the resident. He stated a staff member (unsure of their title) told him Resident #2 was found at 2:15 PM lethargic and placed in bed in a supine position with oxygen applied. EMS responder #1 stated if a resident is in respiratory distress the last thing that should have been done was place them in a supine position. Review of hospital records revealed Resident #2 was taken to the Emergency Department (ED) on [DATE] at 2:40 PM. She was intubated by EMS prior to her arrival in the ED. Resident #2 experienced cardiopulmonary arrest on 4 occasions while in the ED and was pronounced deceased around 6:20 PM on [DATE] in the hospital. On [DATE] at 4:12 PM an interview was conducted with the Director of Nursing (DON). He stated Nurse #1 had notified him of the situation on [DATE] that Resident #2 was awake and alert at lunch time however she had been asked to come back to the room by NA's at 2:00 PM to find the resident unresponsive. Nurse #1 had told him she checked the residents code status, initiated CPR and called 911. The interview revealed NA#1 had told him she tried to notify Nurse #1 earlier in the day on [DATE] that something was wrong with Resident #2. The DON stated he expected the nurses to check the residents code status and immediately call for assistance if a resident was experiencing a critical episode. Nurses were expected to conduct CPR until EMS services arrived. He stated he had conducted an in-service on CPR and code status on [DATE] related to the incident following reopening of the investigation. On [DATE] at 3:44 PM a second interview was conducted with the DON. The interview revealed if a resident had previously not had an order for [REDACTED]. On [DATE] at 3:35 PM an interview was conducted with the Nurse Practitioner. The interview revealed she had concerns of the facility accepting care of residents who were too acute for the staff to care for. She stated regarding a change of condition in a resident requiring the use of supplemental oxygen she would want the nurse on duty to notify her immediately after identifying the need for oxygen and assess the resident. She also stated the practice of using a needle to poke an unresponsive patients' foot was unacceptable. The Administrator was notified of the Immediate Jeopardy on [DATE] at 5:30 PM. On [DATE] at 1:19 PM the facility provided the following credible allegation of Immediate Jeopardy removal. F600- Free from Abuse and Neglect Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On [DATE] around 10:55 am Resident's #2 family member arrived to facility. Nurse Aide (NA) #1 arrived around 10:55 am for her scheduled shift and was approached by Resident #2's family member before entering the facility for her scheduled shift. Resident#2's family member asked NA#1 to help un-cover Resident's #2 arms since she is unable to do so herself. NA#1 arrived to Resident's #2 room shortly after clocking into work and assisted Resident #2 with un-covering her arms and ensuring she was comfortable. Resident #2 stated she was comfortable but not feeling well. At 11:05 AM Resident #2's family member banged on the window a few minutes after NA#2 exited the room. Nurse #1 arrived in the room. Resident #2's family member stated Resident #2 was throwing up. Nurse #1 stated Resident #2's head was elevated in the bed and did not notice any sign of her throwing up. Nurse#1 instructed NA#1 and NA#2 to assist Resident#2 into a Geri chair and to sit up. Nurse#1 offered Resident#2 a ginger ale to help if she was nauseous. Resident#2 declined the ginger ale. At around 11:45 AM Resident #2's family member left the facility. At 12:30 PM NA#1 assisted feeding Resident#2. NA#1 held a conversation with Resident#2 the entire duration of the meal. Resident #2 stated she was not very hungry but would eat her salad. NA#1 stated, she was eating fine just slow, she told me she had always ate and chewed slowly. No complaint of nausea made. After lunch around 1:00 PM NA#2 picked up lunch trays and was completing incontinence rounds when NA #1 came and got NA #2 and said Resident #2 was unresponsive. Both NA#1 and NA #2 reported to the Nurse #1 change in condition. Nurse #1's response was it is fine that is her normal. Nurse #1 did not go to Resident #2 ' s room. Around ,[DATE] minutes later NA #1 entered Resident #2's room, Resident #2 was sitting up in geri-chair with eyes closed and mouth open. NA#1 called Resident #2's name several times and conducted a sternum rub with no response. NA #1 attempted to get a response by rubbing a cool washcloth on her face. Resident #2 did not respond. Around 1:10pm Nurse#1 was notified Resident#2 was unresponsive. Nurse #1 went to Resident #2's room. Vital signs obtained; O2 saturation 84% at Room Air. Oxygen applied and Resident #2 assisted to bed. Nurse #1 left the room while Resident#2 was unresponsive. At 2:00 PM NA #1 checked Resident #2's vital signs which her oxygen saturation level wouldn't read and was still unresponsive. NA #1 went to find Nurse #1 who was in the breakroom. NA #1 asked Nurse #1 to come assess Resident #2. Between 2:00 PM to 2:30 PM Nurse #1 came to Resident #2's room and instructed NA #1 and NA #2 to assist the resident back to bed. During time in Resident #2's room, Nurse #1 yelled for Nurse #2 to check Resident #2's chart to determine code status. Nurse #2 went to nurse's station to check and yelled back stating Resident #2 was a Full Code. Nurse #1 asked NA #1 to get the Nurse Supervisor (Nurse #3). Nurse #3 was returning into facility from taking out residents to smoke. Nurse #3 stated she saw Nurse Aides (NA #1 and NA #2) going into Resident #2's room so Nurse #3 walked down the hall to see what was going on. When Nurse #3 entered the room Nurse #1 was trying to get a blood pressure and pulse on Resident #2. Nurse #3 tried to obtain pulse but immediately saw Resident #2 was not breathing and could not find a pulse. Nurse #3 heard another nurse state Resident #2 is a full code. Nurse #3 started compressions until EMS arrived. Also, during the 2:00 PM to 2:30 PM time Resident #2's family member arrived at the facility to see Resident #2 with oxygen on in the bed. Resident #2's family knocked on the window to find resident unresponsive. Resident #2's family member called 911 at 2:34 PM. At 2:38 PM EMS arrived and took over chest compressions. Pulse obtained, but resident was still unresponsive. Resident #2 was intubated. Resident #2 left facility with EMS and was transferred to Atrium Health Lincoln. Resident #2 expired at the hospital on [DATE]. Based on the investigation Nurse #1 failed to notify Physician/Nurse Practitioner and Responsible Party of change in condition. Nurse #1 did not notify anyone to include the Physician and Responsible Party that Resident #2 was unresponsive. The Nurse#1 also failed to respond timely to resident having an acute episode. On [DATE] DHHS in facility for Complaint Survey. On [DATE] during visit a surveyor made Regional Director of Clinical Services and Administrator aware of an allegation of abuse/neglect for Resident #2. The Administrator submitted a 24-hour report for allegation of abuse/neglect and suspended Nurse#1. Law enforcement was also notified. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. Current residents have the potential to be affected by this alleged deficient practice. On [DATE] the facility Social Worker conducted resident interviews of all interviewable residents (BIMS greater than 8) to ensure free from abuse and neglect. Any negative findings will be addressed immediately according to the facility abuse and neglect policy and reported to the appropriate agencies. On [DATE], the Regional Director of Clinical Services completed a review of current residents Code Status to ensure accurate to include: physician's orders [REDACTED]. Any issues identified were addressed. On [DATE], current resident skin assessments completed by Registered Nurse, no new issues noted. On [DATE], current resident assessments were completed by a Registered Nurse to ensure the following was in place for any change in conditions identified, no new changes in condition noted. · Family/Responsible Party Notification · Physician Notification · Physician order [REDACTED].>· Appropriate documentation (SBAR/progress note if indicated) · Interventions to prevent further changes and /or worsening of · Appropriate Care Plan and Nursing Assistant Kardex On [DATE], the Regional Director of Clinical Services educated the Nurse Managers (Director of Nursing and Assistant Director of Nursing) regarding Abuse and Neglect, Notification of a Change of Condition, How to Identify and Respond/Manage a change in condition and Code Status/Code Blue to include recognition and response to include the following: The nurse must notify the Attending Physician and Resident Representative as soon as possible when the resident has a change in condition. For acute change in condition stay with resident, do not leave resident unattended. Take appropriate actions by following physician orders. Reassess resident call physician back and follow MD orders that may include to transfer resident out to hospital. Nurses and Certified Nursing Assistants to report on change in residents ' condition during shift change. In the event of an emergency situation, 911 to be called and the attending physician and the Resident Representative to be notified as soon as possible. The nurse to complete an evaluation of the Patient/Resident. Document evaluation in the medical record. Document resident/patient change in condition on 24 Hour Report CNAs must notify licensed nurse with any change in condition. If nurse does not respond or take action CNA is to report concern to another nurse/house supervisor and/or call DON immediately. Upon discovering, or being made aware of, an unresponsive resident: One nurse to stay with resident at all times and another staff member to bring chart to resident ' s room to verify Code Status (2 Nurses) at bedside. Initial approach to a full code resident to follow CPR training May include: - Verbal stimulus to rouse resident - Gentle shaking of shoulders to rouse resident - Sternal rub to rouse resident WILL NOT include: - Poking the feet with a needle - Using any object to poke or prod any body part - Using any other stimuli that may reasonably be expected to cause damage to the body Only nurses will perform CPR, other staff may: o Call 911 o Open door of facility for responders o Bring chart to Nurse for review o Bring crash cart to Code Blue Education was initiated by the Nurse Managers (Director of Nursing and Assistant Director of Nursing) on [DATE] and will be on-going, no staff will return to work until they have completed the mandatory education on abuse and neglect and notification of change in condition. This education will be provided to all new employees as part of new hire orientation, contract staff and agency staff, this education will be provided prior to starting work. All staff currently working will be educated on abuse and neglect immediately. On [DATE], the Nurse Managers then initiated education with licensed nurses regarding Abuse and Neglect, Notification of a Change of Condition, How to Identify and Respond/Manage a change in condition and Code Status to include recognition and response to include the following: Abuse and Neglect policy reviewed with staff to include education timely response to resident's change in condition. The nurse must notify the Attending Physician and Resident Representative when the resident has a change in condition. For acute change in condition stay with resident, do not leave resident unattended. Take appropriate actions by following physician orders. Reassess resident call physician back and follow MD orders that may include to transfer resident out to hospital. Nurses and CNAs to report on change in residents ' condition during shift change. In the event of an emergency situation, 911 to be called and the attending physician and the Resident Representative to be notified as soon as possible. The nurse to complete an evaluation of the Patient/Resident. Document evaluation in the medical record. Document resident/patient change in condition on 24 Hour Report CNAs must notify licensed nurse with any change in condition. If nurse does not respond or take action CNA is to report concern to another nurse/house supervisor and/or call DON immediately. Upon discovering, or being made aware of, an unresponsive resident: One nurse to stay with resident at all times and another staff member to bring chart to resident ' s room to verify Code Status (2 Nurses) at bedside. Initial approach to a full code resident to follow CPR training May include: Verbal stimulus to rouse resident Gentle shaking of shoulders to rouse resident Sternal rub to rouse resident WILL NOT include: Poking the feet with a needle Using any object to poke or prod any body part Using any other stimuli that may reasonably be expected to cause damage to the body Only nurses will perform CPR, other staff may: o Call 911 o Open door of facility for responders o Bring chart to Nurse for review o Bring crash cart to Code Blue On [DATE], the Nurse Managers then initiated education with Certified Nursing Assistants regarding Abuse and Neglect, Notification of a Change of Condition, How to Identify and Respond/Manage a change in condition and Code Status to include recognition and response to include the following: