**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. Resident #5 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction, hemiplegia affecting right dominant side, heart failure. The nurse aide care card identified to check Resident #5 for incontinence on rounds and wash, rinse and dry perineum, change clothing as needed after incontinence episodes and encourage Resident #5 to participate with ADLs as able. The quarterly MDS dated [DATE] identified Resident #5 had severely impaired cognition, required total assistance with toilet use, and was always incontinent of urine and stool. Review of the nurse aide flowsheet dated 8/19/21 on the 3:00 PM - 11:00 PM shift identified toilet use (incontinent care) activity did not occur. The August 2021 nurse aide flowsheet failed to reflect complete documentation for all shifts. The care plan dated 8/11/21 identified Resident #5 has bladder incontinence related to confusion, impaired mobility, inability to communicate needs, and physical limitations. Interventions included to check for incontinence on rounds. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes. Interview with RN #3 on 9/2/21 at 5:36 PM identified on 8/19/21 he was notified by LPN #9 and NA #14 that 9 residents were found soaked, saturated, and soiled with urine or feces when rounds were made at the beginning of the 11:00 PM - 7:00 AM shift. Interview with NA #14 on 9/3/21 at 6:05 PM identified on 8/19/21 at the beginning of the 11:00 PM - 7:00 AM shift during her round she observed Resident #5's bed linens were saturated with urine, so she provided Resident #5 a bed bath and changed the bed linen. NA #14 indicated after she provided care to Resident #5, she notified LPN #9 and RN #3 that Resident #5 was soiled and saturated and left in a urine-soaked bed. Interview with LPN #9 on 9/7/21 at 8:57 AM identified when she made round on 8/19/21 at the beginning of her shift on the 11:00 PM - 7:00 AM she and NA #14 observed Resident #5 bed linens were saturated with urine, and NA #14 provided Resident #5 with a bed bath and changed the bed linen. LPN #9 indicated she notified RN #3 that Resident #5 bed was soiled and saturated and left in a urine-soaked bed. Interview LPN #9 on 9/7/21 at 9:00 AM identified after care was provided to Resident #5, she and NA #14 made round and observed a total of 9 residents that were saturated and soiled with urine or feces. 10. Resident #23 was admitted to the facility on [DATE] with diagnoses that include transient cerebral ischemic attack, hemiplegia left nondominant side, and cognitive deficits following cerebral infarction. The nurse aide care card identified to offer Resident #23 the bed pan/commode every 2 hours. The quarterly MDS dated [DATE] identified Resident #23 had intact cognition and required supervision with toilet use and was always continent of urine and stool. The care plan dated 6/22/21 identified Resident #23 has an ADL self-performance and mobility deficit related to deconditioning left sided weakness. Interventions failed to reflect how peri-care was provided. Review of the August 2021 nurse aide flowsheet identified toilet use activity did not occur. Additionally, documentation was incomplete for all shifts. Interview LPN #9 on 9/7/21 at 9:00 AM identified after care was provided to Resident #5, she and NA #14 made round and observed a total of 9 residents that were saturated and soiled with urine or feces. Resident #23 and his/her bed linens were saturated with urine, so she provided Resident #23 a bed bath and changed the bed linen. Interview with LPN #9 on 9/7/21 at 8:57 AM identified Resident #23 and the bed linen was saturated with urine. LPN #9 indicated NA #14 provided Resident #23 with a bed bath and changed the bed linen. 11. Resident #32 was admitted to the facility on [DATE] with diagnoses that include severe morbid obesity due to excess calories, mild cognitive impairment, Alzheimer's disease. The nurse aide care card identified to offer Resident #32 to the toilet at 3:00 AM rounds. Instruct Resident #32 to use bed pan for toileting. The care card failed to reflect how resident uses the toilet during the day and evening. The quarterly MDS dated [DATE] identified Resident #32 had moderately impaired cognition, required extensive assistance with toilet use and was frequently incontinent of urine and stool. Review of the August 2021 nurse aide flowsheet identified Resident #32 was continent. The flowsheet failed to reflect complete documentation for all shifts. The care plan dated 8/19/21 identified Resident #32 had an ADL self-care performance and mobility deficit related to impaired cognition and deconditioning. Interventions included to encourage the resident to assist in ADL performance to promote independence. The care plan failed to reflect interventions related to continence and toilet use. Interview with NA #14 on 9/3/21 at 6:05 PM identified on 8/19/21 when she arrived for the 11:00 PM - 7:00 AM shift, Resident #32 and his/her bed linens were saturated with urine. NA #14 identified Resident #32 placed him/herself into the wheelchair and propelled him/herself to the nurse's station. Resident #32's brief was saturated with urine which left a trail of urine on the floor from the residents room to the nurse's station. NA #14 indicated she provided Resident #32 a bed bath and changed the bed linen. Interview with LPN #9 on 9/7/21 at 8:57 AM identified Resident #32 was completely soaked/saturated in urine. LPN #9 indicated Resident #32 came to the nurse's desk and a trail of urine followed him/her from the room to the nurse's desk. NA #14 provided Resident #32 with bed bath and linen change. 12. Resident #35 was admitted to the facility on [DATE]/18 with diagnoses that included dementia, macular degeneration and anxiety disorder. The nurse aide care card identified Resident #35 was incontinent: check for incontinence on rounds. Wash, rinse, and dry perineum. Change clothing as needed after incontinence episodes. The physician's order dated 6/28/21 directed to provide extensive assistance for ADL's. The care plan dated 6/29/21 identified Resident #35 has bladder incontinence related to confusion, dementia, impaired mobility, inability to communicate needs. Interventions included to check for incontinence on rounds. Wash, rinse, and dry perineum. Change clothing as needed after incontinence episodes. The quarterly MDS dated [DATE] identified Resident #35 had severely impaired cognition, required extensive two-person physical assistance with toilet use, and was frequently incontinent of urine and stool. Review of the general note from e-record dated 8/20/21 at 4:35 AM identified Resident #35 was found to be laying in a completely soaked bed. Brief was soaked and breaking down, leaving the little beads all over the resident. Resident #35's labia was reddened. Resident #35 had dried feces on buttocks. After Resident #35 was cleaned and complete bed change was done, Resident #35 was in tears when thanking NA #14. Interview with NA #14 on 9/3/21 at 6:05 PM identified on 8/19/21 during the 11:00 PM - 7:00 AM shift, Resident #35 and his/her bed linens were saturated with urine and dried feces on buttocks. NA #14 provided Resident #35 a bed bath and changed the bed linen. Interview with LPN #9 on 9/7/21 at 8:57 AM identified Resident #35 and the bed linen was saturated with urine and dried feces to buttocks. LPN #9 indicated NA #14 provided Resident #35 with a bed bath and changed bed linen. 13. Resident #39 was admitted to the facility on [DATE] with diagnoses that include dementia without behavioral disturbance, depressive episodes, bipolar disorder. The nurse aide care card identified to check Resident #39 for incontinence on rounds. Wash, rinse, and dry perineum. Change clothing as needed after incontinence episodes. The quarterly MDS dated [DATE] identified Resident #39 had severely impaired cognition, required extensive assistance with toilet use, and was frequently incontinent of urine and always incontinent of stool. The care plan dated 7/6/21 identified Resident #39 has bladder incontinence related to confusion, impaired mobility. Interventions included check for incontinence on rounds. Wash, rinse, and dry perineum. Change clothing as needed after incontinence episodes. Interview with NA #14 on 9/3/21 at 6:05 PM identified on 8/19/21, during the 11:00 PM - 7:00 AM shift, Resident #39 and his/her bed linen was saturated with urine and Resident #39 had a large bowel movement. NA #14 provided Resident #39 with a bed bath and changed the bed linen. Interview with LPN #9 on 9/7/21 at 8:57 AM identified Resident #39 and the bed linen was saturated with urine and Resident #39 had a bowel movement. LPN #9 indicated NA #14 provided Resident #39 with a bed bath and changed bed linen. 14. Resident #40 was admitted to the facility on [DATE] with diagnoses that include seizures, acute myocardial infarction, atrial fibrillation, mild cognitive impairment. The nurse aide care card failed to reflect how to provide toilet use or incontinent care for Resident #40. The physician's order dated 7/2/21 directed Resident #40 requires assistance of 2 staff for ADL's. The quarterly MDS dated [DATE] identified Resident #40 had severely impaired cognition, required extensive two-person physical assistance with toilet use, and was frequently incontinent of urine and stool. The care plan dated 7/13/21 identified Resident #40 has an ADL self-care deficit related to limited mobility. Interventions failed to reflect the delivery of care regarding toilet use and incontinence. Review of the general note from e-record dated 8/20/21 at 7:01 AM identified Resident #40 was found sitting in his/her wheelchair fully cloth, with johnny gown in his/her lap. Resident #40 was completely soaked. Resident #40 indicated to staff they handed me my johnny gown, turned off the light and walked out the door and I did not see them since. Interview with NA #14 on 9/3/21 at 6:05 PM identified Resident #40 was found in the room on 8/20/21 at 12:30 AM sitting in the wheelchair fully clothed with pants and shirt in the dark with the door closed. Resident #40 was holding on to a johnny gown in his/her hand and Resident #40 indicated the girls said that they were coming back and gave him/her the johnny gown and they never came back. Resident #40 was saturated in urine and feces. NA #14 indicated she provided care to the resident and she did not have to change the bed linen because the resident was in the wheelchair. Interview with LPN #9 on 9/7/21 at 8:57 AM identified Resident #40 was sitting in his/her wheelchair on 8/20/21 at 12:30 AM with johnny coat on his lap in the dark with the room door closed. Resident #40 indicated they gave me the johnny coat and said they will come back, and they did not come back. NA #14 provided Resident #40 with care and put him/her to bed. 15. Resident #47 was admitted to the facility on [DATE] with diagnoses that include vascular dementia without behavioral disturbance, glaucoma, chronic obstructive pulmonary disease. The nurse aide care card identified for Resident #47 failed to address toilet use and incontinent care. The care plan dated 4/15/21 identified Resident #47 has an ADL self-care performance and mobility deficit related to dementia. Interventions included to assist with ADL's and mobility. Interventions failed to reflect how to provide toilet use and incontinent care. The quarterly MDS dated [DATE] identified Resident #47 had severely impaired cognition, required extensive assistance with toilet use, and was always incontinent of urine and stool. The physician's active order dated 8/1/21 directed that Resident #47 requires assistance with ADL's. Interview with NA #14 on 9/3/21 at 6:05 PM identified on 8/20/21 during the 11:00 PM - 7:00 AM shift, Resident #47 was found with his/her bed linen saturated with urine. NA #14 provided Resident #47 a bed bath and changed the bed linen. Interview with LPN #9 on 9/7/21 at 8:57 AM identified Resident #47 and the bed linen was saturated with urine. LPN #9 indicated NA #14 provided Resident #47 with a bed bath and changed the bed linen. 16. Resident #53 was admitted to the facility on [DATE] with diagnoses that include catatonic schizophrenia, bipolar disorder, malignant neoplasm of breast. The nurse aide care card identified Resident #53 requires extensive assistance for ADL'S, transfer and to toilet with no device. The quarterly MDS dated [DATE] identified Resident #53 had severely impaired cognition, required extensive two-person physical assistance with toilet use, was frequently incontinent of urine and always incontinent of stool. The August 2021 physician's orders directed to assist with ADL's. The care plan dated 8/9/21 identified Resident #53 has bladder incontinence related to impaired mobility, and confusion. Interventions included to offer to toilet on rounds. Review of the August 2021 flowsheet identified toilet use (incontinent care) activity did not occur. The flowsheet failed to reflect complete documentation. Interview with NA #14 on 9/3/21 at 6:05 PM identified during the beginning of the 11:00 PM - 7:00 AM shift, Resident #53 was found with his/her bed linen saturated with urine, and that the urine was dripping off the bed onto to the floor. NA #14 provided Resident #53 a bed bath and changed the bed linen. Interview with LPN #9 on 9/7/21 at 8:57 AM identified Resident #53 and the bed linen was saturated with urine. LPN #9 indicated NA #14 provided Resident #53 with a bed bath and changed the bed linen. 17. Resident #63 was admitted to the facility on [DATE] with diagnoses that include dementia without behavioral disturbance, congestive heart failure, cardiomegaly. The nurse aide care card identified to offer Resident #63 to the toilet on rounds. The care plan dated 7/21/21 identified Resident #63 has bladder incontinence related to confusion, impaired mobility. Interventions included for Resident #63 to use toilet on rounds. The quarterly MDS dated [DATE] identified Resident #63 had severely impaired cognition, required extensive assistance with toilet use and was frequently incontinent of urine and stool. The August 2021 physician's orders directed to provide assistance with ADL'S. Review of the general note from e-record dated 8/20/21 at 5:40 AM identified Resident #63 was found at the beginning of the shift soaked lying in bed. Interview with NA #14 on 9/3/21 at 6:05 PM identified at the beginning of the 11:00 PM - 7:00 AM shift on 8/19/21, Resident #63 was found in a urine saturated bed. NA #14 provided Resident #47 a bed bath and changed the bed linen. Interview with LPN #9 on 9/7/21 at 8:57 AM identified Resident #63 and the bed linen was saturated with urine. LPN #9 indicated NA #14 provided Resident #63 with a bed bath and changed the bed linen. Interview with RN #2 on 9/2/21 at 5:05 PM identified she worked on 8/19/21 during the 3:00 PM -11:00 PM shift and was not aware that 9 residents had not been provided incontinent care. RN #2 indicated she did make round on the C wing but did not go into the resident rooms. RN #2 indicated it is the responsibility of the nurse aides to provide incontinent care and put residents to bed. If the resident refuses care, the nurse aide is to report it to the charge nurse. RN #2 indicated she was not notified of any issues on C wing. Interview with the Administrator on 9/3/21 at 1:00 PM identified she was made aware of the allegation of neglect which occurred during the 3:00 PM - 11:00 PM shift on 8/19/21 when she came in on the morning of 8/20/21. The Administrator identified the 11:00 PM - 7:00 AM supervisor had left a list of 9 residents under her door which indicated that incontinent care had not been provided to the residents by the 3:00 PM -11:00 PM staff. Additionally, that care was provided by NA #14 during the 11:00 PM - 7:00 AM shift. The Administrator indicated that she placed the list on her desk and went to morning meeting followed by running an errand for the facility picking up antigen test supplies and then indicated it slipped her mind. The Administrator indicated the expectation of the facility is that all residents are treated with respect, dignity, and incontinent care should have been performed by the 3:00 PM - 11:00 PM shift. Interview with the DNS on 9/3/21 at 4:55 PM identified she did not work on 8/20/21 and was not aware of the allegation of neglect. The DNS indicated the expectation of the facility was that all residents are treated with respect, dignity, and good customer service. Interview with LPN #2 on 9/7/21 at 11:50 AM identified she worked on 8/19/21 on the 3:00 PM - 11:00 PM shift on C wing. LPN #2 indicated she was not aware of that 9 resdients had not been provided incontinent care. LPN #2 indicated she had sufficient nurse aides on the unit on 8/19/21 during the 3:00 PM - 11:00 PM shift on C wing. LPN #2 indicated it is the responsibility of the nurse aide to make rounds and provide incontinent care and put residents back to bed. LPN #2 indicated she can't remember that day specifically. LPN #2 identified that she was directed to inform the nurse aides on the wing to complete the documentation on all resident flowsheets, even if they were not assigned to the residents. Review of the incontinent care policy identified incontinent care will cleanse the perineum, help prevent skin breakdown, and prevent odors and infections. Incontinent care will be provided to any resident who is incontinent of bowel and/or bladder by the CNA. Frequency of incontinent care will be determined by the interdisciplinary team. The procedure may be performed in the bathroom or while the resident is in bed. Review of the abuse and neglect policy identified residents have the right to be free from abuse, corporal punishment, involuntary seclusion, and psychosocial harm. Resident will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Neglect - any failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness. Reporting mechanism: Facility in-house reporting - whenever there is a witnessed or alleged report of a resident abuse action, as defined above, the following is initiated. The Administrator or on-call designee and Director of Nursing Services are to be notified immediately. Review of the resident rights policy identified all resident have rights guaranteed to them under Federal and State laws and regulations. Each resident has the right to be treated with dignity and respect. All activities and interactions with residents by any staff, temporary agency staff or volunteers must focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident's, goals, preferences, and choices. When providing care and services, staff will respect each resident's individuality, as well as honor and value their input. Right to perform facility services or refuse. The facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Each resident will be treated with dignity and respect. The facility failed to ensure incontinent care was provided in a timely manner and was failed to ensure that Resident #5, 23, 32, 35, 39, 40, 47, 53, 63 were free from neglect during the 3:00 PM - 11:00 PM shift. 18. Resident #79 was admitted to the facility on [DATE] with diagnoses that included severe morbid obesity, reduced mobility, anxiety disorder and major depressive disorder. Review of the May 2021 physician's orders directed to transfer Resident #79 via a mechanical lift with the assistance of 3 staff as the resident is unable to ambulate. Additionally, the orders identified Resident #79 requires the assistance of 2 staff (extensive assistance) for upper/lower body dressing, and toilet transfers and limited assistance for personal hygiene. Review of the weight's summary dated 5/18/21 identified Resident #79 weighed 402.1 lbs. The quarterly MDS dated [DATE] identified Resident #79 had intact cognition, required extensive two-person physical assistance with toilet use and extensive one-person physical assistance with personal hygiene. Additionally, the MDS indicated Resident #79 was always continent of urine. The care plan dated 6/2/21 identified Resident #79 had a self-performance and mobility deficit related to deconditioning and weakness. Interventions included to encourage the resident to participate in ADLs to promote independence. The care plan did not address how staff should provide assistance regarding Resident #79's bowel and bladder needs. Review of the nurse aide care card directed to record bowel movement pattern each day (describe the amount and consistency). The nurse aide care card did not address how staff should provide assistance regarding Resident #1's bowel and bladder needs. Interview with Resident #79 on 8/16/21 at 1:05 PM identified that usually when he/she rings the call bell, it takes the nurse aides 40 minutes to an hour to answer. Resident #79 indicated that sometime in June 2021, during the 11:00 PM - 7:00 AM shift, he/she needed help and rang the call bell for approximately 4 hours, but the staff did not answer or come to his/her room. In another incident, Resident #79 indicated recently, after returning from a hospitalization, during an 11:00 PM - 7:00 AM shift, the resident rang the call light because he/she had to urinate. Resident #79 could not remember the exact time but was also yelling for help. The staff on the night shift never came into his/her room to help or provide care so he/she had to urinate in the bed and lay in it. Resident #79 indicated that when the 7:00 AM - 3:00 PM shift arrived, the nurse aide answered the call light a little after 7:00 AM. Resident #79 indicated at that time, NA #1 provided care and the resident reported to NA #1 that he/she had been ringing for help since 5:00 AM and had been laying in urine because no one came to help. Resident #79 indicated he/she lays in bed waiting for staff to answer the call bell, it happens all the time, it goes on all the time. The resident stated he/she many times has had to urinate right in his/her bed and lay in the urine, screaming for help because no one comes, and he/she indicated the bed gets cold because it's wet. The resident indicated he/she has had to call 911 in the past when staff don't answer the call bell. The resident indicated he/she rings for the bedpan and will urinate on the bedpan, but if no one comes, he/she has no choice and cannot hold it, so will urinate in the bed. If staff answer his/her call light in a timely manner, he/she uses the bed pan. Interview with Resident #4, (Resident #79's roommate), on 8/16/21 at 1:12 PM identified he/she does not remember the exact date but does remember an incident when he/she was woken up by Resident #79 screaming for help at approximately 5:00 AM. Resident #4 indicated the night shift did not come to answer the call bell or come in the room to help Resident #79. It wasn't until the day shift arrived that Resident #79 received help. Interview with NA #1 on 8/16/21 at 1:30 PM identified she does not remember exactly the day or date, but it happened when Resident #79 came back from the hospital recently. NA #1 indicated when she came in at 7:00 AM, Resident #79's light was ringing, and she answered the call light. NA #1 indicated Resident #79 was crying and stated that the nurse aide (lady) on the night shift did not provide care. NA #1 indicated Resident #79 and his/her bed and linens were saturated with urine, so she provided Resident #79 a bed bath and changed the bed linen. NA #1 indicated after she provided care to Resident #79, she notified RN #2 and LPN #1 of Resident #79's complaint that the night shift had not provided care and that Resident #79 was soiled and saturated and left in a urine-soaked bed. Interview with LPN #1 on 8/16/21 at 3:47 PM identified he is the regular nurse on the B unit and assigned to Resident #79. LPN #1 indicated he does not remember NA #1 reporting to him that Resident #79 was complaining about the night shift not answering the call light or providing the resident the bed pan, and subsequently the resident soiled and saturated the bed with urine. LPN #1 indicated that one time during the day shift, he does remember an incident when Resident #79's family member called the facility and reported that if someone does not go into the resident room to provide toileting assistance that he/she was going to call 911. Interview with RN #4 on 8/16/21 at 4:00 PM identified she does not remember NA #1 informing her that Resident #79 complained that the night shift did not provide care during the shift and that the resident was left in a urine-soaked bed. Interview with Social Worker #1 on 8/17/21 at 9:53 AM identified she was not aware of the resident's complaint regarding the night shift not providing him/her with care during the night. Interview with the Former DNS on 8/17/21 at 2:05 PM identified she was not aware of the alleged complaint by Resident #79 that the 11:00 PM - 7:00 AM shift did not provide care for 2 hours and that the resident was left in a urine soaked bed. Review of the nurse's notes dated 7/1/21 through 8/16/21 failed to reflect the facility addressed Resident #79's alleged complaint to NA #1 that the night shift (11:00 PM - 7:00 AM shift) did not provide the bed pan after the resident rang the call light at approximately 5:00 AM, until NA #1 came in on the day shift, (7:00 AM - 3:00 PM shift) and NA #1 provided care, a little after 7:00 AM, 2 hours. Review of the bowel/bladder, nursing policy identified to establish a nursing care plan on an individualized basis for bowel/bladder retraining, continence management, for incontinence management. Review of the abuse and neglect policy identified residents have the right to be free from abuse, corporal punishment, involuntary seclusion, and psychosocial harm. Resident will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Neglect - any failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness. Reporting mechanism: Facility in-house reporting - whenever there is a witnessed or alleged report of a resident abuse action, as defined above, the following is initiated. The Administrator or on-call designee and Director of Nursing Services are to be notified immediately. The facility failed to ensure Resident #79, who was alert, oriented and continent, was free from neglect during the 11:00 PM - 7:00 AM shift, when staff did not provide assistance with toilet use when requested, and subsequently the resident urinated in the bed, was left in a urine saturated bed and found in a urine saturated bed by the day shift over 2 hours later. Based on observation, review of clinical records, facility documentation, interviews, and policies, for six (6) of sixteen (16) residents, who required total assistance with bathing, incontinent care, and repositioning, (Resident #60, #27, #44, #4, #77, and #17), the facility neglected to provide the necessary care resulting in Immediate Jeopardy, and for one of three residents reviewed for abuse (Resident #45), the facility failed to ensure that the resident was free from abuse. Additionally, for 9 residents (Resident #5, 23, 32, 35, 39, 40, 47, 53, 63) who were not provided incontinent care on 8/19/21 during the 3:00 PM - 11:00 PM shift, the facility failed to ensure the residents was free from neglect. And for 1 resident (Resident #79), who rang the call bell for over 2 hours during the 11:00 PM - 7:00 AM shift without a response, the facility failed to ensure the resident was free from neglect. The findings include Please Cross Reference F 725 The findings include: 1. Resident #60's diagnoses included dementia with behavioral disturbances. The MDS dated [DATE] identified the Resident had severe cognitive impairment, required limited assistance of one staff for toilet use, occasionally incontinent of urine and frequently incontinent of bowel. The RCP dated 8/1/21 identified the Resident had an ADL deficit related to Dementia. Interventions included assist with ADL's as needed. On 9/4/21 at 12:35 PM during tour of C wing, Resident #60 was observed placing a plate of food in the top drawer of the dresser. Upon surveyor inquiry, NA #6 stated, oh s/he always does that. NA #6 was observed to remove the plate of food from the dresser drawer. At 12:38PM, the commode near R #60's bed was soiled with feces including the floor. The Resident was observed with visible feces on his/her hands. NA #6 was heard to say to the LPN on the unit, in the presence of the Administrator, the Resident needs to be cleaned and we need housekeeping. Observation at 12:55 PM noted NA #6 walking down the hallway and reported to the nurse she was going to lunch. Interview at that time with NA #6 stated that she did not provide care to the Resident because s/he's not my Resident and she (NA #6) needed to go to lunch. The NA further stated that she was going to tell the Resident's Aide when she found her, that Resident #60 needed incontinent care. The facility failed to provide care to the Resident for at least seventeen (17) minutes although numerous staff members were aware the Resident was incontinent and had feces on his/her hands. Interview with the Administrator and LPN #3 on 9/4/21 at 12:55 PM stated NA #6 should have provided care to the Resident when s/he was observed with feces on his/her hands. After surveyor inquiry, the NA #6 was instructed to provide incontinent care to the Resident and then suspended pending investigation. Interview with the Administrator and DON on 9/5/21 at 2:00 PM stated that although they removed NA #6 from the schedule, they had not yet started the investigation related to neglecting to provide care to Resident #60. 2. On 9/4/21 during a tour of the facility starting at 11:45 AM, the following was observed: On the A wing- 15 of the 26 Residents were observed in bed, B wing- 8 of 33 Residents were observed in bed, and on the C wing- 12 of the 33 Residents were observed in bed. Interviews with the staff on the units during tour stated some Residents prefer to stay in bed until after lunch and they were doing the best they could. On 9/4/21, the facility submitted an action plan to the Department to address the care needs of the Residents. The facility identified that the Supervisor would conduct rounds on Residents every two (2) hours to ensure timely care was provided and the Charge Nurses were to assist with rounds on the units. 3. Resident #27's diagnoses included altered mental state and dementia. The annual MDS dated [DATE] identified the Resident had moderately impaired cognition, total dependence on staff for toilet use, extensive assistance with personal hygiene, and frequently incontinent of bowel and bladder. The RCP dated 6/30/21 identified the resident had bowel and bladder incontinence related to impaired cognition and mobility. Interventions included offer toileting on rounds. On 9/5/21 at 10:30 AM, Resident #27 was observed lying in b[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #37 was admitted to the facility on [DATE] with diagnoses that included epilepsy with seizures, acute and chronic respiratory failure, heart failure, hypertension, orthostatic hypotension. The annual MDS dated [DATE] identified Resident #37 had intact cognition, was always continent of bowel and bladder and required supervision with toileting. Additionally, the resident required extensive assistance for dressing and limited assist for personal hygiene. The Occupation Therapy note dated 4/13/21 indicated Resident #37 had a raised toilet seat/commode for transfers and toileting. The reportable event form dated 5/8/21 at 2:30 PM indicated Resident #37 was in the bathroom and caught his/her left outer lower leg on the raised toilet seat. A laceration noted which was Y shaped measuring 4.0 cm x 2.5 cm x 0.4cm wound. The laceration was from the raised toilet seat front knob. Blood was noted all over it and the leg was caught on it causing laceration. Interventions included the raised toilet seat to be changed and a pressure dressing applied to Resident #37's leg and ice until transferred to hospital for stitches. The care plan indicated the intervention to have maintenance change the raised toilet seat in bathroom, on maintenance book to be done on Monday 5/10/21. The APRN note dated 5/8/21 at 8:37 AM noted Resident #37 had a left leg open area due to knob on the raised toilet seat with large amount of blood noted. Resident #37 was on Eliquis and area looks deeply impacted. Send resident to the emergency room for further evaluation. The nurses note dated 5/8/21 at 6:54 PM noted Resident #37 returned from the hospital with 9 stitches to the laceration of the left outer lower leg. Attempted to call emergency room because no information on stitches or tetanus shot on discharge paperwork. The nurses note dated 5/8/21 at 7:02 PM indicated put in maintenance book to have raised toilet seat removed and another one reapplied due to knob in front caused laceration. The hospital discharge paperwork dated 5/8/21 indicated Resident #37 went to the emergency room for a laceration to the left lower leg. An interview with the Administrator on 9/15/21 at 9:00 AM indicated she did not recall if she went and looked at the raised toilet seat that caused the laceration to Resident #37's leg. An interview with the Director of Maintenance on 9/15/21 at 9:40 AM indicated he did not have any of the maintenance logs prior to 7/21/21. The DOM indicated he was not at the facility in May 2021. Interview with DNS #2 on 9/15/21 at 9:45 AM indicated she did recall the incident. DNS #2 indicated she did not see the raised toilet seat until after it was changed. DNS #2 indicated the supervisor informed her there was something very sharp on the leg of the raised toilet seat that caused the laceration and the supervisor told her she put in the maintenance book to have it changed. DNS #2 indicated the first raised toilet seat was like a commode with legs but the new one was just the plastic that screws onto the top of the toilet. DNS #2 indicated she did not ask the DOM at that time to see the commode because all she cared was that it had already been changed. Interview with RN #2 on 9/15/21 at 10:00 AM indicated she did remember looking at the raised toilet seat that was like a commode with metal legs over the toilet and on one of the legs where there was a bolt, it had a very sharp edge, and there was blood on it so she knew that was where Resident #37 had received the laceration to his/her left lower leg on the outside. RN #2 noted the bolt stuck out and was not covered and was not flush. RN #2 indicated she sent Resident #37 to the hospital and he/she returned with 9 stitches. RN #2 indicated she put it in the maintenance book, but she removed it with maintenance later on that shift and maintenance put a new raised toilet seat on. 3. Resident #79 was admitted to the facility on [DATE] with diagnoses that included severe morbid obesity, reduced mobility, anxiety disorder and major depressive disorder. Review of the May 2021 physician's orders directed to transfer the resident via a mechanical lift with the assistance of 3 staff. Review of the weight's summary dated 5/18/21 identified Resident #79 weighed 402.1 lbs. The quarterly MDS dated [DATE] identified Resident #79 had intact cognition, and transfer activity occurred only once or twice during the reference period. Additionally, the MDS identified transfers occurred with 2 person plus physical assistance. The care plan dated 6/2/21 identified Resident #79 had a self-performance and mobility deficit related to deconditioning and weakness. Interventions included to encourage the resident to participate in ADLs to promote independence. The care plan failed to reflect the physician's order for transfers via mechanical lift with the assistance of 3 staff. Review of the nurse aide care card failed to reflect that the resident required the assistance of 3 staff during mechanical lift transfers. Interview with Resident #79 on 8/16/21 at 1:05 PM identified that sometime in May 2021, during a mechanical lift transfer from the bed to the wheelchair, with NA #1 and NA #23, the lift tilted to the side with the resident in it and the nurse aides had to struggle to keep the resident from falling onto the floor in the lift. Resident #79 indicated he/she was upset that the incident happened and was scared because he/she thought that he/she was going to fall onto the floor. Resident #79 indicated that during the incident they were all screaming as the nurse aides were trying to get him/her into the wheelchair. Resident #79 indicated that both nurse aides are small and short and during the incident, the lift hit the resident in the head. Resident #79 indicated that the nurse aides could have gotten really hurt. Both nurse aides had to struggle to keep the resident from falling onto the floor in the lift. Resident #79 indicated he/she landed in the wheelchair in a slouching position. Resident #79 indicated after the incident, NA #23 was pinned in back of the wheelchair against the wall, and the lift flipped backwards and fell onto NA #1 and she got hurt. Resident #79 indicated NA #1 and NA #23 started yelling for LPN #1. Resident #79 indicated LPN #1 came into the room and helped to reposition him/her properly in the wheelchair and help the 2 nurse aides. Interview with Resident #4 on 8/16/21 at 1:12 PM identified he/she was in the room and witnessed the incident with Resident #79 when the mechanical lift tilted, and the 2 nurse aides got hurt. Resident #2 indicated the incident happened in May 2021. Resident #4 indicated the privacy curtain was not pulled for privacy and he/she could see everything that happened. Resident #4 indicated NA #1 and NA #23 were getting Resident #79 out of the bed with the lift and when NA #1 started turning the lift around to put Resident #79 into the wheelchair, the lift tilted and both nurse aides were doing their best to prevent Resident #79 from falling and to get him/her into the wheelchair. Resident #2 indicated the 2 nurse aides managed to get Resident #79 into the wheelchair, but NA #23 got pinned between the back of the wheelchair and the wall, and the tilted lift fell on NA #1. Both nurse aides started yelling for help. Interview with NA #1 on 8/16/21 at 1:30 PM indicated she was not aware that Resident #79 required the assistance of 3 staff with mechanical lift transfers and indicated the nurse aide care card did not reflect that information. NA #1 indicated on 5/28/21 she and NA #23 were transferring Resident #79 from the bed to the wheelchair in the lift, and the lift tilted. NA #1 indicated she and NA #23 tried as hard as they could to prevent the lift from fully tipping over and to get the resident into the wheelchair. NA #1 identified she was afraid that Resident #79 would land on the floor. As they turned the lift toward the wheelchair, it tilted, and she and NA #23 did everything they could to prevent Resident #79 from falling onto the floor in the lift and to get the resident into the wheelchair safely. When they managed to place the resident into the wheelchair, NA #23 got pinned behind the wheelchair and the wall, and the mechanical lift fell on NA #1. NA #1 indicated she and NA #23 started yelling for LPN #1. LPN #1 came into the room to help properly position Resident #79 into the wheelchair. Both nurse aides were doing everything possible to prevent the resident from falling on the floor as the lift was tilted. NA #1 indicated it is the facility policy to have 2 nurse aides at all times when the mechanical lift is being used on a resident. Interview with NA #23 on 8/16/21 at 3:26 PM identified that a couple of months ago, she and NA #1 were transferring Resident #79 from the bed to the wheelchair via a mechanical lift and indicated they are required to have 2 staff members when using the mechanical lift. NA #23 indicated she was not aware that Resident #79 needed the assistance of 3 staff with transfers using the mechanical lift. NA #23 indicated the 600-pound capacity mechanical lift was used, the resident was properly position on the lift pad, and the base was opened. As the resident was being transferred to the wheelchair, the lift tipped over. NA #23 was positioned in back of the wheelchair guiding the resident into the wheelchair. NA #23 identified when the lift tipped, Resident #79 fell into the wheelchair and NA #23 was pinned between the wheelchair and the wall. Both she and NA #1 started screaming for help. NA #23 indicated Resident #79 was crying and cursing during and after the incident. Interview with LPN #1 on 8/16/21 at 3:47 PM identified he was aware of the mechanical lift incident involving Resident #79. LPN #23 indicated he heard yelling and he ran into Resident #79's room and observed Resident #79 slouching in the wheelchair. LPN #1 indicated he assessed Resident #79 but failed to document the assessment in the clinical record and failed to notify the physician, APRN or the conservator of the incident. LPN #1 indicated Resident #79 did not fall or was injured, and that was why he didn't document the incident in the clinical record or notify the physician or the conservator. LPN #1 indicated the 2 nurse aides did get hurt. Interview with RN #4 on 8/16/21 at 4:00 PM identified she was aware of the incident on 5/28/21 with Resident #. RN #4 indicated Resident #79 did not fall on the floor and was not injured and that is why she did not complete a reportable event form. RN #4 indicated she assisted in helping to properly position Resident #79 in the wheelchair after the incident. RN #4 indicated she assessed Resident #79 but did not document the assessment or notify the physician or conservator. RN #79 indicated she was not aware of the physician's order to have 3 staff transfer Resident #79 with mechanical lift and was not aware that the nurse aide care card did not include that information. Interview with the Former DNS on 8/17/21 at 2:05 PM identified she was on vacation when the incident happened and indicated she would have expected RN #4 and LPN #1 to assess Resident #79, document the incident in the clinical record and complete a reportable event form. Interview with the Director of Physical Therapy on 8/17/21 at 2:42 PM indicated he was not aware of the incident with the mechanical lift on 5/28/21. The Director of Physical Therapy indicated the nursing department did not notify the rehabilitation department and identified the rehabilitation department recommend that Resident #1 have the assistance of 3 staff during mechanical lift transfers. Interview with MD #2 on 8/17/21 at 4:06 PM identified the facility did not notify her of the mechanical lift incident that took place on 5/28/21 with Resident #79 but she would have expected to be made aware even if the resident was not injured. MD #2 indicated the facility staff should have followed the order that directed to provide the assistance of 3 staff with mechanical lift transfers. Review of the mechanical lift procedure policy identified the mechanical lift will be used to transfer patient/resident for whom manual transfer is not recommended. Because of mechanical lift models may vary in weight capacity, check the manufacture's specifications before attempting patient/resident transfer. Make sure the bed and wheelchair wheels are locked before beginning the transfer. Always have two people to perform this procedure; one to operate the lift and one to observe and reassure the patient/resident. The facility failed to provide 3 staff during a mechanical lift transfer on 5/28/21 with Resident #79. Subsequently, there was an incident in which the lift tilted with the resident in it and he/she was hit in the head with the lift, and 2 nurse aides were injured. Based on observation, review of clinical records, facility documentation, interviews, and policies, for one of three residents at risk for elopement, (Resident #45), the facility failed to provide the necessary supervision when the resident was left unattended outside by staff on two occasions resulting in a finding of Immediate Jeopardy. In addition, the facility failed to check the placement and function of the resident's wander guard in accordance with facility policy. Additionally, for 2 of 7 residents (Resident #37 and 79) reviewed for accidents, the facility failed to ensure a safe environment resulting in injury. The findings include: The findings include: 1. Resident #45 had a diagnosis of an intracranial hemorrhage and encephalopathy. Review of the State of Connecticut court of probate paperwork dated 5/28/21 identified that the resident had been involuntarily conserved due to inability to make decisions even with appropriate assistance and was unable to meet essential requirements for personal needs. A quarterly Minimum Date Set dated 6/21/21 identified that the resident had severe cognitive impairment, required limited assist with activities of daily living, and required supervision with locomotion while in a wheelchair on and off the unit. A nurse's note dated 7/4/21 at 3:49 PM identified that the resident was sitting at the front door and when the door opened the resident bolted through the door and the staff were unable to stop him. A nurse's note dated 7/13/21 at 11:01 AM identified that the resident was able to remove the wander guard, two (2) wander guards were found in the Resident's drawer, and the wander guard was moved to the underside of the resident's wheelchair. A care plan dated 7/14/21 identified that the resident was an elopement risk with repeated attempts to exit the building, and has a history of cutting the wander guard off with interventions that included distracting the resident from exit seeking behavior, staff to sit with the resident while outside, and a wander guard which will be checked for placement twice a shift, and function will be checked daily. A nurse's note dated 7/17/21 at 6:31 PM identified that the resident had wheeled past a family member who was coming into the building, and was able to exit the building, the resident was yelling that h/she was going home and proceeded in the wheelchair to the end of the sidewalk . A nurse's note dated 7/21/21 at 3:46 PM identified that the resident packed up belongings and then attempting to get out the locked front door, h/she was positioned at the front door waiting for a staff or visitor to enter the facility so h/she could get out the door. The resident had attempted to enter the code into the door lock unsuccessfully. A nurse's note dated 7/28/21 at 8:32 PM identified that the resident wanted to go outside after dinner, it was explained to the resident that someone needed to be with h/her, and that someone would go out with h/her around 6:00 PM. At 5:45 PM the resident was observed climbing out of the window in the dining room, and only had one foot inside the building. A nurse had gone outside and was able to steady the resident so h/she would not fall. The resident was difficult to redirect and sat in the middle of the road for 15 minutes. The resident was subsequently placed on one to one supervision until psychiatric services could evaluate h/her. Psychiatric services made some medication changes, determined that the resident was not a threat to self or others and the one to one was discontinued. A nurse's note dated 8/12/21 at 7:10 PM identified that the resident asked to go outside, and h/she was told it would be a minute or so. The resident immediately became aggressive then opened the window in the dining room, but did not go out the window, was redirected and then taken to sit on the secured patio outside of B wing (the secured patio is surrounded by a white fence). a. A nurse's note dated 8/26/21 at 6:25 PM written by Registered Nurse (RN) #2 identified that the resident was observed in the back of the building and found in a rut by the C wing exit door. The resident stated that h/she left the unsecured patio area in the front of the building because h/she wanted to go for a ride. It was explained to the resident that it was a safety issue because there was a hill on the property which put him/her at risk for injury. The resident refused to come back into the building and was left sitting in front of the glass door on the unsecured patio by RN #2 . Interview with RN #2 on 9/8/21 at 1:16 PM identified that she was the nursing supervisor on 8/26/21 and was alerted by a Nurse Aide (NA) that the resident was out on the sidewalk by the C wing door. RN #2 immediately ran to the area and helped the resident to get h/her wheelchair out of the rut. The resident refused to go back inside, therefore; the Supervisor placed the resident in front of the glass door so h/she could be seen by the Receptionist. RN #2 identified that she was uneasy leaving the resident outside, however, she was told by Administration that it was OK if the Receptionist watched the resident. Interview with Receptionist #1 on 9/6/21 at 6:00 PM stated that she let Resident #45 out onto the unsecured patio in front of the building on 8/26/21 and on that particular day there were many residents out front therefore she was not able to maintain the resident in her line of vision. Receptionist #1 stated that she left the front desk area to use the bathroom and when she came back she was notified that the resident had been found on the sidewalk in front of the C wing exit door. The Receptionist identified that she is not required to find coverage for her breaks, and although she knew that she was supposed to watch the resident and was aware that the resident wore a wander guard device, she was not aware that the resident was an elopement risk. Interview with the Director of Nurses on 9/6/21 at 6:30 PM identified that the resident gets agitated at times when he cannot go outside, and does not like to sit on the secured patio, therefore, the resident is allowed to sit outside on the unsecured patio in front of the building as long as the receptionist is at the front desk and can supervise h/her. However, on 8/26/21 the resident was out on the unsecured patio in front of the building and not in the direct line of sight of the Receptionist as h/she should have been. The DON identified that the receptionist should have placed the resident where she could see h/her and alerted a staff member if she needed to go on a break to provide coverage for the supervision of Resident #45 . b. On 9/6/21 at 4:08 PM, the surveyor observed Resident #45 in his/her wheelchair on the front patio of the facility unsupervised. As the surveyor entered the building the resident followed the surveyor through the front door and the wander guard alarm sounded, there were no staff readily visible upon entry into the building. Interview with the Director of Nurses on 9/6/21 at 4:20 PM verified that the resident did have a wander guard on and was an elopement risk. The DON further stated that the resident was usually let outside to sit in the front of the building and the Receptionist watches the resident through the glass door. (Receptionist was not present at the time of the observation). The DON identified that the resident must have been let outside by a staff member because a code must be entered into the keypad to allow the door to open and silence the alarm. The DON was unable to identify which staff member allowed the resident to sit outside unsupervised. Interview with Receptionist #2 on 9/6/21 at 5:00 PM identified that Resident #45 was not outside when she left for the day at 3:00 PM. She further identified that when the resident does go outside she keeps an eye on him through the glass window. Interviews with staff throughout the building on 9/6/21 at 4:40 PM failed to identify which staff member disarmed the wander guard and let the resident out of the building unsupervised. Review of the elopement policy identified that safe environment is provided for Residents who are at risk to wander. c. Review of Resident #45's August 2021 Treatment Administration Record (TAR) identified that 7 out of 31 days the wander guard function was not checked, and the placement was not checked for 30 times out of a possible 186 times for the month. d. Review of the July 2021 TAR identified that Resident #45's the wander guard function was not checked on 2 days out of 31 and the placement was not checked for 19 times out of possible 92 times for the month. e. Review of the June 2021 TAR identified that Resident #45's wander guard function was not checked for 7 days out of 30 days, and the placement was not checked 13 times out of a possible 90 times. Interview with the DON on 9/7/21 identified that the wander guard function should be checked daily, and per the physician's order, placement should be checked 2 times a shift. Review of the wander guard policy identified that the wander guard function will be checked once daily and the placement will be checked once a shift. On 9/7/21 the facility submitted an immediate action plan to include facility wide education of staff to ensure the safety of Residents that require wander guard monitoring. All Residents who wear wander guards that request to sit outside will be supervised by a staff member. A facility wide audit of Residents with wander guards will be completed to ensure placement and function are being monitored and that physician's orders and care plans are up to date. Wander guard audits will be completed weekly for 4 weeks, and monthly for 3 months or until the Quality Insurance and Performance Improvement (QAPI) committee determines resolution. During an onsite visit on 9/8/21, the action plan was verified as implemented, therefore, the Immediate Jeopardy was abated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility documentation, interviews, and policy review, the facility failed to ensure that staffing levels were adequate to meet the needs of four (4) of thirty three (33) residents on the B wing (Residents #4, #17, #44, and Resident #77) in accordance with the plan of care which resulted in a finding of Immediate Jeopardy. Additionally, for 2 out of 3 wings reviewed for staffing, the facility failed to ensure there was sufficient nurse staffing to meet the needs of the residents on 9/3/21 at the beginning of the 7:00 AM to 3:00 PM shift and for 1 resident (Resident #79), reviewed for an allegation of neglect, the facility failed to have sufficient nursing staff to maintain the residents highest practicable physical, mental, and psychosocial well-being. The findings include: Please cross reference F 600 The findings include: 1. Review of the schedule for B wing dated 9/6/21 for the 7:00 AM to 3:00 PM shift identified the census was 33 and there was one (1) charge nurse, and two (2) Nurse Aides (NA) assigned. NA #5 worked 7:00 AM until 12:00 PM, and NA#1 worked 8:00 AM until 2:00 PM. B wing was staffed with 1 NA from 7:00 to 8:00 AM (NA #5), 2 NA from 8:00 AM until 12:00 PM (NA #1 & 5), and 1 NA from 12:00 PM until 2:00 PM (NA #1). There were no NA ' s on the unit from 2:00 PM until 3:00 PM. Interview with Nurse Aide (NA) #1 on 9/6/21 at 7:40 PM identified that she was unable to provide incontinent care, bathing and turning and repositioning to Resident #4, Resident #17, Resident #44, and Resident #77. NA #1 stated that she didn't have time to provide care to all of the residents, because there were 2 NA for 33 residents (approximately 17 residents each) and then at noon she was the only NA for 33 residents. NA #1 further identified that she was able to set up and provide the meals for Resident #4, Resident #17, Resident #44 and Resident #77, but she was unable to provide any other care for the 7:00 AM to 3:00 PM shift. NA #1 identified that she had worked on 9/6/21, although it was her day off, she had informed the facility ahead of time that she could only work until 2:00 PM. Multiple attempts to contact NA #5 were unsuccessful. Interview with the Director of Nurses on 9/6/21 at 6:36 PM identified that she had been in the building since 11:00 AM on 9/6/21 and was unaware of that there were only 2 NA on the B wing. The DON stated she was also unaware that there was only 1 NA on the B wing from 12:00 to 2:00, and that there were no Aides on the B wing from 2:00 PM to 3:00 PM. Review of the 7:00 AM to 3:00 PM schedule for 9/6/21 with the DON identified that there had been one agency NA that was a no call, no show and one call out for the 7:00 AM to 3:00 PM shift on 9/6/21, leaving only 2 NA to work the unit. The DON identified that the residents are heavy care on B wing and the wing should have 4 NA on the 7:00 AM to 3:00 PM shift. The DON identified that the residents should have been provided with bathing, incontinent care, and repositioning every 2 hours, and the NA should have asked for help if she could not do so. Interview with LPN #1 on 9/7/21 who was the charge nurse on B wing on 9/6/21 at 4:14 AM identified that the staffing on 9/6/21 for the 7:00 AM to 3:00 PM shift on 9/6/21 was not unusual. LPN #1 stated that when NA#5 came to work on 9/6/21, it was identified that she was not on the schedule, however she agreed to stay until 12:00 PM. Interview with Registered Nurse (RN) #1 on 9/7/21 at 10:30 AM identified that she was the nursing supervisor on 9/6/21 for the 7:00 Am to 3:00 PM shift and was aware of the staffing issue on the B wing, and stated that she had tried to contact all of the staffing agencies and called all of the staff and no one was able to come in that day. Interview with the Staffing Coordinator (SC) on 9/7/21 at 1:00 PM identified that she was not in the building on 9/6/21 because it was a holiday. The SC identified that there is no staffing policy, but the B wing should have at least 3 NA, but ideal staffing would be 4 NA on the 7:00 Am to 3:00 PM shift. The SC further identified that the facility has contracts with four (4) staffing agencies and when she calls, they usually don't have anyone available. The staffing coordinator identified that the facility is also having a job fair to recruit staff, and the facility offers bonuses in an attempt to get staff to work extra shifts. The SC further identified that at times when there are not enough NA's licensed staff will work as NA's. The facility submitted and action plan to the Department on 9/7/21 that identified that nursing management, department heads and staff that have a NA certification, temporary NA's, and agency staff will be utilized when the staffing is inadequate. The nursing scheduler and nursing supervisors were educated on notifying Administration and the Director of Nurses when staffing levels do not meet the State Agency Public Health Code for staffing. Staffing audits will be conducted daily for a week, weekly for a month, and monthly for 3 months. During an onsite visit on 9/8/21, the action plan was verified as implemented, therefore, the Immediate Jeopardy was abated. 2. Review of the census list on 9/3/21 identified the facility capacity is 97 beds and the census was 85 residents in the facility. There were 22 residents on A wing, 31 residents on B wing, and 32 residents on C wing. Tour of the wings on 9/3/21 at 7:05 AM identified the following: A wing had 2 nurse aides on the 7:00 AM - 3:00 PM shift, (22 residents). B wing had zero nurse aides and one LPN, (31 residents). C wing had zero nurse aides and ne LPN, (32 residents). Interview with LPN #3 on 9/3/21 at 7:20 AM on C wing identified she was aware that the 11:00 PM - 7:00 AM nurse aides had left, and that there were no nurse aides on during the 7:00 AM - 3:00 PM shift on C wing. LPN #3 indicated the facility has been short of staff for a very long time. LPN #3 indicated that some nurse aides come in at 8:30 AM or 9:00 AM or 9:30 AM. LPN #3 indicated that it is very difficult to try and pass out the medications and answer the call lights until a nurse aide comes in. Observation between 7:30 AM - 7:40 AM identified the following: A wing had 2 nurse aides and one LPN, (22 residents). B wing had zero nurse aides and one LPN, (31 residents). C wing had zero nurse aides and ne LPN, (32 residents). Interview with LPN #1 on 9/3/21 at 7:33 AM on B wing identified he was aware that the 11:00 PM - 7:00 AM nurse aides had left, and there were no nurse aides on the 7:00 AM - 3:00 PM shift when he made round at the beginning of the shift, and there were still no staff on the wing at 7:30 AM. LPN #1 indicated that a nurse aide should have stayed on the unit until the 7:00 AM - 3:00 PM shift came in. On 9/3/21 at 7:44 AM identified NA #5 arrived on C wing. Interview with NA #5 identified she punched in at 7:21 AM and she is the only nurse aide on the C wing. Observation on 9/3/21 at 7:57 AM identified NA #22 coming from A wing to B wing. Interview with NA #22 identified she was asked to go to B wing and monitor the call lights and pass out the breakfast trays until a nurse aide came in. Observation between 8:00 AM - 8:30 AM identified the following: A wing with one nurse aide and one LPN on the wing, (22 residents). B wing with one nurse aide and one LPN on the wing, (31 residents). C wing with one nurse aide and one LPN on the wing, (32 residents). On 9/3/21 at 8:41 AM, NA #24 went to the Human Resource (HR) office. Interview with NA #24 identified she punched in at 8:30 AM. NA #24 indicated today was her day off and the facility called her to come in because they needed help. NA #24 indicated she was directed to go to C wing. On 9/3/21 at 8:44 AM, NA #25 arrived. Interview with NA #25 identified she was supposed to be at the facility at 8:00 AM and she is from an agency. NA #25 indicated she notified HR that she cannot be at work at 8:00 AM for personal reasons and indicated when she arrived, she was directed to go to B wing. On 9/3/21 at 8:50 AM, NA #26 arrived. Interview with NA #26 identified she was schedule to come in at 9:00 AM. She indicated she was directed to go to B wing until another nurse aide comes in and then she will become the half between B and C wing. Interview with the Administrator on 9/3/21 at 9:00 AM identified she was not aware that the 11:00 PM - 7:00 AM staff had left the facility before the 7:00 AM - 3:00 PM staff came in. She indicated the facility has been experiencing some staffing challenges at times. She indicated the facility supplement with three agencies for nurse aides. The Administrator indicated in-services will be given to the nurse's aide. Interview with Human Resource Director on 9/3/21 at 1:00 PM identified she was not aware that some of the nurse aides were not on the wings. She indicated staffing has been challenging for all shifts. Human Resource Director indicated the facility has placed an ad for nurse aide. Interview with the DNS on 9/3/21 at 2:34 AM identified she was not aware of the schedule issues this morning. The DNS indicated the supervisor called her and notified her that DPH was at the facility, but they did not inform her that there were only 2 nurse aides in the facility at the time of the call. She indicated that the 11:00 PM - 7:00 AM staff should have remained on the wing until the 7:00 AM - 3:00 PM staff came in. Review of the regulations of Connecticut State Agencies identified the facility's administrator and director of nurses shall meet at least once every 30 days to determine the number, experience, and qualifications of staff necessary to comply with this section. The facility shall maintain written and signed summaries of actions taken and reasons, therefore. In a chronic and convalescent nursing home, there shall be at least one licensed nurse on duty on each patient always occupied floor. In no instance shall a chronic and convalescent nursing home have staff below the following standards: The facility failed to ensure there was sufficient staffing to meet residents needs on 9/3/21 at the beginning of the 7:00 AM to 3:00 PM shift. 3. Resident #79 was admitted to the facility on [DATE] with diagnoses that included severe morbid obesity, reduced mobility, anxiety disorder and major depressive disorder. Review of the May 2021 physician's orders directed to transfer Resident #79 via a mechanical lift with the assistance of 3 staff as the resident is unable to ambulate. Additionally, the orders identified Resident #79 requires the assistance of 2 staff (extensive assistance) for upper/lower body dressing, and toilet transfers and limited assistance for personal hygiene. The quarterly MDS dated [DATE] identified Resident #79 had intact cognition, required extensive two-person physical assistance with toilet use and extensive one-person physical assistance with personal hygiene. Additionally, the MDS indicated Resident #79 was always continent of urine. The care plan dated 6/2/21 identified Resident #79 had a self-performance and mobility deficit related to deconditioning and weakness. Interventions included to encourage the resident to participate in ADLs to promote independence. The care plan did not address how staff should provide assistance regarding Resident #79's bowel and bladder needs. Interview with Resident #79 on 8/16/21 at 1:05 PM identified that usually when he/she rings the call bell, it takes the nurse aides 40 minutes to an hour to answer. Resident #79 indicated that sometime in June 2021, during the 11:00 PM - 7:00 AM shift, he/she needed help and rang the call bell for approximately 4 hours, but the staff did not answer or come to his/her room. In another incident, Resident #79 indicated recently, after returning from a hospitalization, during an 11:00 PM - 7:00 AM shift, the resident rang the call light because he/she had to urinate. Resident #79 could not remember the exact time but was also yelling for help. The staff on the night shift never came into his/her room to help or provide care so he/she had to urinate in the bed and lay in it. Resident #79 indicated that when the 7:00 AM - 3:00 PM shift arrived, the nurse aide answered the call light a little after 7:00 AM. Resident #79 indicated at that time, NA #1 provided care and the resident reported to NA #1 that he/she had been ringing for help since 5:00 AM and had been laying in urine because no one came to help. Resident #79 indicated he/she lays in bed waiting for staff to answer the call bell, it happens all the time, it goes on all the time. The resident stated he/she many times has had to urinate right in his/her bed and lay in the urine, screaming for help because no one comes, and he/she and the bed gets cold because it's wet. The resident indicated he/she has had to call 911 in the past when staff don't answer the call bell. The resident indicated he/she rings for the bedpan and will urinate on the bedpan, but if no one comes, he/she has no choice and cannot hold it, so will urinate in the bed. If staff answer his/her call light in a timely manner, he/she uses the bed pan. Interview with Resident #4, (Resident #79's roommate), on 8/16/21 at 1:12 PM identified he/she does not remember the exact date but does remember an incident when he/she was woken up by Resident #79 screaming for help at approximately 5:00 AM. Resident #4 indicated the night shift did not come to answer the call bell or come in the room to help Resident #79. It wasn't until the day shift arrived that Resident #79 received help. Interview with NA #1 on 8/16/21 at 1:30 PM identified she does not remember exactly the day or date, but it happened when Resident #1 came back from the hospital recently. NA #1 indicated when she came in at 7:00 AM, Resident #79's light was ringing, and she answered the call light. NA #1 indicated Resident #79 was crying and stated that the nurse aide (lady) on the night shift did not provide care. NA #1 indicated Resident #79 and his/her bed and linens were saturated with urine, so she provided Resident #79 a bed bath and changed the bed linen. NA #1 indicated after she provided care to Resident #79, she notified RN #2 and LPN #1 of Resident #79's complaint that the night shift had not provided care and that Resident #79 was soiled and saturated and left in a urine-soaked bed. Interview with LPN #1 on 8/16/21 at 3:47 PM identified he is the regular nurse on the B unit and assigned to Resident #79. LPN #1 indicated he does not remember NA #1 reporting to him that Resident #79 was complaining about the night shift not answering the call light or providing the resident the bed pan, and subsequently the resident soiled and saturated the bed with urine. LPN #1 indicated that one time during the day shift, he does remember an incident when Resident #79's family member called the facility and reported that if someone does not go into the resident room to provide toileting assistance that he/she was going to call 911. The facility failed to provide sufficient nursing staffing to ensure Resident #79, who was alert, oriented and continent, was free from neglect during the 11:00 PM - 7:00 AM shift, when staff did not provide assistance with toilet use when requested, and subsequently the resident urinated in the bed, was left in a urine saturated bed and found in a urine saturated bed by the day shift over 2 hours later.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation on 9/2/21 at 9:05 AM on C wing identified RN #4 left a resident's room and went in and out of 4 different other rooms looking for gloves. No gloves were found in the 4 rooms. RN #4 asked a nurse aide for gloves and the nurse aide pulled a pair of gloves out of her scrub pocket. Tour of A wing, B wing, and C wing on 9/2/21 at 9:15 AM with RN #4 identified the following; Of the 13 rooms on A wing, gloves were not available in 10 rooms/bathrooms: rooms 3, 4, 5, 6, 7, 9, 10, 11, 13, and 15. Of the 17 rooms on B wing, gloves were not available in 11 rooms/bathrooms: rooms #16, 17, 19, 20, 21, 23, 24, 25, 26, 29, and 31. Of the 17 rooms on C wing, gloves were not available in 16 rooms/bathrooms: rooms 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, and 49. Interview with NA #9 on 9/2/21 at 10:05 AM on C wing identified she was aware that there were no gloves in the resident rooms. NA #9 identified that she must go and get one box of gloves from the supervisor's office at the beginning of her shift (7:00 AM - 3:00 PM) and place the box of gloves on the railing in the hallway. NA #9 indicated that one box of gloves is to be used among all the staff on the whole unit for the shift. NA #9 indicated that she must put extra gloves in her scrub pocket. NA #9 indicated that the DNS informed the staff that the facility will not be putting gloves in the resident rooms anymore. Interview with LPN #3 on 9/2/21 at 10:08 AM identified she was not aware that the resident rooms did not have gloves and indicated she uses the gloves on the medication cart and at times the nurse's aides will get gloves from the medication cart. Interview with NA #6 on 9/2/21 at 10:12 AM identified she was aware there were no gloves in the resident rooms. NA #6 identified there have not been gloves in the rooms for a very long time and she does not know why. NA #6 indicated when she needs gloves, she must stop resident care, leave the room, and get the gloves in the hallway. Observation with RN #4 on C wing on 9/2/21 at 10:15 AM identified one box of gloves on the railing in the hallway. Interview with LPN #5 on 9/2/21 at 10:25 AM identified she was aware that the resident rooms did not have gloves and identified that when she needs gloves, she gets them from the medication cart. LPN #5 indicated she does not know who is responsible to replenish the rooms with gloves. Interview with RN #4 on 9/2/21 at 10:35 AM identified she was not aware that the resident rooms and bathrooms did not have boxes of gloves available. RN #4 indicated central supply staff is to supply the rooms with gloves. RN #4 indicated that she was not aware that the DNS notified the staff that gloves will not be provided in the resident rooms. Observation on 9/2/21 at 10:43 AM of Physical Therapist (PT) #3 on the B wing leaving the residents room, walking approximately 10 feet to the medication cart to obtain gloves, and re-entering the resident's room to continue therapy. Interview with PT #3 identified gloves had not been readily available for staff in the resident rooms for a very long time (months), which resulted in the staff having to search for gloves prior to caring for a resident or having to leave a resident's room to obtain additional gloves during care. Interview with LPN #1 on 9/2/21 at 10:45 AM on the B wing identified he was aware that there are no gloves in the resident rooms. LPN #1 indicated the facility does not put gloves in the room, and the facility does not want gloves in the rooms. LPN #1 indicated it has been this way for a while. LPN #1 indicated that the medication cart has gloves, and the nurse's aide must go to the supervisor office for gloves, and they are allowed one box for the wing and shift. Interview with NA #5 on 9/2/21 at 10:50 AM on the B wing identified she was aware that there are no gloves in the resident rooms. NA #5 indicated at the beginning of the shift (7:00 AM - 3:00 PM) she must go to the supervisor's office and get one box of gloves and place the box of glove on the railing in the hallway. She identified that the one box of glove is to be used among the staff for the wing for the shift. NA #5 indicated that she put multiple gloves in her scrub pocket because it's difficult to be in the middle of care and have to stop and go and get gloves out in the hallway. Observation on B wing on 9/2/21 at 10:51 AM one box of gloves on the railing in the hallway. Interview with NA #20 on 9/2/21 at 10:52 AM on the B wing identified she was aware that there are no gloves in the resident rooms. She identified that one staff must get one box of glove from the supervisor's office at the beginning of the shift (7:00 AM - 3:00 PM) and place the box of glove on the railing in the hallway. She indicated that one box of glove is to be used among the staff on the unit for the shift. She indicated during care if she needs glove, she must stop and go into the hallway and get another pair of gloves. Interview with Housekeeping Director on 9/2/21 at 10:59 AM identified she was not aware of the resident rooms not having gloves available to the staff. She indicated central supply is responsible to put gloves in the resident rooms. She indicated the Administrator asked her to go and put a box of gloves in all the rooms right now. Interview with the Administrator on 9/2/21 at 11:07 AM identified she was aware that the resident rooms did not have gloves available to the staff. She indicated since 8/2020 during the Covid-19 pandemic, the facility did not have gloves in the resident rooms. The gloves have been controlled in the supervisor office since she has been at the facility (8/2020). The Administrator identified that was the procedure that was in place at the facility when she was employed. She indicated when a resident is positive Covid-19 a box of gloves is put in the rooms or on the isolation cart. Interview with DNS on 9/2/21 at 11:10 AM identified she was aware that the resident rooms did not have gloves. She identified gloves are kept in the supervisor's office and the staff is to get a box at the beginning of each shift due to excessive use, control and to prevent overuse. The DNS indicated it is the company's rule. The DNS indicated gloves should have been readily available to staff for resident care and universal standard precaution. Interview with NA #12 on 9/2/21 at 12:05 PM identified she was aware that there were no gloves in the resident rooms. NA #12 identified there has been no gloves in the resident room since her employment in 1/2021. She indicated she get a used box of gloves from the previous shift or searches for a box of gloves. She indicated that she keeps the box of gloves with her going from resident room to resident room. Interview with NA #21 on 9/2/21 at 12:19 AM on A wing identified she was aware of the resident rooms not having gloves. She indicated it has been like this for a very long time. NA #21 indicated she must search for gloves or go to the supervisor's office for one box of gloves. And she places the one box of gloves on railing in the hallway for the staff on the wing. Interview with the former DNS on 9/2/21 at 2:06 PM identified she was aware of the resident rooms not having gloves. The former DNS identified that this was the procedure for the facility for approximately a year. She identified that gloves should have been readily available for staff in the resident's room for care not having to go out into the hallway when needed. The former DNS indicated that is not the correct universal standard precaution. Interview with NA #2 on 9/2/21 at 4:21 AM identified she was aware that the resident rooms did not have gloves. She indicated that she gets one box of gloves from the supervisor's office and stuff her pocket with gloves. NA #2 indicated she places the box in the linen closet for the rest of the shift. NA #2 indicated the facility stop putting gloves in the resident rooms since the beginning of the year. Interview with RN #2 on 9/2/21 at 4:44 PM identified she was aware that there were no gloves in the resident rooms and the bathrooms. RN #2 identified that the staff is supposed to come to the supervisor's office, and they are provided with one box of gloves for the whole wing. She indicated that gloves had not been readily available in resident rooms since the beginning of the year. She indicated universal precaution is gloves are available in resident rooms for care. Interview with Central Supplies staff on 9/8/21 at 12:38 PM identified she was told by the Administrator last year not to put any gloves in the resident's rooms and bathrooms. She indicated the Administrator directed her to put gloves in the supervisor's office only. She indicated she was only doing what she was told by the Administrator. Subsequently to surveyor inquiry, the facility's Housekeeping Director brought additional boxes of gloves to A, B, and C wings and stocked the resident rooms with gloves. Review of the facility gloving policy identified to prevent the transmission of infectious organisms between residents, staff and visitors. Protective gloves should be worn by all personnel during any procedure that may involve handling secretions and excrements of blood or bodily fluids. Gloves should only be worn once and then discarded. Gloves must be changed in between resident contact. Gloves must be changed any time their integrity is compromised. It is the policy of this facility that gloves be worn with reasonable anticipation of contact or handling of blood or body fluids, mucous membranes, non-intact skin, potentially infectious materials, when performing vascular access procedures, and/or touching contaminated surfaces. Review of the CDC (Center for Disease Control) guidelines for PPE for Isolation Precautions identified to wear gloves when it is anticipated that contact with potentially infectious materials could occur on the patient or the patient's surrounding environment and change gloves during patient care when the hands move from a contaminated body-site to a clean body site. Standard Precautions: infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status. Standard precautions is based on the principle that all blood, body fluids, secretions, excretions except sweat, regardless of whether they contain visible blood, non-intact skin, and mucous membranes may contain transmissible infectious agents. Furthermore, equipment or items in the patient environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents. Standard precautions include but are not limited to hand hygiene; use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure; safe injection practices, and respiratory hygiene/cough etiquette. Also, equipment or items in the patient environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents (e.g., wear gloves for direct contact, properly clean and disinfect or sterilize reusable equipment before use on another patient). The use of PPE during resident care is determined by the nature of staff interaction and the extent of anticipated blood, body fluid, or pathogen exposure to include contamination of environmental surfaces. Furthermore, appropriate use of PPE includes but is not limited to the following: o Gloves worn before and removed after contact with blood or body fluid, mucous membranes, or non-intact skin; o Gloves changed, and hand hygiene performed before moving from a contaminated-body site to a clean-body site during resident care. The facility failed to ensure an adequate number of gloves (personal protective equipment) were readily available to staff accordance to universal standard precautions and infection control policies. 3. Resident #48 was admitted to the facility on [DATE] with diagnoses that included tracheostomy, malignant neoplasm of bronchus or lung, malignant neoplasm of upper lobe, right bronchus or lung, artificial openings of gastrointestinal tract. Physician's order dated originally 7/4/21 and current through 9/13/21 directed to change disposable oxygen supplies every week and as needed on (Saturday 11:00 PM - 7:00 AM) shift. Label and date all supplies every Saturday night. Physician's orders dated originally dated 7/4/21 and current through 9/13/21 directed to suction tracheostomy as needed. Suctioning is a sterile procedure, and a new sterile gloves and suction catheter should be used each time. Physician's orders dated originally 7/4/21 and current through 9/13/21directed to administer cool mist aerosol via air compressor with 2 Liters of oxygen via liquid or concentrator to trach mask to equal 28% oxygen every shift. The admission MDS dated [DATE] identified Resident #48 had intact cognition and required extensive assistance with personal hygiene. The care plan dated 7/21/21 and currently in effect identified Resident #48 has a tracheostomy. Interventions included to provide trach care as needed, suction as necessary, and use universal precautions as appropriate. Additionally, Resident #48 requires a J-tube. Interventions included to provide local care to J-tube site as ordered and monitor for sign and symptoms of infection. Further, Resident #48 has Chronic Obstructive Pulmonary Disease (COPD). Interventions included to administered oxygen per physician's order. Review of the July 2021 MAR identified to change disposable oxygen supplies every week and as needed. Label and date all supplies every Saturday night. Documentation on 7/10/21, 7/17/21, and 7/24/21 identified oxygen supplies were changed with nurses' initials. Review of the August 2021 MAR identified to change disposable oxygen supplies every week and as needed. Label and date all supplies every Saturday night. Documentation on 8/7/21, 8/14/21, 8/21/21, and 8/29/21 identified oxygen supplies were changed with nurses' initials. Review of the September 2021 MAR identified to change disposable oxygen supplies every week and as needed. Label and date all supplies every Saturday night. Documentation on 9/4/21 identified oxygen supplies were changed with nurse initial. Observation with LPN #3 on 9/9/21 at 11:15 AM identified the following: a. Used suction tubing with no cover lying on table. b. Nebulizer handheld with no cover lying on the table, c. Oxygen nasal cannula tubing with a piece of tape around tubing dated 7/25/21. (Resident #48 was on continuous cool mist aerosol via air compressor with 2 Liters of oxygen via liquid or concentrator to trach mask to equal 28% oxygen every shift). d. Catheter syringe with no cover lying on the table. Interview with LPN #3 on 9/9/21 at 11:16 AM identified she was not aware of the issue until now and she was not the charge nurse on duty. LPN #3 indicated it was the 11:00 PM to 7:00 AM nurse's responsible to change the oxygen tubing weekly per the physician's order. LPN #3 indicated the equipment's should have been covered with the plastic bags. Interview with RN #9 on 9/14/21 at 8:21 AM identified she was the charge nurse on duty on 9/9/21 from 9:00 AM - 11:30 AM and she was not aware of the issue. RN #9 indicated she does not recall if the respiratory equipment's was covered or not in the plastic bags. Interview with the DNS on 9/15/21 at 11:31 AM identified she was not aware of the issue. The DNS indicated the nurse's should have changed the oxygen tubing per physician's order and placed the plastic covers after each equipment usage. Subsequent to surveyor inquiry, Resident #48's oxygen tubing was changed and dated 9/9/21. Additionally, the suction tubing, handheld nebulizer, and catheter syringe was discarded and replaced. Review of the provide clean nebulizer equipment policy identified to ensure clean nebulizer treatments. It is the policy of the facility to provide clean nebulizer treatments. Place nebulizer tubing & accessories in plastic bag. Review of the facility replace oxygen tubing & set up policy identified it is the policy of this facility to provide a clean oxygen delivery system. Replace oxygen tubing weekly. Record date & initials. Place oxygen tubing & accessories in plastic bag that is dated & initials. Review of the facility gastrostomy/jejunostomy site care policy identified to promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown and infection. Review of the facility per nasal cannula policy identified nasal cannula shall be changed every week. The facility failed to ensure infection control practices were maintained related to respiratory and g-tube equipment and facility failed to change oxygen tubing per physician's orders. Based on observations, review of the clinical record, facility documentation, interviews, and policy review, the facility failed to ensure that visitors were screened for symptoms of COVID-19 upon entry into the facility in accordance with facility policy, failed to maintain compliance with the submitted action plan to address screening of visitors, failed to ensure the COVID-19 observation unit had proper signage posted at the entrance of the unit, failed to ensure staff utilized Personal Protective Equipment (PPE) while caring for Residents on the observation unit, and that PPE was properly discarded after use, resulting in a finding of Immediate Jeopardy. Additionally, the facility failed to ensure an adequate number of gloves were readily available to staff for care, and for 1 resident, (Resident #48) the facility failed to ensure infection control measures were implemented related to respiratory and G tube care. The findings include: 1. On 9/4/21 at 10:53 AM, the surveyor entered the building and remained in the entryway until 11:00 AM. During that time staff were observed in the hallways and walking by but did not approach the surveyor to provide screening for COVID-19. Further observation noted four (4) visitors in the dining room visiting with R#25 and R #78. At 11:00 AM the surveyor walked to the A/B wing nurse's station to ask for the person in charge. The RN Supervisor greeted the surveyor and upon inquiry was told they had no one to sit at the front desk to monitor visitors who entered the building. As of 11:10 AM, no staff had inquired if the surveyor was screened. Further interview with the RN Supervisor at 11:10 AM stated that the Receptionist was not available until 2:00 PM and people will not be screened. The RN Supervisor stated that she does not have enough staff in the building to have someone sit at the front desk to screen people, so she will screen them if she sees them. Observations at 11:23 AM noted the RN Supervisor went to the dining room where the four (4) visitors were and had them complete the COVID-19 screening questions and the RN Supervisor was observed to take each visitors temperature. Interview with R #78 visitors at 11:30 AM stated they arrived at 10:40 AM and they were not screened until now when the RN Supervisor came into dining room. Interview with R #25's visitors at 11:30 AM stated they arrived at 11:10 AM and they were also not screened until now when the RN Supervisor came into room. Interview with the Administrator on 9/4/21 at 12:40 PM stated the facility policy directed that all people who enter the building are to be screened prior to going anywhere in the building. The Administrator stated that the person who was supposed to be the weekend Receptionist was currently working in the kitchen as a dietary aide because they are short of help. Review of the indoor visitation policy dated 4/2021 identified that all visitors will have their temperature taken and be screened for COVID-19 symptoms. On 9/4/21, the facility provided the Department with an action plan that identified all visitors would be screened for COVID-19 symptoms including temperature prior to visitation. The on-duty Receptionist will screen all visitors, and in the absence of the Receptionist, the Nursing Supervisor or designee will perform visitor screening and temperature. 2. Upon surveyor entrance into the facility on 9/7/21 at 7:30 AM there were no staff in the lobby to screen for symptoms of COVID-19 in accordance with facility policy and the submitted action plan dated 9/4/21. The surveyor entered the dining room adjacent to the entrance to the facility, and ten (10) minutes later (7:40 AM) the Administrator entered the facility. Subsequent to surveyor request, the surveyor was screened for COVID-19 symptoms. Interview with the Administrator on 9/7/21 at 7:40 AM identified that the Supervisor should have screened the surveyor, however, there was no way to identify when a visitor entered the front entrance because the door is unlocked at 6:30 AM. The Administrator stated that the front door would now remain locked until 8:00 AM when the Receptionist arrives. This intervention was added to the action plan originally submitted on 9/4/21 . 3. Interview with the Director of Nurses (DON) on 9/6/21 at 5:30 PM identified that the C wing was the COVID-19 observation unit (quarantined unit) because a Nurse Aide who worked on 9/3/21 had tested positive for COVID-19 on 9/5/21. a. Observation on 9/6/21 at 6:00 PM of the C wing unit identified that although the doors to the entrance of the unit were closed, the doors lacked signage to identify what type of PPE was necessary to be worn on the unit. Interview with the Director of Nurses on 9/6/21 at 6:00 PM identified that she was unaware that the entrance to the unit required signage to alert those who enter of what type of PPE is required. Review of CDC Guidelines (https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html) directed in part to place signage at the entrance to the COVID-19 unit that instructs staff they must wear personal protective equipment (PPE ). b. Tour of the COVID-19 observation unit on 9/6/21 at 6:15 PM with the Director of Nurses and the Administrator identified that room [ROOM NUMBER] had a yellow precautions sign outside the door indicating that the resident required droplet and contact precautions (gloves, gown, eye protection, and a face mask). Further observation identified that Nurse Aide (NA) #1 and NA #2 were in the room preparing to take the resident to the bathroom, both were in close proximity to the resident, and only wearing a surgical mask and gloves, and lacked the necessary face shield and isolation gown. Interview with NA#1 and NA#2 at the time of the observation identified that they did not know that the unit was a COVID-19 observation unit, and that they were required to wear PPE. NA#1 and NA#2 further identified that they had been providing personal care such as toileting, incontinent care, and repositioning for several residents since the beginning of their shift at 3:00PM without the benefit of face shields or isolation gowns. NA#1 and NA#2 identified that they did not see the yellow isolation signs posted outside of every room. Interview with Licensed Practical Nurse (LPN) #2 on 9/6/21 at 6:25 PM, who was the charge nurse on the observation unit, identified that she had given all of the residents their medications and was not aware that she needed to wear anything else but a face mask while administering medications, she thought that full PPE needed to be worn when only giving personal care . CDC Guidance identified that HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html) Interview with the DON at the time of the observation identified that she did not think that the PPE was necessary because the residents were all negative when they had their rapid COVID tests on 9/5/21 (2 days after the potential exposure to COVID-19). Interview with the Administrator at the time of the observation identified that the facility had a plentiful supply of PPE, and that the residents were to be on observation for COVID-19 for 14 days and PPE is required until the 14 days has concluded, regardless of what the COVID test results were. c. On 9/6/21 at 8:30 PM on the COVID-19 observation unit, NA #1 was observed to exit out of a droplet precaution room, removed her isolation gown while in the hallway, crumbled it in her gloved hands then walked half the length of the hallway to dispose of the isolation gown. Review of the Centers for Disease Control Guidelines for the removal of PPE (https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html) identified that all PPE must be removed prior to exiting the resident's room. Review of the facility policy for PPE on a COVID-19 observation unit dated 12/2020 identified that a face mask, eye protection, gloves, and an isolation gown were necessary to provide care to residents on the observation unit. Subsequent to observations, on 9/6/21, the facility provided the Department with an immediate action plan that included staff education regarding the requirements of PPE use on the COVID-19 in accordance with CDC guidelines. d. On 9/7/21 at 10:30 AM, the doors to the COVID-19 observation unit lacked signage to inform staff/visitors that the unit was under quarantine, despite the same observation the day prior. Interview with the Administrator on 9/7/21 at 10:30 AM identified that she would ensure signage was added to the doors of the COVID observation unit. Subsequent to this observation, signage was placed on the doors at the entrance of the COVID-19 observation unit which indicated that the unit was quarantined. e. Further observation on 9/7/21 at 10:32 AM identified a droplet and contact precaution sign outside of room [ROOM NUMBER]. Physical Therapist (PT) #1 was identified to be in the room repositioning Resident #53 in bed, the resident was noted to cough several times while being repositioned. PT #1 was wearing gloves and a face mask; however, he lacked a face shield and an isolation gown while providing care to the resident. Interview with PT #1 at the time of the observation identified that he was unaware that the unit was under observation for COVID-19, and he had not seen the yellow isolation sign upon entering the room. Interview with the Administrator on 9/7/21 at 10:30 AM identified that PT#1 should have been wearing a face shield and gown in addition to the face mask and gloves while caring for the resident. f. During tour of the COVID-19 observation unit on 9/7/21 at 10:55 AM, Resident #25 was sitting on h/her bed without a face mask and was speaking to a visitor who also lacked a face mask. Interview with the visitor at the time of the observation identified that he worked at a group home where the Resident resided previously, and visited the resident daily, however he did not know that Resident #25 was on observation for COVID-19 exposure. Interview with LPN #2 on 9/7/21 at 11:00 AM, who was Resident #25's nurse, identified that she was aware that the visitor was in Resident #25's room, and did not inform him that the entire unit was on observation for COVID-19 exposure, nor offer him any PPE. g. Further tour of the COVID-19 observation unit on 9/7/21 at 11:00 AM identified that a visitor was observed coming out of Resident #80's room. Interview with the visitor at the time of the observation identified that she was from the Resident's group home and was not informed that the Resident was on an observation unit for COVID-19 exposure. The visitor was observed wearing a face mask upon exiting the room and identified to the surveyor that she was not wearing any other PPE besides the face mask while visiting the resident. Interview with the Administrator on 9/7/21 at 11:05 AM identified that Resident #25 and Resident #80 did not qualify for compassionate care visits and she thought that the visitors from the group home were allowed because they were included in the Resident's plan of care. Review of the plan of care for Resident #25 and Resident #80 failed to reflect any interventions including visits from group home staff. Review of the facility visitation policy dated 4/2021 identified that indoor visitation should be limited solely to compassionate care visits for vaccinated and unvaccinated residents that are in quarantine until they have met the criteria for release from quarantine. h. Further tour of the COVID-19 observation unit on 9/7/21 at 11:00 AM identified that NA #8 came out of a droplet precaution room and took her gown off, crumpled it up in her un-gloved hands and walked down the hallway to dispose of the gown. Interview with the Administrator on 9/7/21 at 12:00 PM identified that the gowns should be offed prior to leaving the room and that she would be obtaining more receptacles for the used PPE so the Nurse Aide's don't have to walk down the hallway to dispose of them. Over the course of multiple days, the facility failed to ensure infection control practices were implemented in accordance with policies despite immediate action plans submitted to the Department resulting in Immediate Jeopardy. On 9/7/21 the facility submitted an immediate action plan that included: The front door will remain locked until the Receptionist reports to work. All visitors will be screened by the Receptionist, Nursing Supervisor or designee to include screening questions and temperature with results recorded in a log. Facility wide re-education on proper use of PPE, audits daily for seven days and weekly for 4 weeks and monthly for 3 months, and audits will be forwarded to the QAPI Committee for further review and recommendations for a three-month period or until the committee determines resolution. During an onsite visit on 9/8/21, the action plan was verified as implemented, therefore, the Immediate Jeopardy was abated.