Based on record reviews, resident, staff, Physician Assistant (PA), and Medical Director (MD) interviews the facility failed to protect a Resident's right to be free from neglect by failing to comprehensively assess a resident prior to moving the resident off of the floor following a fall with injury, seek immediate medical treatment or hospitalization to provide the necessary care and services to the resident, and provide effective pain management. On 5/27/24 Resident #40 sustained a fall with injury and a comprehensive assessment was not completed prior to transferring the resident to bed. The resident's left leg was observed internally rotated and shorter than the right leg. Nurse #3 immediately summoned Emergency Medical Services (EMS) but after review of his chart and speaking to the Director of Nursing (DON), she was instructed to cancel EMS because Resident #40 had an advance directive that indicated Do Not Hospitalize unless his comfort needs could not be met at the facility. The resident was medicated with a one-time dose of Ibuprofen (pain medication, decreases inflammation) 600 milligrams (mg) in addition to the resident's routine order for oxycodone-acetaminophen 5-325 mg (narcotic pain medication) every 6 hours. This was not effective to manage the resident's pain as evidenced pain scale ratings of an 8 out of 10 (with 10 being the worst pain possible) and non-verbal signs of pain that included crying, moaning, guarding (protecting/holding) his left leg, grimacing, and unable to be consoled by staff. An x-ray was performed on 5/28/2024 which revealed Resident #40 had sustained an acute fracture of the proximal left femur (thigh bone). Resident #40 was transferred to the hospital on 5/28/2024 where he was admitted for further evaluation and pain management. This deficient practice occurred for 1 of 3 residents reviewed for neglect (Resident #40). Immediate jeopardy began on 5/27/2024 when staff neglected to provide the necessary care and services to Resident #40 following a fall with injury. Immediate jeopardy was removed on 06/12/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: This tag is cross-referenced to: F684: Based on record review, and Resident, staff, Physician Assistant (PA), and Medical Director (MD) interviews the facility failed to perform a comprehensive assessment including vital signs before moving a resident off the floor after a fall with injury and failed to seek immediate medical treatment or higher level of care. On 5/27/2024 at 10:40 pm Nurse #1, Nurse #2, Nurse #3, Nurse Aide (NA) #1, and NA #2 responded to Resident #40's room after they heard Resident #44 yell that Resident #40 was on the floor. Resident #40 was found face down on the floor. Nurse #1 and Nurse #2 rolled Resident #40 over, transferred Resident #40 by picking him up under his arms while NA #1 held traction to Resident #40's left leg. When Resident #40 was placed back in bed, Nurse #3 assessed Resident #40 and obtained vital signs at which time she noticed Resident #40's left leg was internally rotated and shorter than the right leg. Nurse #3 immediately summoned Emergency Medical Services (EMS) but after review of his chart and speaking to the Director of Nursing (DON), she was instructed to cancel EMS because Resident #40 had an advance directive that indicated Do Not Hospitalize unless his comfort needs could not be met at the facility. An x-ray was performed on 5/28/2024 which revealed Resident #40 had sustained an acute fracture of the proximal left femur (thigh bone). Resident #40 was transferred to the hospital on 5/28/2024 where he was admitted for further evaluation and pain management. The deficient practice was identified for 1 of 3 residents reviewed for change of condition (Resident #40). F697: Based on observations, record review, staff, Physician Assistant (PA), and Medical Director (MD) interviews the facility failed to provide effective pain management for a resident (Resident #40) after a fall, with obvious deformity, or transfer him to the hospital for pain that could not be managed in the facility as outlined by his advanced directive. On 5/27/2024 Resident #40 was found face down on the floor beside his bed and was noted to have internal rotation and shortening of the left hip and leg. Resident #40 was crying, moaning, guarding (protecting/holding) his left leg, grimacing, and unable to be consoled by staff. Nurse #3 immediately summoned Emergency Medical Services (EMS) but after review of the resident's chart and speaking to the Director of Nursing (DON), she was instructed to cancel EMS because Resident #40 had an advance directed that indicated Do Not Hospitalize unless his comfort needs could not be met at the facility. Nurse #3 notified the provider on-call and obtained an order for a one-time dose of Ibuprofen (pain medication, decreases inflammation) to be given for pain and a left hip/pelvis x-ray. Nurse #3 administered that medication as well as oxycodone-acetaminophen 5-325 mg (pain medication) that was scheduled (for every 6 hours) at 12:00 am and Resident #40 continued to grimace in pain throughout the remainder of her shift. Nurse #3 administered the 6:00 am oxycodone-acetaminophen. Nurse #10 administered oxycodone-acetaminophen 5-325 mg tablet on 5/28/2024 at 12:19 pm, and documented a pain assessment of 8 out of 10 for Resident #40. An x-ray was performed in the facility on 5/28/2024 which revealed Resident #40 had sustained an acute fracture of the proximal left femur (thigh bone) and Resident #40 was transferred to the hospital on 5/28/2024 where he was admitted for further evaluation and pain management. The deficient practice occurred for 1 of 3 residents (Resident #40) reviewed for pain management. The Administrator was notified of Immediate Jeopardy on 6/5/2024 at 11:35 am. The facility provided the following credible allegation of immediate jeopardy removal: o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility neglected to thoroughly assess resident #40 on 5/27/24 at 10:40 pm after he fell from his wheelchair to the floor on his left side face down. Resident #40 was discovered by his roommate who summoned assistance from staff. Nurse #1, Nurse #2, NA #1, and NA #2 lifted resident #40 under his arms and held traction to Resident #40's left leg and picked him up from the floor and placed him in the bed. Nurse #3 completely assessed Resident #40 and observed that the left leg was internally rotated and shortened. Nurse #1 described left leg as a limp noodle. The facility neglected to ensure Resident #40 immediately received the necessary care and services from a higher level of care after sustaining an obvious injury status post fall, effective pain management strategies identified through his assessment, and neglecting to implement identified services according to Resident #40's MOST form. Resident #40 still resides in the facility and continues to participate in his Plan of Care receiving all necessary care and services to include a pending orthopedic follow-up appointment. Awaiting the orthopedics office to review the referral documentation and provide the facility with the appointment date. Resident #40 is currently on an increased frequency of Oxycodone 5/325 mg PO Q4 hours. Resident #40's pain is assessed prior to scheduled routine administration, in addition to his routine pain assessment every shift identifying nonverbal pain including facial grimacing, moaning, and crying. On 6/7/24, the Chief Nursing Officer and Director of Nursing reviewed Resident #40's medical records documentation revealing he's receiving all necessary care and services. All current residents have the potential to be affected by this deficient practice. On 6/7/24, the Chief Nursing Officer and Director of Nursing reviewed risk management events of falls with obvious injuries within the last 30 days, as well as alert and oriented interviewed with pain issues. No residents were identified requiring a higher level of care and/or current ineffective pain management regimens were identified. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete Starting 6/7/24, the Chief Nursing Officer educated the Director of Nursing on the process at the time of an event ensuring residents immediately receive a higher level of care for obvious injuries, effective pain management strategies implemented and understanding MOST forms in relation to residents' immediate needs after an event. Education includes when the MOST form indicates comfort measures are to be implemented and the facility's unable to manage, the resident should be provided services and care at a higher level. At no time will the DON direct the facility staff to neglect providing the necessary services required from a higher level of care following an obvious injury or ineffective pain management strategies be acceptable standards of practice. The Director of Nursing, along with the clinical team, will review all falls/incidents daily in the clinical meeting to determine if the event required residents to receive a higher level of care and/or the need for additional care and services. The pain assessment conducted with each event will be reviewed during the clinical meeting for immediate interventions implemented and real time effectiveness. The clinical team will also review the MOST forms to ensure facility's compliance with resident/responsible party's wishes. If the post assessment following pain interventions are not effective, the Director of Nursing, along with the clinical team, will notify the clinicians of its ineffectiveness and implement additional and/or alternative measures as indicated. Starting 6/7/24, The Director of Nursing/Staff Development Coordinator will in-service all facility staff (including contracted agency staff) on Neglect, including failing to provide the necessary care and services from a higher level of care and effective pain management strategies following an event with obvious injuries. The Director of Nursing/Staff Development Coordinator will educate all new hires during orientation and scheduled contracted agency nurses prior to working their shift. The Administrator and Chief Nursing Officer will ensure all facility staff (including contracted agency staff) are educated. Effective 6/10/24, the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 6/12/24 A validation of immediate jeopardy removal was conducted on 06/13/24. The inital audit of residents records and pain interviews with alert and oriented residents were reviewed with no issues noted. Staff interviews across all departments were able to verbalize that they had recieved the education on neglect, how to respond if they were aware of neglect, and who to immediately report it to. The staff were able to verbalize examples of neglect and ways to identify neglect. Nursing staff were able to verbalize the need to review residents MOST forms after falls with injury and the need to contact the residents responsible party if the resident required a higher level of care. Nursing staff were also able to verbalize the pain assessment protocol and who to report any changes in pain or ineffectiveness of currently scheduled pain medication. The immediate jeopardy removal date of 06/12/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff, and Medical Director interviews the facility failed to ensure that Cardiopulmonary Resuscitation (CPR) was administered effectively when Resident #70 went into sudden cardiac arrest and CPR was initiated by Nurse Aide (NA) #3, NA #4, and NA #5 and continued for 7 minutes without a backboard. The backboard creates a hard surface for effective compressions that allow for adequate recoil (allowing the chest to fully expand after compression which pushes the blood to vital organs) and ensure perfusion for vital organs. During CPR Nurse #4 and the Staff Development Coordinator observed NA #3's compression were not effective or deep enough to create recoil and had to instruct NA #3 that his compressions were not deep enough before switching NA #3 out with another staff member that could assist. NA #3 and NA #4 were not certified in CPR for Healthcare Providers. Emergency Medical Services (EMS) arrived and placed a backboard under Resident #70 and continued CPR. Resident #70 expired. This deficient practice was for 1 of 1 resident reviewed who required CPR. Immediate Jeopardy began on [DATE] when staff administered CPR without the use of backboard and delivered compression that were not effective. Immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of a D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring systems are in place. The findings included: Review of the facility's CPR policy revised [DATE] read in part, Requirements for CPR: 1. Personnel must provide basic life support, including CPR to a resident who requires such emergency care prior to arrival of emergency medical personnel. 2. Properly certified and trained staff must be available at all times. 3. Supplies (crash cart) a. backboard, b. face shield and resuscitator (ambu bag), c. automated external defibrillator (if available), d. oxygen mask, tubing, cannula, and tank, e. suction machine and equipment, and f. vital sign equipment to include pulse oximetry. Resident #70 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, chronic respiratory failure, and history of pulmonary embolism. Review of a care plan initiated on [DATE] read, Advance Directive Full Code. The intervention included: advance directive will be followed as ordered. A physician order dated [DATE] read, Full code. The quarterly Minimum Data Set (MDS) dated [DATE] indicated that Resident #70 was cognitively intact, and he required assistance with activities of daily living. An interview was conducted with the Business Office Manager on [DATE] at 10:10 AM, she stated that she was completing her angel rounds in the facility on [DATE] and she went into Resident #70's room and he did not look right. She stated she asked Resident #70 if he was ok, and he did not respond so she went and asked NA #4 to come and check on him. She stated that when NA #4 saw Resident #70's he stated he passed away but all the nurses came and started life saving measures and she stayed out of the way. An interview with the Activity Assistant was conducted on [DATE] at 10:13 AM who stated on [DATE] she was passing out activity information to the residents and the Business Office Manager said Resident #70 does not look right. She stated she went into his room, and he was sitting straight up in bed with his head on the pillow and was white as snow with black lips. The Activity Assistant stated that they grabbed NA #4 and the Director of Nursing (DON), and nursing staff attempted life saving measures. The Scheduling Coordinator was interviewed on [DATE] at 9:45 AM. She stated on [DATE] the DON had instructed her to overhead page Code Blue and to call EMS. She stated she stayed on the phone with EMS until they arrived at the facility with the DON next to her in case, they needed any information that she could not provide. A continuous observation was made on [DATE] at 9:48 AM to 10:13 AM. At 9:48 AM an overhead page was heard in the facility Code Blue Resident #70's room number, Upon arrival at Resident #70's room, the surveyors stood in the hallway outside of Resident #70's room where the scene was visible but not in the way of emergency personnel. There were three male NAs later identified as NA #3, NA #4, and NA #5 starting Cardiopulmonary Resuscitation (CPR). Resident #70 was pale but had no signs of lividity (pooling of blood) and did not appear rigid. After lowering the head of Resident #70's bed NA #5 began performing chest compressions without placing a backboard under Resident #70. When the crash cart arrived at the room at 9:52 AM NA #4 began delivering rescue breathes via an ambu bag (artificial manual breathing unit). NA #4 and NA #5 continued to provide rescue breaths and compression for 5 minutes when NA #5 stopped compressions and NA #3 started compressions. The Staff Development Coordinator who was observed to deliver the facility's crash cart and vital sign machine at 9:52 AM, arrived at the room along with Nurse #4 and began assisting. Nurse #4 was overheard instructing NA #3 that his compressions were not deep enough, and he needed to push harder to create recoil. NA #3 was overheard saying he did not want to break Resident #70's ribs. Nurse #4 continued to coach NA #3 until she took over compressions. At 9:55 AM EMS and fire rescue arrived on scene and began questioning why Resident #70 was not on a backboard. When the Captain of Fire Rescue asked about the backboard, the Staff Development Coordinator began attempting to remove the headboard from the bed but was initially unable to remove it. After multiple attempts to remove the headboard the Staff Development Coordinator realized that there was pins holding the headboard in place, she pulled the pins and the headboard was removed. Staff were observed to remove the headboard of the bed and log roll Resident #70 onto his side and place the headboard under Resident #70 at 9:57 AM and then EMS continued CPR efforts. At 10:03 AM the Captain of the Fire Rescue demanded to see the Director of Nursing (DON) and when she arrived at the room inquired why there was no backboard under Resident #70 when CPR was initiated. He stated, this is a skilled nursing facility, and they should have the needed equipment in place when we get here. EMS continued with rescue efforts, but they were unsuccessful, and they called time of death 10:13 AM. The EMS report dated [DATE] read in part, patient was found by staff pulseless and apneic in his room but still warm to touch. CPR started. Arrived on scene, patient found pulseless and apneic and staff started CPR 5 minutes ago. He has a history of respiratory failure and pulmonary embolism. His skin is mottled, and he appears to have a bluish hue from the neck up. NA #5 was interviewed on [DATE] at 1:53 PM and stated that someone he could not recall who, alerted him that Resident #70 did not have a pulse and was pale. NA #5 stated that he was CPR certified and he went into Resident #70's room and began chest compressions until the crash cart arrived with the ambu bag. He stated that NA #4 began using the ambu bag and he continued chest compressions until he got tired and then he switched off with NA #3. NA #5 stated he did what he was trained to do in his CPR class. NA #5 was also unaware where the crash cart and back board were located. NA #5 stated he had been trained to verify code status and initiate compressions, which is what he did. NA #4 was interviewed on [DATE] at 3:20 PM, who stated on [DATE] he was passing out isolation gowns going from room to room and when he got to Resident #70's room he was sitting straight up in bed and was slumped over. NA #4 stated he immediately went and got the DON from her office and when he returned to the room NA #5 was putting the head of bed down to start chest compressions. Nurse #4 arrived at the room and when the crash cart arrived, she started using the bag and after about 5 minutes NA #5 got tired and they switched off. NA #4 stated he did compressions for a bit and then switched off with NA #3. He added that they did not have a backboard under Resident #70 until EMS arrived and he heard them ask where the backboard was located. NA #4 stated when EMS arrived, he stepped out of the way. He added that he had completed his CPR training online, but his certification had expired. NA #4 stated he had some training when he was hired but could not recall what they trained him on and added he did not do direct patient care very often because his main job was central supply. During compression NA #4 stated he was counting them and someone else was using the bag. NA #3 was interviewed via phone on [DATE] at 8:57 AM. NA #3 stated that on [DATE] he arrived at work at 7:05 AM and started his rounds working from the bottom of the hall to the top. He stated he went in and spoke to Resident #70, and the resident appeared to be his usual self. He stated that breakfast trays arrived at the unit, and he passed those out and began assisting some of the residents that needed assistance. NA #3 stated he had just finished feeding one of his residents and walked out into the hallway and heard two staff members, one from the business office and one from activities but he did not know their names saying that something was wrong with Resident #70, so he went to go and check on him. He stated when he got to the room, he could tell that something was wrong, so he went to alert the DON. He stated that staff began to arrive at the room, and someone began chest compressions until the crash cart arrived, but he was not sure who. NA #3 stated that he did assist with chest compressions and recalled Nurse #4 telling him his chest compressions had to be deeper. NA #3 stated he was hesitant because he did not want to crack Resident #70's bones and the Staff Development Coordinator took over compressions until EMS arrived. He stated that he stayed back out of the way until EMS arrived then he left room. He added that he had only been employed at the facility for a short time and his CPR certification had expired and was no longer valid. NA #3 stated that he did realize that there was no backboard under Resident #70 but was not sure if they needed one or not. A nurses note dated [DATE] at 7:34 PM written by Nurse #4 read; Resident was found unresponsive with brown vomit coming from his mouth. His pulse was checked, and chest compressions initiated and continued until EMS arrived. The time of death was 10:13 AM per EMS and fire department. Resident's family members, the DON and covering Medial Director (MD) were notified. Funeral home was called to pick up the resident body. The body left at 2:06 PM. No medication or treatment rendered. Nurse #4 was interviewed via phone on [DATE] at 9:08 AM. Nurse #4 recalled that on [DATE] she was at her medication cart on the 200 hall, and someone told her that there was a code in the building on the 400 hall. Nurse #4 stated she secured her medication cart and went to Resident #70's room. The Staff Development Coordinator had gone to get the crash cart and vital sign machine. Compressions had already been started by NA #5 and she stated she told NA #5 if he got tired to let her know. She stated when the Staff Development Coordinator returned with the vital sign machine, she checked vital signs and there were none. Nurse #4 stated she realized at that time that there was no backboard under Resident #70. She stated that the staff attempted to get the headboard off the bed to place under him but there were pins holding it in place. Once they were able to get the pins out, they pulled the headboard off, log rolled Resident #70 onto his side and put the headboard under him. Nurse #4 stated it was very chaotic and she could not recall the actual sequence of events but at some point, NA #3 switched over to do compressions on Resident #70 and she realized that his compressions were not effective and there were not creating recoil. Nurse #4 stated NA #3 stated that he did not want to break Resident #70's rib and I coached him and told him to go deeper your compressions have to be effective. When Nurse #4 realized that NA #3's compressions were still not effective they switched off to another staff member. Shortly after that EMS and fire rescue arrived and took over the scene. Nurse #4 stated she was not aware that the facility's backboard was not on the crash cart but knew that it was supposed to be on the cart. Nurse #4 confirmed that she was trained in CPR by the American Heart Association but had not received any training on cardiac arrest or emergency response in the facility. The Staff Development Coordinator was interviewed on [DATE] at 10:27 AM. She stated she started with the facility last week and on Monday morning she saw the DON in the hallway, and she asked her to go to [Resident 70's room] and run the code. The DON asked her to grab the crash cart, but she did not know where it was located and was told it was in the conference room. The Staff Development Coordinator explained after grabbing the crash cart from the conference room she took it to Resident #70's room and handed the ambu bag over to Nurse #4 and the staff that were in the room performing compressions switched positions. She stated when she arrived at Resident #70's room chest compressions were already in progress by Nurse #4, and she believed NA #3 and NA #4 were also in the room. Nurse #4 asked her to get the vital sign machine, so she did and when she returned to the room NA #3 was delivering chest compressions. The Staff Development Coordinator stated that she did realize that there was not a backboard under Resident #70, and she knew that there was not a backboard on the crash cart, and she thought it was better to start chest compressions without it then to take the time to search the building for the backboard. While NA #3 was delivering compressions she realized that his compressions were not effective, and she tried to coach NA #3, but he stated that he was worried about cracking Resident #70's ribs. The Staff Development Coordinator stated she took over compressions from NA #3 until EMS arrived on the scene. She added that they were able to remove the headboard of the bed and place that under Resident #70 and continued CPR with EMS taking over the scene. The DON was interviewed on [DATE] at 11:14 AM. The DON stated on [DATE] NA #4 came to her office and told her to come to Resident #70's room. She stated when she went to Resident #70's room he had no radial pulse and was warm to touch, and the Medication Aide was behind her at her computer and stated Resident #70 was a full code. The DON stated she instructed the Scheduling Coordinator to overhead page code blue and to call EMS. The DON stated all the nursing staff started to arrive at Resident #70's room, the Staff Development Coordinator grabbed the crash cart, and they began CPR. The DON stated she did not participate in CPR and stayed out of the way of the other nursing staff. She was unaware that NA #3 and NA #4 that were participating in CPR were not trained, and that the compressions NA #3 were delivering were not effective until today. The DON stated that anyone that was not trained in CPR should not administer CPR. She explained she had been at the facility since [DATE], and she had not had consistent staff and no one to oversee the training program. The Staff Development Coordinator was only recently hired and had not had time to develop and implement all the things that needed to be done at the facility. The DON further explained the backboard was supposed to be on the crash cart so all the required equipment would be available to the staff and the staff should have put the backboard under Resident #70 before beginning chest compressions. The DON also confirmed that the staff were not aware the crash cart was in the conference room due to the remodeling of the nursing station office and that they should have been aware of where the crash carts were located. An observation of the crash cart at nursing station #1 ([DATE]/400) nursing station on [DATE] at 12:35 PM revealed the cart to be stocked with an ambu bag and backboard along with numerous others supplies that would be required for an emergency. There was no checklist located on the cart. The Administrator was interviewed on [DATE] at 4:10 PM who stated he had been at the facility for a few months. He stated that until recently they had a vacancy in the Staff Development Coordinator position and that there was a lot gaps in the training program that they were trying to get filled. The Administrator stated that if staff were not certified in CPR, then they should not have been participating in CPR and the staff that were involved should have ensured the correct equipment was being used. The Medical Director (MD) was interviewed on [DATE] at 2:55 PM. She stated that the DON had called and told her about Resident #70 on [DATE]. She stated that Resident #70 had severe Parkinson's disease and had declined since coming to the facility. The MD stated that potentially Resident #70 may have aspirated but she was not for sure. The MD stated she was not familiar with the protocol for CPR or Emergency Response in the building, but she had always told the facility to call EMS before calling her. She stated that only staff trained in CPR should be performing CPR and the trained staff should know the basics of CPR which included placing a backboard under the resident to ensure effective chest compressions. The MD stated I do not think that not having a backboard under Resident #70 would have changed his outcome. The Administrator was notified of the immediate jeopardy on [DATE] at 5:13 PM. The facility provided the following credible allegation of immediate jeopardy removal: o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to ensure that Cardiopulmonary Resuscitation (CPR) was administered effectively when Resident #70 went into sudden cardiac arrest and CPR was initiated by 3 Nurse Aides (NA) without the use of a backboard and 2 of the NAs were without CPR certification. Starting [DATE], the Staff Development Coordinator (SDC) will complete an audit of the current CPR status of the nursing staff to include licensed nurses, certified nursing assistants, certified medication aides and agency nursing staff. The SDC will provide a CPR list of the nursing staff with current CPR certifications at each nursing station. Only certified CPR staff that are listed on the CPR list will be allowed to perform CPR. The Director of Nursing (DON), SDC, and nursing supervisor will be responsible for reviewing the daily staffing to ensure a CPR certified staff is working each shift. On [DATE], the 2 facility CPR carts were checked by the Staff Development Coordinator to ensure missing supplies were replaced on the carts and both carts have back boards. On [DATE], the DON will place the crash cart checklist on nursing station #1's crash cart and ensure that the crash cart checklist is in place on nursing station #2's crash cart. Starting [DATE], the SDC will educate the night shift licensed nurses on completing the crash cart checklist sheet on nursing station #1(100,200,300, 400 halls) and nursing station #2 (500, 600, 700 halls). The night shift licensed nurses will be responsible for completing the crash cart checklists each night and ensuring the carts are stocked, and the back boards are in place. All the current residents who have full code status are at risk as a result of this deficient practice. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete Starting [DATE], the Director of Nursing and the Staff Development Coordinator (SDC) will educate the nursing staff to include the licensed nurses, certified medication aides, and the certified nursing assistants on the CPR policy to include ensuring only nursing staff certified to perform CPR with current CPR certification status will be allowed to perform CPR, and making sure the back board is in place before initiating CPR to ensure that chest compressions are effective and allow for chest recoil. A list of the nursing staff with current CPR certifications will be placed at each nursing station. Nursing staff will not be allowed to perform CPR without their name listed on the CPR list and without a current CPR certification. The CPR list will be updated weekly by the SDC, to include newly hired and/or agency staff's CPR expiration and renewal dates. By [DATE], the Director of Nursing/Staff Development Nurse will conduct a mock Code Blue drill for training purposes on the 7am -7pm shift and 7pm- 7am shift. The Director of Nursing/Staff Development Nurse will conduct a mock Code Blue drill monthly thereafter. Starting [DATE], the Staff Development Coordinator (also a Certified CPR instructor) will begin teaching the American Heart Association CPR class and certifying staff pending their post class passing test scores. The class will be provided for staff whose CPR certifications are expired or staff without CPR certification. Starting [DATE], the Director of Nursing and the SDC will educate the licensed nurses on ensuring that the CPR crash carts are being checked daily, after use and the back board is in place. The night shift licensed nurses will be responsible for completing the crash cart checklist sheet each night and ensuring that the CPR crash carts are stocked, and the back boards are in place. The DON will be responsible for checking the CPR crash carts and reviewing the daily CPR crash cart checklist for completion weekly to ensure continual compliance. Starting [DATE], the Staff Development Coordinator (SDC) and the Director of Nursing will be responsible for ensuring all nursing staff to include licensed nurses, certified nursing assistants (CNA), certified medication aides (CMA), weekend, agency and prn staff receive the CPR education. Staff including new hires and prn staff will not be allowed to work without completing this education. The education will be ongoing to include new hires and prn staff. Effective [DATE], the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: [DATE] A validation of immediate jeopardy removal was conducted on [DATE]. The list of current staff certified in CPR was located in a binder at each nursing station. In addition, those staff that were certified were highlighted on the daily schedule, so they were easily identified by all staff. Both crash carts were located in the building, one at each nursing station, the logbook was on each cart and had been checked each night since [DATE]. A mock code blue had been conducted on each shift and staff responded accordingly. Interviews with the scheduling coordinator revealed that she ensured staff certified in CPR were scheduled on each shift. Interviews with other nursing staff revealed that they had been educated on where the crash carts were located, their role in emergency response, and how to identify which staff were certified in CRP. They were also able to verbalize that only staff certified in CPR should participate in CPR. The IJ removal date of [DATE] was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and Resident, staff, Physician Assistant (PA), and Medical Director (MD) interviews the facility failed to perform a comprehensive assessment including vital signs before moving a resident off the floor after a fall with injury and failed to seek immediate medical treatment or higher level of care. On 5/27/2024 at 10:40 pm Nurse #1, Nurse #2, Nurse #3, Nurse Aide (NA) #1, and NA #2 responded to Resident #40's room after they heard Resident #44 yell that Resident #40 was on the floor. Resident #40 was found face down on the floor. Nurse #1 and Nurse #2 rolled Resident #40 over, transferred Resident #40 by picking him up under his arms while NA #1 held traction to Resident #40's left leg. When Resident #40 was placed back in bed, Nurse #3 assessed Resident #40 and obtained vital signs at which time she noticed Resident #40's left leg was internally rotated and shorter than the right leg. Nurse #3 immediately summoned Emergency Medical Services (EMS) but after review of his chart and speaking to the Director of Nursing (DON), she was instructed to cancel EMS because Resident #40 had an advance directive that indicated Do Not Hospitalize unless his comfort needs could not be met at the facility. An x-ray was performed on 5/28/2024 which revealed Resident #40 had sustained an acute fracture of the proximal left femur (thigh bone). Resident #40 was transferred to the hospital on 5/28/2024 where he was admitted for further evaluation and pain management. The facility also failed to follow up with a provider about an abnormal radiology report, failed to obtain ordered laboratory testing, failed to ensure the necessary diagnostics were completed for a resident (Resident #196) that had confusion reported by the RP on 12/24/2023, and failed to immediately initiate Emergency Medical Services (EMS) when Resident #196 was only responsive to painful stimuli. Resident #196 was transferred to the hospital on [DATE] at 2:04 pm and was admitted for respiratory failure and placed on Bilevel Positive Airway Pressure (BiPAP, non-invasive ventilator). The deficient practice occurred for 2 of 3 residents reviewed for change of condition (Resident #40 and Resident #196). Immediate jeopardy began on 5/27/2024 when nursing staff failed to assess or obtain vital signs prior to moving Resident #40 after finding him face down on the floor and failed to follow through with emergency medical services for a resident with obvious signs of injury. Immediate jeopardy was removed on 6/12/2024 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of G (actual harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. Example #2 is being cited at a lower scope and severity of a G. The findings included: Resident #40 was admitted to the facility on [DATE]. His recent diagnosis as of January 2024 included dislocation of the internal left hip and was deaf and mute. Review of a Medical Order for Scope of Treatment dated 7/13/2023 completed by PA #1 revealed Resident #40 did not want to be resuscitated if he had no pulse and was not breathing. The MOST form stated Resident #40 wanted comfort measures to include keep clean, warm dry. Use medication by any route, positioning, wound care and other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Resident #40 was not to be transferred to the hospital unless comfort needs could not be met in the facility. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #40 was severely cognitively impaired. Resident #40 was coded as no impairment of his upper extremities, impairment on one side of his lower extremities. Resident #40 was coded as maximum assist for chair/bed to chair transfers. Resident #40 was coded as requiring substantial/maximal assistance with bed mobility, sitting to standing, lying to sitting, was not ambulatory, and used a wheelchair. A review of the care plan dated 5/8/2024 revealed Resident #40 required partial to moderate assistance with transfers. An interview was conducted on 6/3/2024 at 10:59 with Resident #44. Resident #44 reported Resident #40 had fallen approximately one week ago. Resident #44 reported he had returned to his room at night after going outside and found Resident #44 lying face down on the floor. Resident #44 stated he yelled for help and multiple staff members arrived. Resident #44 stated he told nursing staff in the room not to move Resident #40 until EMS could assess him because he was afraid Resident #40's leg was broken. Resident #44 stated Resident #40 was sent to the Emergency Department the next day and was found to have a broken leg. An interview was conducted on 6/4/2024 at 4:51 pm with Nurse #1. Nurse #1 reported she worked night shift (7:00 pm to 7:00 am) on 5/27/2024 on 400 hall and was passing medications when she heard Resident #44 yell that Resident #40 was on the floor. Nurse #1 stated she, NA #1, and NA #2 ran into Resident #40's room. Nurse #1 stated Resident #40 was found lying on his left side in a fetal position and appeared to have his left hand under his left hip. Nurse #1 reported that Nurse #2 arrived in the room, and they all rolled Resident #40 over. Nurse #1 reported she thought that something was wrong with his left hip. Nurse #1 reported she thought Resident #40 had recently had hip surgery and wanted to get him off the hard floor, which is why she had not assessed him and obtained vital signs prior to transferring Resident #40 into bed. Nurse #1 reported that she, in addition to Nurse #2, NA #1, and NA #2 picked Resident #40 off the floor and placed him in bed and recalled his left leg as looking like a limp noodle. An attempt to speak to Nurse #2 was made on 6/4/2024 and was unsuccessful. An interview was conducted on 6/4/2024 at 7:26 pm with NA #2. NA #2 reported she worked night shift (7:00 pm to 7:00 am) on 5/27/2024 and was assigned to the 400-hall. NA #2 reported she heard Resident #44 yell that Resident #40 was on the floor. NA #2 reported when she arrived in the room, Resident #40 was lying next to the wheelchair and appeared to have his right leg under the wheelchair. She reported Resident #40 was on his left side in a fetal position. NA #2 reported Resident #40's leg was moved when they rolled him onto his back. NA #2 stated that she had assisted Nurse #1, Nurse #2, and NA #1 as they transferred Resident #40 to the bed by helping lift under his arms. NA #2 stated she was not able to recall Nurse #1, Nurse #2, or Nurse #3 assessing Resident #40 until Resident #40 was in the bed. NA #2 stated she observed Resident #40's leg to not look right and appeared to be disfigured. NA #2 reported someone obtained vital signs after Resident #40 was placed back in the bed. An interview was conducted on 6/4/2024 at 7:57 pm with NA #1. NA #1 reported she worked night shift (7:00 pm to 7:00 am) on 5/27/2024 and was assigned 200 and 400 halls. NA #1 reported she was in the hall when she heard Resident #44 yell that Resident #40 was on the floor. NA #1 stated when she arrived at the room, Resident #40 was laying on his left side and appeared to have his right leg tangled in the wheelchair. NA #1 reported Resident #40's leg was moved from under the wheelchair when they rolled him over in the floor. NA #1 stated Nurse #1 thought Resident #40's leg was broken, and stated Resident #40 needed to be placed in the bed. NA #1 reported she held traction to Resident #40's left leg and kept it straight while the Nurse #1, Nurse #2, and NA #2 picked Resident #40 up using his arms. NA #1 reported traction was the pull and hold the leg in a neutral position. NA #1 reported she had been an Emergency Medical Technician (EMT) in the past, but that she did not function as one at the facility. A review of an incident report dated 5/27/2024 at 10:40 pm completed by Nurse #3 revealed Resident #40 was found lying face down on the floor beside the bed. An assessment revealed Resident #40 had internal rotation and shortening of the left leg, a small head laceration to the top of the scalp, and a small laceration to the left outer ankle. An interview was conducted on 6/4/2024 at 12:38 pm with Nurse #3. Nurse #3 reported she was passing medications on 300-hall when NA #1 and NA #2 came to tell her that Resident #40 was lying on the floor by the bed. Nurse #3 reported that when she arrived in Resident #40's room, Nurse #1, Nurse #2, NA #1, and NA #2 were transferring Resident #40 into bed. Nurse #3 stated after Resident #40 was in the bed she performed an assessment by asking him if he was okay and got his vital signs. Nurse #3 reported she observed his left leg internally rotated and shorter than his right leg. Nurse #3 stated she instructed another staff member to call 911 and began to print out his paperwork at which time she noticed Resident #40 had a Do not hospitalize order in his Electronic Medical Record (EMR). Nurse #3 reported she immediately called the Director of Nursing (DON) and was instructed by the DON to cancel Emergency Medical Services (EMS) and contact the on-call provider because the family would not want Resident #40 to be sent to the hospital. Nurse #3 stated she cancelled EMS and contacted the on-call provider, PA #2, that Resident #40 had internal rotation and shortening of his left leg, at which time PA #2 ordered Ibuprofen 600 milligrams (mg) one time for pain and was instructed to perform neurological checks every four hours. Nurse #3 stated if she had gotten to the room prior to Nurse #1, Nurse #2, NA #1, and NA #2 transferring Resident #40 to bed, she would have instructed them not to move him until she had assessed him and obtained vital signs. A physician's order dated 5/27/2024 at 10:54 pm for Resident #40 revealed an order for an x-ray of the left hip and pelvis written by the MD. The order was entered by Nurse #3 after she called to report Resident #40's left leg was internally rotated and shorter than his right leg. The pain documentation, on the MAR, from 5/27/2024 through 5/28/2024 revealed Resident #40 experienced pain 6 out of 10 during day shift on 5/28/2024 with no time noted and 8 out of 10 on 5/28/2024 at 12:19 pm prior to being transferred to the hospital. A radiology report dated 5/28/2024 at 9:37 am revealed Resident #40 had a dislocation of a left hip arthroplasty (a surgery to restore the hip joint) and an acute fracture of the proximal (close to the hip) left femur noted as new since 1/12/2024. Nurse #10 documented that she administered oxycodone-acetaminophen 5-325 mg tablet on 5/28/2024 at 12:00 pm, as scheduled (6:00 am, 12:00 pm, 6:00 pm, 12:00 am), and documented a pain assessment of 8 out of 10 for Resident #40. The physician's orders dated 5/28/2024 at 12:15 pm written by PA #1 revealed Resident #40 was to give another dose oxycodone-acetaminophen 5-325 mg tablet, one time only, for increased pain. Nurse #10 documented that she administered oxycodone-acetaminophen 5-325 mg tablet on 5/28/2024 at 12:19 pm, one time, and documented a pain assessment of 8 out of 10 for Resident #40. A review of a PA #1's progress noted dated 5/28/2024 revealed Resident #40 was seen after he fell from bed during the night (5/27/2024). Resident #40 had complained of pain. An x-ray was obtained that revealed a fracture of the left femur with lateral displacement. The PA spoke with the Resident Representative (RR) who agreed to have Resident #40 sent to the hospital for evaluation and possible reduction. On 5/28/2024 at 1:15 pm, PA #1 ordered Resident #40 to be transferred to the hospital. An interview was conducted on 6/4/2024 at 3:19 pm with PA #1. PA #1 reported she was made aware of Resident #40's fall the following day, 5/28/2024 when she arrived at the facility. PA #1 stated she was very familiar with Resident #40 and could tell on 5/28/2024 he was in a lot of pain and was grimacing. PA #1 reported she ordered an additional pain pill to be administered, and ultimately sent him to the hospital for further evaluation. The PA stated Resident #40's leg did not appear to be in the neutral position it should be in. The PA stated she ordered an x-ray on 5/28/2024 which revealed an old dislocation and a new fracture. The PA reported she was not aware staff had transferred Resident #40 back to bed prior to assessing him and obtaining vital signs. The PA stated that if Resident #40's leg was stabilized she could not see a problem with moving him prior to performing an assessment and obtaining vital signs. The PA reported that the facility staff always do things the way they are supposed to and follow protocol. The PA was unsure of what the facility's protocol was for assessing a resident after a fall. The PA reported after she received the x-ray results, she contacted the family, and sent Resident #40 to the Emergency Department for further evaluation. PA #1 verified she had received the x-ray results on 5/28/2024 at 9:37 am but had difficulty reaching Resident #40's RR to get permission to transfer him to the hospital, which caused a delay in his transfer to the hospital. PA #1 reported she was not an expert in orthopedics and was not familiar with traction. The Emergency Medical Services (EMS) report dated 5/28/2024 at 1:43 pm revealed Resident #40 had pointed to his left leg, and made a grimacing face as if to say that it hurt and there was obvious deformity noted in the left hip with inward rotation. Review of ED department evaluation on 5/28/24 Resident #40 presented to the Emergency department after he fell to the ground while transferring from his bed on 5/27/2024. Documentation revealed Resident #40 was complaining of pain and appeared to be less ambulatory. Resident #40 had an x-ray of his left hip and pelvis that demonstrated left hip arthroplasty with an associated fracture dislocation. Resident #40 was admitted to the facility for further evaluation and pain management medications were adjusted (he was administered hydrocodone-acetaminophen 5-325 mg every 6 hours) and his oxycodone was continued. Resident #40 was recommended nonsurgical interventions, he was not a surgical candidate, and was to follow up in two weeks with outpatient orthopedics. Resident #40 was discharged back to the facility on 5/29/2024. A review of the June 2024 MAR revealed Resident #40 had received oxycodone-acetaminophen 5-325 mg on 6/4/2024 at 12:00 pm, as scheduled. An observation and interview were conducted on 6/4/2024 at 1:16 pm. Resident #40 was lying in bed turned on his right size and pointed to his left upper outer thigh area, made a grimacing face and a squeezing motion with his hands. Resident #40 nodded yes that he had pain and mouthed the pain medication only helped a little. An interview was conducted on 6/5/2024 at 8:41 am with the Director of Nursing (DON). The DON reported she was aware of Resident #40's fall on 5/27/2024. The DON reported she was not aware Nurse #1, Nurse #2, and Nurse #3 failed to assess Resident #40 and obtain vital signs prior to transferring him to bed. The DON stated she expected staff to assess the resident for physical injury/deformity, pain, mental status changes, and obtain vital signs prior to moving a resident after a fall. The DON acknowledged staff could have caused additional harm to the resident if they were not assessed prior to being moved after a fall. The DON stated a Nurse should have assessed Resident #40 prior to transferring him back to bed. She further stated the facility had not investigated the incident because they knew he had fallen. The DON stated Nurse #3 should have contacted the family about Resident #40's condition and to get permission to send Resident #40 to the hospital on the night of the fall, 5/27/2024. The DON reported there was confusion because his advanced directives said to Do Not Hospitalize, so she advised staff to get RP permission. Nurse #3 was sending the resident out and the DON stopped her. An interview was conducted on 6/5/2024 at 3:09 pm with the MD. The MD reported she had been made aware on 5/28/2024 of Resident #40's fall on 5/27/2024 by PA #1. The MD stated PA #1 had Resident #40 sent to the hospital for evaluation because she was concerned how his leg looked. The MD was not aware Resident #40 had been transferred to the bed prior to being assessed or having vital signs obtained. The MD stated the Nurse should have performed a quick assessment to ensure Resident #40 was breathing and had no obvious deformity prior to moving him. The MD stated if there was obvious deformity staff could cause additional harm to the resident. An interview was conducted on 6/7/2024 at 3:23 pm with the Administrator. The Administrator reported he knew Resident #40 fell on 5/27/2024 but had not been made aware Resident #40 had not been assessed prior to transfer back to his bed. The Administrator agreed Resident #40 should have been assessed prior to moving him from the floor to the bed. The Administrator was made aware of Immediate Jeopardy on 6/5/2024 at 11:35 am. The facility provided the following credible allegation of immediate jeopardy removal: o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to thoroughly assess resident #40 on 5/27/24 at 10:40 pm after he fell from his wheelchair to the floor on his left side face down. Resident #40 was discovered by his roommate who summoned assistance from staff. Nurse #1, Nurse #2, NA #1, and NA #2 lifted resident #40 under his arms and held traction to Resident #40's left leg and picked him up from the floor and placed him in the bed. Nurse #3 completely assessed Resident #40 and observed that the left leg was internally rotated and shortened. Nurse #1 described left leg as a limp noodle. Nurse #3 immediately summoned Emergency Medical Services (EMS) but after speaking to the Director of Nursing (DON) Nurse #3 cancelled EMS even though Resident #40 had obvious deformity that warranted a higher level of care to manage the resident's comfort needs which could not be met in the facility. On 5/28/24, Resident #40 was further assessed by the provider and sent to the emergency room. The facility failed to identify the resident's obvious injury status post fall requiring a higher level of care. Starting 6/6/24, the Director of Nursing (DON) will review falls within the last 30 days to ensure residents were assessed by licensed nurses identifying obvious injuries prior to being moved to determine if the resident required a higher level of care. All the current residents with falls are at risk as a result of this deficient practice. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete On 6/10/24, the Chief Nursing Officer will educate the DON on directing the staff that call regarding falls with injury to the MOST forms and when to notify family and/or EMS. Starting 6/5/24, the Director of Nursing will educate licensed nurses on assessing resident status post falls, to include vital signs, neuro checks, range of motion, skin assessment and pain assessment, prior to being moved. Residents assessed with obvious injuries will be transferred to a higher level of care warranted by their MOST form. The Director of Nursing and clinical team will review falls daily, in clinical meetings, to ensure assessments were completed and if indicated, resident receive a higher level of care. The MOST forms will be reviewed/updated weekly and/or changes in condition by the Social Workers and kept in a binder at both nursing stations. Residents without a MOST form, Staff will notify Resident/Resident's responsible party, along with the provider, on assessment findings and guidance to determine if a higher level of care and services are warranted. Starting 6/5/24, the Director of Nursing and the SDC will educate the licensed nurses to review resident MOST forms before calling Emergency Medical Services and if obvious deformity to include indications of fracture are observed residents should be immediately transferred to a higher level of care because resident's comfort needs cannot be met at the facility. Starting 6/5/24, the Director of Nursing and the Staff Development Coordinator will educate all staff to include the certified nursing assistants (CNA), certified medication assistants (CMA), licensed nurses, therapy staff, housekeeping/ laundry staff, dietary staff, social services, administrative staff, weekend staff, agency and prn staff on ensuring that residents that experience falls are not moved prior to an assessment by a licensed nurse and reporting any changes from baseline immediately to the nurse. Starting 6/5/24, the Staff Development Coordinator (SDC) and the Director of Nursing will be responsible for ensuring all staff to include licensed nurses, certified nursing assistants (CNA), certified medication aides (CMA), dietary staff, social services, housekeeping/laundry staff, therapy staff, maintenance staff, administrative staff, weekend staff, agency staff and prn staff receive the education. Staff including new hires and prn staff will not be allowed to work without completing this education. The education will be ongoing to include new hires and prn staff. The SDC will be responsible for ensuring the education is completed. Effective 6/5/24, the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 6/12/24 A validation of immediate jeopardy removal was conducted on 06/13/24. The inital audit of falls within the last 30 days was reviewed with no issues noted and no residents that required a higher level of care identified. Nursing staff were able verbalize that they had recieved the education that after a fall, no resident was to be moved until assessed for injury by the licensed nurse. Licensed nurses were able to verbalize the steps to assessment including range of motion, vital signs, and neurological checks. They verbalized that if there was obvious injury that would be indicative of a fracture they were to check the MOST from, consult with the residents medial provider, as well as the residents responsible party for direction and the potential need to transfer to the acute care setting. The nursing staff were aware that the MOST forms were kept in a binder at each nursing station. Non nursing staff were able to verbalize that they had recieved education on not moving or touching a resident that had fallen but to immediately alert the licensed nurse. The education was verified to be a part of the new hire orientation packet. The immediate jeopardy removal date of 06/12/24 was validated. 2. Resident #196 was admitted to the facility on [DATE] with a diagnosis of respiratory failure (condition that makes it difficult to breath independently). A review of a care plan dated 12/18/2023 which revealed Resident #196 had an altered respiratory status and difficulty breathing related to respiratory failure with interventions which included monitoring for signs and symptoms of respiratory distress, increased respirations, decreased pulse oximetry, increased heart rate, restlessness, diaphoresis (sweating), headaches, lethargy (lack of energy), confusion, hemoptysis (bloody sputum), cough, pleuritic pain (chest wall pain), accessory muscle usage, and skin color changes. A review of the 5-day Minimum Data Set (MDS) dated [DATE] revealed Resident #196 was severely cognitively impaired with no behaviors. Review of a physician order dated 12/25/2023 read; Obtain chest-ray related to increased confusion per family members observation. A review of a radiology report for a 2-view (from the front and from the side of the body) chest x-ray dated 12/25/2024 at 2:16 pm revealed Resident #196 had left lower airspace disease related to either pneumonia or atelectasis. A review of the December 2023 progress notes revealed no progress note indicating a provider was made aware of the abnormal chest x-ray. Review of a physician order dated 12/25/23 read; Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) related to increased confusion per family members observation. A review of the December 2023 progress notes revealed no progress note indicating a provider was made aware of laboratory results or the inability to obtain laboratory results. A review of the Resident #196's December 2023 Medication Administration Record (MAR) indicated Nurse #6 had collected a CBC and BMP on 12/25/2023 at 1:24 am. A review of Resident #196's vital signs collected on 12/26/2023 at 10:15 am revealed a blood pressure of 147/96, heart rate of 98, a respiration rate of 16 breaths per minute, an oxygen saturation of 92%, and a temperature of 97.6 degrees Fahrenheit. A review of a nursing assessment dated [DATE] at 11:23 am revealed Resident #196 was confused, had crackles/rales (wet sounds), and pitting edema (swelling). A review of Resident #196's vital signs collected on 12/26/2023 at 1:24 pm revealed a blood pressure of 168/89, heart rate of 102, a respiration rate of 16 breaths per minute, no oxygen saturation was obtained, and a temperature of 98.8 degrees Fahrenheit. A review of a nursing note dated 12/26/2023 at 1:47 pm written by Nurse #5 which revealed the MD had been contacted regarding a change in Resident #196's condition and was advised to transfer Resident #196 to the hospital. A review of a nursing note dated 12/26/2023 at 2:03 pm written by Nurse #5 revealed Resident #40 had been transferred to the hospital with Emergency Medical Services. A review of the EMS record dated 12/26/2023 at 2:09 pm revealed Resident #196 was diagnosed with pneumonia via a chest s-ray and staff reported Resident #196 had been lethargic and not acting normally. Nursing staff reported the facility physician requested Resident #196 to be sent to the hospital. EMS documented vital signs which read; heart rate of 104, blood pressure 123/77, and an oxygen saturation of 93% on 3 liters of oxygen per minute. A review of the Emergency Department documentation dated 12/26/2023 revealed Resident #196 had presented with altered mental status and shortness of breath. Resident #196 was admitted to the intensive care unit with acute hypoxemic respiratory failure (decreased oxygen saturation without increased carbon dioxide) and sepsis (severe infection). Resident #196 had an oxygen saturation of 83% on 6 liters of oxygen per minute on arrival to the Emergency Department and was placed on the BiPAP. An interview was conducted on 6/4/2024 at 8:36 pm with Nurse #6. Nurse #6 reported she worked on 12/24/2023 during the night shift (7:00 pm to 7:00 am) and was assigned Resident #196. Nurse #6 stated after she had started her shift, Resident #196's Representative (RR) reported Resident #196 had acted more confused. Nurse #6 stated she called the provider on-call and was given orders to obtain laboratory testing and a chest x-ray. Nurse #6 reported she had not obtained laboratory testing that night because she never drew blood at night and was not able to draw blood. Nurse #6 was not able to recall documenting that she had collected Resident #196's labs, and was not sure why it was documented that she had on the MAR. An interview was conducted on 6/4/2024 at 4:07 pm with PA #2. PA #2 reported she was notified by Nurse #6 on 12/24/2023 that Resident #196 was confused and had a cough. PA #2 reported she ordered laboratory testing and a chest x-ray. PA #2 stated she was never called about the results of the laboratory testing or chest x-ray. PA #2 reported she was not on-call 12/25/2024, and that the on-call provider that day should have been notified. An interview was conducted on 6/4/2024 at 10:23 am with Nurse #5. Nurse #5 stated she worked 12/26/2024 and was assigned Resident #196. Nurse #5 stated she recalled Resident #196 had a chest x-ray performed that day, but she had not seen the results. Nurse #5 stated radiology reports would come over the fax machine and a Nurse or the Director of Nursing (DON) would contact the provider on call. Nurse #5 stated she had not notified the on-call provider because she had not received the radiology report and indicated if she had received it, she would have called the provider on call. Nurse #5 reported she had not called to check the results of the chest x-ray. Nurse #5 reported she had not collected laboratory testing on Resident #196 because she was not prompted to do so on the computer system used in the facility. Nurse #5 stated she thought the labs had been completed since Nurse #6 had checked the collection off on the MAR. Nurse #5 stated when she arrived on shift 12/26/2023, she had given medications to Resident #196 and noticed he was confused but was responsive and answering questions. Nurse #5 reported she had checked on him hourly. Nurse #5 stated around lunchtime (11:30 am) she noticed Resident #196 had pitting edema (swelling), crackles (wet lung sounds), and was only responsive to painful stimuli. Nurse #5 stated Resident #196 continued to wear oxygen at 3 liters per minute. Nurse #5 reported she notified the physician, at the time documented in the Electronic Health Record (EHR), 1:47 pm and received an order to send Resident #196 to the Emergency Department. Nurse #5 was unsure why there was an approximately 2-hour delay in her notification to the MD and she obtained one set of vital signs prior to transfer and was unable to recall if she obtained an oxygen saturation or not. Nurse #5 reported she transferred Resident #196 to the Emergency Department via Emergency Medical Services (EMS) at 2:04 pm. An interview was conducted on 6/4/2024 at 8:36 pm with Nurse #7. Nurse #7 stated she worked on 12/25/2024 on night shift (7:00 pm to 7:00 am). Nurse #7 was assigned Resident #196 and was not able to recall receiving chest x-ray results during her shift and had not called to check on them. Nurse #7 stated if she received it she would called the on call provider with the results. Nurse #7 stated she would assume dayshift had notified the provider since it had resulted during dayshift. Nurse #7 reported she drew blood at night if it was ordered but was not able to recall Resident #196. An interview was conducted on 6/5/2024 at 3:32 pm with the MD. The MD reported she had been contacted by Nurse #5 on 12/26/2023 at 1:47 pm that Resident #196 had a change in condition and was less responsive. The MD stated Nurse #5 had not informed her Resident #196 was only responsive to painful stimuli at 11:23 am on 12/26/2023. The MD stated she would expect Nurses to notify the MD as soon as possible with mental status changes. An interview was conducted on 6/7/2024 at 8:37 am with the Director of Nursing (DON). The DON stated abnormal radiology results were faxed to the facility. The DON stated Nurses checked the fax machine routinely for results and were to notify the on-call provider of any results. The DON also reported she obtained results from labs and radiology every morning and notified the provider as well. The DON confirmed there was no indication in Resident #196's medical record that the on-call provider had been notified of the x-ray or that nursing staff had called to check on the results of the chest x-ray. The DON stated she assumed it was because the report was not marked as alert which would usually indicated to staff the provider should be contacted. The DON reported laboratory tests were to be drawn and sent out. She stated the facility utilized an outside phlebotomist, but that Nurses could draw labs and use the courier until a certain time. The DON stated after the courier hours were over, if the resident had labs that needed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff, Physician Assistant (PA), and Medical Director (MD) interviews the facility failed to provide effective pain management for a resident (Resident #40) after a fall, with obvious deformity, or transfer him to the hospital for pain that could not be managed in the facility as outlined by his advanced directive. On 5/27/2024 Resident #40 was found face down on the floor beside his bed and was noted to have internal rotation and shortening of the left hip and leg. Resident #40 was crying, moaning, guarding (protecting/holding) his left leg, grimacing, and unable to be consoled by staff. Nurse #3 immediately summoned Emergency Medical Services (EMS) but after review of the resident's chart and speaking to the Director of Nursing (DON), she was instructed to cancel EMS because Resident #40 had an advance directed that indicated Do Not Hospitalize unless his comfort needs could not be met at the facility. Nurse #3 notified the provider on-call and obtained an order for a one-time dose of Ibuprofen (pain medication, decreases inflammation) to be given for pain and a left hip/pelvis x-ray. Nurse #3 administered that medication as well as oxycodone-acetaminophen 5-325 mg (pain medication) that was scheduled (for every 6 hours) at 12:00 am and Resident #40 continued to grimace in pain throughout the remainder of her shift. Nurse #3 administered the 6:00 am oxycodone-acetaminophen. Nurse #10 administered oxycodone-acetaminophen 5-325 mg tablet on 5/28/2024 at 12:19 pm, and documented a pain assessment of 8 out of 10 for Resident #40. An x-ray was performed in the facility on 5/28/2024 which revealed Resident #40 had sustained an acute fracture of the proximal left femur (thigh bone) and Resident #40 was transferred to the hospital on 5/28/2024 where he was admitted for further evaluation and pain management. The deficient practice occurred for 1 of 3 residents (Resident #40) reviewed for pain management. Immediate jeopardy began on 5/27/2024 when Resident #40 had fallen and was noted to have an obvious deformity and was not immediately transferred to the acute care hospital to ensure effective pain management. Immediate jeopardy was removed on 6/10/2024 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: Resident #40 was admitted to the facility on [DATE]. His recent diagnosis as of January 2024 included a dislocation of the internal left hip. Resident #40 was documented as deaf and mute. Review of a Medical Order for Scope of Treatment dated 7/13/2023 completed by PA #1 revealed Resident #40 did not want to be resuscitated if he had no pulse and was not breathing. The MOST form stated Resident #40 wanted comfort measures to include keep clean, warm dry. Use medication by any route, positioning, wound care and other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Resident #40 was not to be transferred to the hospital unless comfort needs could not be met in the facility. A review of physician's orders dated 1/17/2024 revealed Resident #40 was ordered oxycodone-acetaminophen 5-325 milligrams (mg) scheduled every 6 hours. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #40 was severely cognitively impaired. Resident #40 was documented as receiving opioids (pain medication). The pain management section of the MDS revealed Resident #40 had a scheduled pain medication regimen, he had not received any as needed pain medications, had not received any non-medication intervention for pain, and had not had any pain in the last 5 days. The care plan dated 5/8/2024 revealed Resident #40 required partial to moderate assistance with transfers. Resident #40 was care planned for chronic pain and risk for pain with interventions which included to evaluate the effectiveness of pain interventions. The pain documentation, on the MAR, from 5/1/2024 through 5/26/2024 revealed Resident #40 had a pain scale of 0 out of 10, when checked during the day and night shift), every day. Review of the MAR from 5/1/2024 through 5/26/2024 revealed documentation for administration of oxycodone-acetaminophen 5-325 mg every 6 hours (12:00 am, 6:00 am, 12:00 pm, and 6:00 pm) as scheduled for Resident #40. An incident report dated 5/27/2024 completed by Nurse #3 revealed Resident #40 was found at 10:40 pm lying face down on the floor beside the bed. An assessment revealed Resident #40 had internal rotation and shortening of the left leg, a small head laceration to the top of the scalp, and a small laceration to the left outer ankle. Nurse #3 documented Resident #40 to be unconsolable, rigid with clenched fists, moaning, groaning, and had facial grimacing. A nursing note dated 5/27/2024 at 10:40 pm written by Nurse #3 revealed Resident #40 was found lying face down on the floor beside his bed. An assessment revealed Resident #40 had internal rotation and shortening of the left leg, pain when moving/repositioning his leg, small head laceration on the left side of his forehead, and a small laceration on his left ankle. Resident #40 was assessed, and vital signs taken. Resident #40 complained of pain in his left hip. Resident #40's physician's orders dated 5/27/2024 written by the MD revealed an order for Ibuprofen (pain medication, decreases inflammation) 600 mg to be administered by mouth one time only for pain. The May 2024 Medication Administration Record (MAR) revealed the following: Nurse #3 documented that she administered Ibuprofen 600 mg to Resident #40 on 5/27/2024 at 11:15 pm and oxycodone-acetaminophen 5-325 mg tablet (which lasts 6 hours) on 5/28/2024 at 12:00 am, as scheduled, and had not documented a pain assessment for Resident #40 or re-evaluated the pain medication's effectiveness. Nurse #3 documented that she administered oxycodone-acetaminophen 5-325 mg tablet again at 6:00 am, as scheduled, and had not documented a pain assessment for Resident #40 or re-evaluated the pain medication's effectiveness. A nursing note dated 5/28/2024 at 5:24 am written by Nurse #3 revealed PA #2 had been contacted to inform PA #2 that Resident #40 had a low blood pressure. An interview was conducted on 6/4/2024 at 12:38 pm written by Nurse #3. Nurse #3 reported she was passing medications on 300 hall on 5/27/2024, and was assigned Resident #40, when Nurse Aide (NA) #1 and NA #2 came to tell her that Resident #40 was laying in the floor by the bed. Nurse #3 reported she observed Resident #40's left leg to be internally rotated and shorter than his right leg. Nurse #3 stated she contacted the on-call provider, PA #2, and informed her Resident #40 had fallen, that she had observed internal rotation and shortening of his left leg, and that he was experiencing a lot of pain, at which time PA #2 ordered Ibuprofen 600 milligrams (mg) one time for pain. Nurse #3 verified Resident #40 was crying, rigid with clenched fists, moaning/groaning, and had facial grimacing. Nurse #3 stated she administered Ibuprofen 600 mg in addition to his scheduled pain medication (oxycodone-acetaminophen) that he already had ordered. Nurse #3 reported the NAs had told her Resident #40 experienced excessive pain, continued to moan anytime his leg was touched, guarded, and was unable to consoled throughout the night. Nurse #3 stated she had contacted PA #2 again on 5/28/2024 at 5:30 am to inform her of a low blood pressure but failed to notify her that Resident #40 was still in pain. Nurse #3 stated she had forgotten to mention it because she was more worried about Resident #40's blood pressure being too low. Nurse #3 reported she had not administered any additional pain medication, except another scheduled dose of oxycodone-acetaminophen 5-325 mg at 6:00 am. PA #2 was unavailable for an interview. An interview was conducted on 6/4/2024 at 7:26 pm with NA #2. NA #2 reported she worked night shift (7:00 pm to 7:00 am) on 5/27/2024 and was assigned 400 hall. NA #2 stated Resident #40 moaned, grimaced, and guarded his left leg anytime he was moved or repositioned throughout the night when she assisted with him, and that Nurse #3 was notified about his pain. NA #2 reported staff checked on Resident #40 at least every 2 hours. An interview was conducted on 6/4/2024 at 7:57 pm with NA #1. NA #1 reported she worked night shift (7:00 pm to 7:00 am) on 5/27/2024 and was assigned 200 and 400 halls. NA #1 reported during the transfer Resident #40 was crying during transfer and when NA #2 would help her turn and reposition Resident #40 throughout the remainder of the shift. NA #1 stated she was hesitant to reposition Resident #40 throughout the night because he was exhibiting nonverbal grimacing, moaning, and guarding of his left leg. The pain documentation, on the MAR, from 5/27/2024 through 5/28/2024 revealed Resident #40 experienced pain 6 out of 10 during day shift on 5/28/2024, with no time noted, and 8 out of 10 on 5/28/2024 at 12:19 pm prior to being transferred to the hospital. An interview was conducted on 6/4/2024 at 4:51 pm with Nurse #1. Nurse #1 reported she worked night shift (7:00 pm to 7:00 am) on 5/27/2024 on 400 hall and was passing medications when she heard Resident #44 yell that Resident #40 was in the floor. Nurse #1 reported she worked the remainder of the shift and came back every couple of hours to check on him throughout the night and thought he was in pain because he would moan. Nurse #1 reported she had not administered any additional medication to Resident #40 because he was not assigned to her. A physician's order dated 5/27/2024, at 10:54 pm, for Resident #40 revealed an order for an x-ray of the left hip and pelvis written by the MD. The order was entered by Nurse #3 after she called to report Resident #40's left leg was internally rotated and shorter than his right leg. A radiology report dated 5/28/2024 at 9:37 am revealed Resident #40 had a dislocation of a left hip arthroplasty (a surgery to restore the hip joint) and an acute fracture of the proximal (close to the hip) left femur noted as new since 1/12/2024. A progress note completed by PA #1, dated 5/28/2024, with no time noted, revealed Resident #40 was seen for evaluation after a fall on 5/27/2024. Resident #40 had complained of pain. The x-ray was reviewed and noted to have a fracture of the proximal left femur with lateral displacement. Resident #40 was recommended for hospital transfer for evaluation. The physician's orders dated 5/28/2024 at 12:15 pm written by PA #1 revealed Resident #40 was to give an additional oxycodone-acetaminophen 5-325 mg tablet one time only for increased pain. An interview was conducted on 6/4/2023 at 3:19 pm with PA #1. PA #1 reported she had been made aware the morning of 5/28/2024 of Resident #40's fall on 5/27/2024. PA #1 stated she was very familiar with Resident #40 and could tell on 5/28/2024 he was in a lot of pain and was grimacing. PA #1 reported she reviewed the x-ray of the left hip/pelvis and noticed an acute fracture. PA #1 reported she ordered an additional pain pill to be administered, and ultimately sent him to the hospital for further evaluation. PA #1 reported she had not been made aware Resident #40 had experienced increased pain throughout the night and would have expected nursing staff to report increased pain to the on-call provider. PA #1 reported Resident #40 was ordered oxycodone-acetaminophen 5-325 mg, 2 tablets, every 6 hours for pain on his arrival back to the facility. Nurse #10 documented that she administered oxycodone-acetaminophen 5-325 mg tablet on 5/28/2024 at 12:19 pm, as scheduled, and documented a pain assessment of 8 out of 10 for Resident #40. On 5/28/2024 at 1:15 pm, PA #1 ordered Resident #40 to be transferred to the hospital. The Emergency Medical Services (EMS) report dated 5/28/2024 at 1:43 pm revealed Resident #40 had pointed to his left leg, and made a grimacing face as if to say that it hurt and there was obvious deformity noted in the left hip with inward rotation with no other obvious injuries were noted. The Acute Care Hospital documentation dated 5/28/2024 through 5/29/2024 revealed Resident #40 presented to the Emergency department after he fell to the ground while transferring from his bed on 5/27/2024. Documentation revealed Resident #40 was complaining of pain and appeared to be less ambulatory. Resident #40 had an x-ray of his left hip and pelvis that demonstrated left hip arthroplasty with an associated fracture dislocation. Resident #40 was admitted to hospital further evaluation and pain management and medications were adjusted (he was administered hydrocodone-acetaminophen 5-325 mg every 6 hours) and his oxycodone was continued. Resident #40 was recommended nonsurgical interventions and was to follow up in two weeks with outpatient orthopedics. Resident #40 was discharged back to the facility on 5/29/2024. The physician's orders dated 5/28/2024 at 6:00 pm revealed Resident #40 was ordered oxycodone-acetaminophen 5-325 mg, 2 tablets, every 6 hours for pain, and was discontinued on 5/31/2024. The physician's orders dated 5/31/2024 at 12:00 pm revealed Resident #40 was ordered oxycodone-acetaminophen 5-325 mg every 4 hours for pain. An observation and interview were conducted on 6/4/2024 at 1:16 pm. Resident #40 was lying in bed turned on his right size and pointed to his left upper outer thigh area, made a grimacing face and a squeezing motion with his hands. Resident #40 nodded yes that he had pain and mouthed the pain medication only helped a little. An interview was conducted on 6/5/2024 at 8:41 am with the Director of Nursing (DON). The DON stated Nurse #3 had contacted her about Resident #40's fall the night of 5/27/2024. The DON stated Nurse #3 told her Resident #40's leg was internally rotated and shorter, and she advised Nurse #3 to contact the on-call provider and the family to see if Resident #40 should be transferred to the hospital for further evaluation. The DON stated she was not aware Resident #40 had experienced increased pain and the provider had not been notified. The DON stated staff were to report increased or uncontrolled pain to the provider. An interview was conducted on 6/5/2024 at 3:09 pm with the MD. The MD reported she had been made aware on 5/28/2024 of Resident #40's fall on 5/27/2024 by PA #1. The MD stated PA #1 had Resident #40 sent to the hospital for evaluation because she was concerned how his leg looked. The MD reported PA #1 had adjusted Resident #40's pain medications after he returned to the facility and that she had seen him earlier on 6/5/2024 and he was smiling and had not appeared to be in pain. The MD was not aware of Resident #40's pain the night of his fall and reported staff should have reported increased or uncontrolled pain. An interview was conducted on 6/7/2024 at 3:23 pm with the Administrator. The Administrator reported he knew Resident #40 fell on 5/27/2024 but had not been made aware Resident #40 had increased or uncontrolled pain that was not reported to the on-call provider. The Administrator agreed the on-call provider should have been made aware of Resident #40's pain, The Administrator was notified of Immediate Jeopardy on 6/5/2024 at 11:35 am. The facility provided the following credible allegation of immediate jeopardy removal: o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to address Resident #40's pain to his left hip after sustaining a fall from his wheelchair which resulted in an acute fracture of the proximal femur. Starting 6/6/24, the Director of Nursing and the licensed nurses will complete new pain assessments of the current residents to include review of progress notes, care plans and resident pain regiments to ensure resident pain is being managed and/or prevented. Interviewable residents will also be interviewed by the licensed nurse to ensure that their current pain regime is adequate. All the current residents are at risk as a result of this deficient practice. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete Starting 6/5/24, the Chief Nursing Officer reviewed the Maple Health Pain Management Prevention Plan with the Director of Nursing. Starting 6/5/24, Director of Nursing and the Staff Development Coordinator will educate the licensed nurses, certified nursing assistants (CNA), and the certified medication aides (CMA) on identifying signs and symptoms of pain, and pain management and prevention to include follow up with the provider if pain management interventions are not effective. Pain will be assessed every shift, after a fall, with changes in condition and before and after pain medication administration and documented in the medication administration record or the progress notes. Starting 6/5/24, the Staff Development Coordinator (SDC) and the Director of Nursing will be responsible for ensuring licensed nurses, weekend nursing staff, CNAs, and CMAs receive the education to include identifying sign and symptoms of pain, and pain management and prevention to include follow up with the provider if pain management interventions are not effective. Staff including new hires and prn staff and agency staff will not be allowed to work without completing this education. The education will be ongoing to include new hires and prn staff. The SDC will be responsible for ensuring the education is completed. Effective 6/5/24, the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 6/10/24 A validation of immediate jeopardy removal was conducted on 06/13/24. The initial pain assessments and interviews were reviewed with no issues noted. Licensed nurses were able to verbalize that they had the education reguarding pain and that pain was assessed after a fall, with change in condition, before and after pain medication administration and would documented in the medical record. Non licensed staff were able to vervalize that if a resident complained of pain or indicated thier pain medication was not effective who to report that information too. The licensed nurses were able to verbalize the need to communicate to the medical provider and involve the responsibel party if the residents pain could not be managed in the facility and needed a higher level of care. The immediate jeopardy removal date of 06/10/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and Medical Director interviews the facility failed to ensure that Nurse Aides (NA) #3 and NA #4 knew how to respond to a medical emergency, and what role to assume during a medical emergency, and were certified in cardiopulmonary resuscitation (CPR) before participating in an emergency situation that resulted in performing CPR on Resident #70. On [DATE] Resident #70 went into sudden cardiac arrest and NA #3, NA #4, and NA #5 began CPR without the use of backboard which creates a hard surface for effective chest compressions that allows for adequate recoil (allow the chest to fully expand after compressions which pushes blood to vital organs). NA #3 and NA #4 were not certified in CPR for Healthcare Providers. During CPR Nurse #4 and the Staff Development Coordinator observed NA #3's compressions were not effective or deep enough to create recoil and had to instruct NA #3 that his compressions were not deep enough before switching out with the Staff Development Coordinator who could assist. EMS arrived and placed a backboard under Resident #70 and continued CPR. Resident #70 expired. In addition, Nurse #4 and the Staff Development Coordinator did not receive orientation on response to medical emergencies. The deficient practice affected 5 of 5 staff reviewed for emergency procedure competencies. Immediate jeopardy began on [DATE] when NA #3 and NA #4 performed CPR on Resident #70 without being trained in CPR for Healthcare Providers. Immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete education and ensuring monitoring system put into place are effective. The findings included: This tag is cross referred to: F678: Based on observations, record review, staff, and Medical Director interviews the facility failed to ensure that Cardiopulmonary Resuscitation (CPR) was administered effectively when Resident #70 went into sudden cardiac arrest and CPR was initiated by Nurse Aide (NA) #3, NA #4, and NA #5 and continued for 7 minutes without a backboard. The backboard creates a hard surface for effective compressions that allow for adequate recoil (allowing the chest to fully expand after compression which pushes the blood to vital organs) and ensure perfusion for vital organs. During CPR Nurse #4 and the Staff Development Coordinator observed NA #3's compression were not effective or deep enough to create recoil and had to instruct NA #3 that his compressions were not deep enough before switching NA #3 out with another staff member that could assist. NA #3 and NA #4 were not certified in CPR for Healthcare Providers. Emergency Medical Services (EMS) arrived and placed a backboard under Resident #70 and continued CPR. Resident #70 expired. A review of a document provided by the facility titled, Orientation Overview with no date noted, indicated that on day 1 and day 2 of orientation new staff would watch a video on emergency preparedness. The required paperwork was listed as CPR card (required for Nurses only, but good to have for other staff), facility codes and security access, and included a facility tour. A review of NA #3's training file revealed his date of hire was [DATE] and there was no Orientation and/or Skills Competencies on emergency situations, how to respond or what their role during an emergency was, and no CPR certification. There was no job description in the file. A review of NA #4's training file revealed his date of hire was [DATE] and there was no Orientation and/or Skills Competencies on emergency situations, how to respond or what their role during an emergency was, and no CPR certification. There was no job description in the file. A review of NA #5's training file revealed his date of hire was [DATE] and there was no Orientation and/or Skill Competencies on emergency situation, how to respond or what their role during an emergency was noted. There was an active CPR certification from the American Heart Association with an expiration of 07/2024. There was no job description in the file. The NA job description dated [DATE] indicated that job requirements included a preference for current/active CPR certification. A review of Nurse #4's training file revealed her date of hire was [DATE] and there was no Orientation and/or Skill competencies on medical emergency situations, how to respond or what her role during an emergency was. There was no CPR certification or job description noted in the file. Nurse #4 was able to produce a copy of her CPR certification from the American Heart Association with an expiration on 08/2024. A review of the Staff Development Coordinator's training file revealed her date of hire was [DATE] and no Orientation and/or Skills Competencies on medical emergency situations, how to respond or what her role during an emergency was. There was no CPR certification or job description noted in the file. The Staff Development Coordinator was able to produce a copy of her CPR certification from the American Heart Association with an expiration on 07/2025. The Nurse job description dated [DATE] indicated that job requirements included: current/active CPR certification. The essential duties and responsibilities included: confirm that all nursing personnel assigned to you comply with the written policies and procedures established by this facility and verify that all nursing service personnel are in compliance with their respective job descriptions. NA #3 was interviewed via phone on [DATE] at 8:57 AM. NA #3 stated he had only been employed at the facility for a short time and his CPR certification had expired and was no longer valid. NA #3 stated that when he came to work at the facility, he was given no training in medical emergencies, how to respond, where emergency equipment was located, and no training in CPR. He also stated he had not completed any competencies or skills check since coming to the facility. The Staff Development Coordinator was interviewed on [DATE] at 10:27 AM. The Staff Development Coordinator stated that she had only been at the facility for less than a week and had not had the time to get the training program started but would be working on that in the future. She explained when she started, she was not given any information on location of emergency supplies or equipment, was told nothing about code situations, how to run one or what was supposed to be on the crash cart or where the crash carts were located. She stated she had to ask the DON where the crash cart was located during the emergency situation on [DATE]. She added that her CPR certification was active and was also trained in advance life support as well. The DON was interviewed on [DATE] at 11:14 AM. She explained she had been at the facility since [DATE], and she had not had consistent staff and no one to oversee the training program. The Staff Development Coordinator was only recently hired and had not had the time to develop and implement all the things that needed to be done at the facility. She stated that at the bare minimum staff should be given a tour of the facility and shown where the crash carts and emergency equipment were located. The DON was asked for the training records for NA #3, NA #4, Nurse #4, and the Staff Development Coordinator and she stated that there were none because she had not had a staff member in that role consistently since she started in [DATE]. She stated that she had plans with the Staff Development Coordinator from a sister facility to come over and train their current Staff Development Coordinator and set up the orientation manual like she wanted, to ensure that all staff received the required training. She further stated that a part of that training was going to include skills and competencies for each staff member. The DON stated that currently new staff were brought into the facility given a quick tour of the facility and then sent out with a staff member to be trained. The Administrator was interviewed on [DATE] at 4:10 PM. He explained the previous Staff Development Coordinator had started the training program but when they began requesting the training she was unable to produce it, so they had to part ways with the employee which created a long-term vacancy in that position. The Administrator was notified of the immediate jeopardy on [DATE] at 5:13 PM. The facility provided the following credible allegation of immediate jeopardy removal: o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to ensure that the staff were trained in Emergency Response, how to respond, when to respond, and their role during medical or clinical emergency situations in the facility. The facility also failed to complete staff competency checklists to include medical and clinical emergency responses, medical and clinical facility codes, and location of medical and clinical emergency equipment. Starting [DATE], the Staff Development Coordinator, Director of Nursing and Unit Manager will ensure that all staff to include nursing staff, administrative staff, dietary staff, laundry/ housekeeping staff, and maintenance staff complete competency checklists based on their job descriptions for medical and clinical emergencies, medical and clinical codes and location of medical and clinical emergency equipment to ensure staff is aware of how to respond in clinical and medical emergencies. Staff will not be allowed to participate in medical and clinical emergencies without completing the competency. All the current residents are at risk as a result of this deficient practice. o Specify the action the entity will take to alter the process or system complete.to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete Starting [DATE], the Staff Development Coordinator will ensure all staff to include the certified nursing assistants (CNA), certified medication assistants (CMA), licensed nurses, therapists, housekeeping/ laundry staff, dietary staff, social services, administrative staff, weekend staff, agency and prn staff complete competency checklists to include medical and clinical emergencies, medical and clinical facility codes and the location of medical and clinical emergency equipment. Starting [DATE], the Director of Nursing and Staff Development Coordinator (SDC) will educate the facility staff to include the certified nursing assistants (CNA), certified medication assistants (CMA), licensed nurses, therapists, housekeeping/ laundry staff, dietary staff, social services staff, administrative staff, weekend staff, agency and prn staff on emergency responses to include how to respond, when to respond, and their role during medical and clinical emergency situations in the facility and where to find the medical and clinical emergency equipment located at the nursing stations. The night shift licensed nurses will complete the medical and clinical emergency equipment check list daily. The DON will check the medical and clinical emergency equipment and the completed medical and clinical check list weekly to ensure compliance. Starting [DATE], the Staff Development Coordinator (SDC) and the Director of Nursing will be responsible for ensuring licensed nurses, weekend staff, CNAs, therapists, housekeeping/laundry staff, dietary staff, social services staff, administrative staff and CMAs including new hires and prn staff will not be allowed to work without completing this education. The education will be ongoing to include new hires and prn staff. The SDC will be responsible for ensuring the education is completed. Effective [DATE], the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: [DATE] A validation of immediate jeopardy removal was conducted on [DATE]. Staff across all departments were able to verbalize that they had received education on responding to emergenices, thier individual role in emergencies, how to respond, location of emergency equipment, and who was able to render care during an emergency. The non lisenced staff were able to report that they could contact EMS services, direct them to the appropriate place, and gather supplies as instructed by the licensed Nurse. The licensed nurse were able to report their role in an emergency, how to direct the non licensed staff, initating and rendering emergency care. Review of the emergency checklist revealed that the staff had been ensuring the emergency equipment was stocked and ready for use each night since [DATE]. The immediate jeopardy removal date of [DATE] was validated.

Based on staff interviews and record reviews, the facility failed to have effective systems in place to ensure there were dietary staff to prepare meals when dietary staff did not arrive to work on the 1/22/23. The Central Supply Clerk and three Nurse Aides (NAs) prepared breakfast, lunch, and dinner resident meals without checking the internal temperature of cooked foods before serving and did not serve resident mechanically altered diets as ordered. This led to the high likelihood for residents to be at risk of choking or aspiration. This situation affected 9 of 9 residents (Resident #1, Resident #22, Resident #53, Resident #69, Resident #31, Resident #57, Resident #8, Resident #17, and Resident #26) for 3 of 3 meals. The staff also prepared breakfast, lunch, and dinner resident meals without checking the internal temperature of cooked foods before serving for 91 of 91 residents. The Immediate Jeopardy (IJ) began on 1/22/23 when dietary staff did not arrive to work their scheduled shift to ensure meal service was provided by trained and competent staff. This resulted in 9 of 9 residents not receiving a pureed diet for 3 of 3 meals. The immediate jeopardy was removed on 2/7/23 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity E (no actual harm that is immediate jeopardy) to ensure monitoring systems are put into place are effective. Findings included: An interview with the Central Supply clerk was conducted on Sunday, 1/24/23 at 1:30 PM. The Central Supply clerk indicated he was working in the facility on 1/22/23 as a medication aide when he and other nursing staff discovered the meal trays for the breakfast meal had not arrived at the floor for distribution around 8:45 AM. He indicated the breakfast meal trays should begin arriving on the unit shortly after 7:30 AM each morning. The Central Supply clerk stated he, along with Nurse Aide #5, went to the dietary department and began knocking on the door. They discovered there were no visible lights on and both doors were securely locked. Following this observation, the Central Supply clerk notified the Administrator via text message that no dietary staff had arrived to prepare food for the residents. The Administrator directed him, NA #5, NA #10, and NA #11 to obtain a master key to enter the dietary department and prepare the breakfast meal. Central Supply clerk explained since he and NA #11 had worked in a kitchen during employment with other companies, they went to the walk-in fridge and walk-in-freezer and began pulling items they recalled were normally served to the residents for the breakfast meal and began prepping them to cook. He stated the following items were prepped and cooked: omelets, sausage patties, oatmeal, grits, scrambled eggs, and French toast sticks. The Central Supply clerk indicated they were unable to puree food, so they cut it in very small pieces and then mashed it with a potato masher to serve to residents on mechanically altered diets such as chopped or ground meats, and puree. The Central Supply clerk stated meal tickets had already been printed which allowed them to serve items based on the tray card; however, they did not call the Dietary Manager, Regional Dietary Manager nor the Consulting Registered Dietician when the menu was altered and to let them know they were unable to use of all kitchen equipment. Central Supply clerk indicated the breakfast meal was delivered to the units for residents shortly after 10 AM on 1/22/23. He acknowledged he and the other staff improvised the best they could and did not obtain temperatures of the food before delivery nor provide the proper textured diets for each resident. The Central Supply clerk indicated at approximately 10:30 AM, a dietary aide (Dietary Aide #2) arrived to work who attempted to assist the nursing staff to wash dishes in the dish machine; however, no one checked to ensure the temperatures were meeting required levels for sanitation during usage. The Central Supply clerk stated he and NA #11 also used the 3-in-1 sink to wash cook wear but did not perform the chemical strip controls to ensure proper levels of chemicals were used to maintain sanitation. The Central Supply clerk further explained no one else from the dietary department arrived to assist on 1/22/23 and therefore, he and NA #11 prepared all meals for residents on that day. He stated they prepared and served the following: lunch- roast beef, sweet potato casserole, spinach, peaches, and cornbread and for supper they served: meatloaf, mashed potatoes, squash casserole, mandarin oranges, and a biscuit. An interview with the Administrator was conducted on 1/23/23 at 12:30 PM. The Administrator indicated he became aware staff from the dietary department had not arrived at work on the morning of 1/22/23 at approximately 8:45 AM when nursing staff and the central supply clerk discovered no meal trays had been delivered to the units and no residents had received their breakfast meal which should have been delivered beginning at 7:30 AM. He indicated he lived out of state came back to the facility as soon as he could. The Administrator gave the authorization for the Central Supply Clerk and the 3 nurse aides (NA #5, NA #10, and NA #11) to begin meal preparation and delivery of the breakfast meal. He arrived at the facility several hours later that day between 2:00-3:00 PM on 1/22/23 at which time breakfast and lunch had already been served to all residents. The Administrator indicated he contacted the Regional Dietary Consultant after being unable to reach the DM on 1/22/23 but was not assisted with providing staff to cover the meal delivery in the facility. The Administrator did not have previous food service experience and told the Central Supply clerk to serve meals based on the residents' meal ticket but was unable to provide any further guidance on preparation or meal service. He did not give any directive regarding preparing snacks at the time. A telephone interview with [NAME] #1 was conducted on 1/26/23 at 10:17 AM. [NAME] #1 revealed he had worked on 1/21/23. [NAME] #1 indicated on 1/21/23 at 4:28 PM, he tried to contact the DM by telephone without success so he followed the call with a text message which would alert the DM he could not work his scheduled shift of 5:30 AM to 5 PM on 1/22/23. [NAME] #1 stated he had not been contacted by the facility to answer any questions about what food was to be prepared or how to use the kitchen equipment on 1/22/23 and did not receive a return call from the DM. [NAME] #1 was also able to verify that they frequently only had 1 cook and 2 dietary aides scheduled to work on the weekends. A review of the monthly dietary schedule revealed the following for 1/22/23: Cook #1 was assigned from 5:30 AM to 5:00 PM. Dietary Aide #1 was assigned from 6:30 AM to 2:30 PM. Dietary Aide #2 was assigned from 10:30 AM to 7:30 PM. A review of the monthly dietary scheduled reflected this was the schedule every other week on Sunday and on the opposite Sunday revealed one cook would be scheduled from 5:30 AM to 2 PM and an additional cook would be scheduled to work from 12:30 PM to 7:30 PM. An interview with Dietary Aide #1 (DA) was conducted on 1/25/23 at 11:30 AM. DA #1 indicated she was scheduled to work on the morning of 1/22/23; however, informed the DM around 3 AM that she would not be able to work her scheduled shift for that day. The DA #1 stated she initially called the DM with no response and then followed it with a text message on 1/22/23 and did not receive a reply from the DM. Multiple attempts were made to contact Dietary Aide #2 without success. Multiple attempts were made to contact the former DM without success as she no longer works with the contracted food service company. An interview with NA # 10 on 1/24/23 at 1:59 PM revealed she arrived to work on 1/22/23 at around 7:00 AM and she along with other nursing staff members began noticing residents' meals had not been delivered around 8:30 AM. NA #10 stated the Central Supply clerk and NA #11 went in the kitchen and began cooking the food and she and NA #5 plated additional items such as drinks and desserts before they were delivered to each unit. NA #10 stated she assisted to serve both breakfast and lunch on 1/22/23, but did not aide in the evening meal because she was scheduled to leave at 4:00 PM. NA #10 explained they were not able to use all of the kitchen equipment and therefore attempted to mechanically alter the puree diet trays by cutting up items really small and then using a potato masher to get the food as smooth as possible before delivering it to the residents. NA #10 reviewed the items listed that were served to the Central Supply clerk's list and agreed those were the items served and that single use disposable wear was used because of lack of dishes and trays. NA #10 also indicated during the lunch meal a few pizzas were ordered by a staff member but the pizza's delivered were too hard for most residents and they instead consumed the meal served by the nursing staff who prepared the meal that day for lunch. An interview with NA #5 on 1/25/23 at 10:30 AM revealed she was assigned to work the unit as a nurse aide on 1/22/23 when she learned the dietary staff members had not arrived to work and residents had not yet had breakfast at around 9 AM. NA #5 indicated she along with the Central Supply clerk (who was assigned to work as a medication aide on 1/22/23), NA #10, and NA #11 went to the kitchen and began getting breakfast ready so residents could have something to eat. NA #5 stated they did the best they could to get residents something to eat although she acknowledged she was aware they were unable to use the kitchen equipment to mechanically alter the foods for residents on a puree diet and therefore those items were cut up finely and mashed with a potato masher to get as best consistency as possible and all meals served were delivered on single serve disposable wear. NA #5 recalled providing residents the food items provided by the Central Supply clerk during his interview. An interview with NA #11 on 1/25/23 at 10:45 AM revealed he was scheduled to work as a nurse aide on 1/22/23 when he was notified the dietary department had not arrived at the facility to prepare meals to the residents. NA #11 stated he, the Central Supply clerk, NA #5, and NA #10 then obtained a key to enter the dietary department where he and the Central Supply clerk had realized they each had some previous culinary experience and therefore they the two of them were the staff members who prepared the food items while NA #5 and NA #10 plated additional items such as desserts and drinks. NA #11 stated they were not able to use the kitchen equipment and therefore they were unable to properly prepare the texture for the puree consistency and therefore cut the items up as small as possible and then mashed them with a potato masher before serving the item to the resident on prescribed puree diets. NA #11 acknowledged they did not follow a menu on 1/22/23; they strictly looked in the walk-in-fridge and walk-in-freezer to find items that were accessible and verified they prepared the following items for residents for breakfast were: scrambled eggs, omelets, oatmeal, grits, French toast, and sausage; for lunch: roast beef, sweet potato casserole, spinach, peaches, and cornbread and for supper they served: meatloaf, mashed potatoes, squash casserole, mandarin oranges, and a biscuit. An interview with the Regional Dietary Consultant was conducted on 1/23/23 at 10:08 AM. She indicated she was contacted on 1/22/23 by the facility Administrator who notified her that the staff from the dietary department had not shown up to prepare food on 1/22/23 and that facility nursing staff were attempting to prepare meals for all residents in the facility. The Consultant indicated she was unsure at the time what occurred further than the staff did not arrive to work. An interview with the Regional Dietary Manager on 1/24/23 at 9:28 AM revealed she was without a phone over the weekend and did not learn of the events of 1/22/23 until the morning of 1/23/23 when she was asked to come to the facility by the Regional Dietary Consultant therefore she did not come to the facility on 1/22/23 to aide in meal service and was unsure what was prepared or what occurred in the department on 1/22/23. She provided the surveyor the monthly schedule and verified it was accurate in how staff were scheduled in the department at the time. A follow-up interview was conducted with the Regional Dietary Manager on 1/24/23 at 2:30 PM. She indicated she was not made aware the dietary cook had made the Dietary Manager (DM) aware on 1/21/23 that he would not be able to work his shift on 1/22/23 and further indicated when the DM was made aware, she should have ensured coverage was obtained with other dietary staff. A telephone interview with the Consulting Registered Dietician (CRD) was conducted on 1/25/23 at 9:27 AM. She stated she was not involved in dietary staffing, schedules, or menu alterations in the facility and had not been contacted regarding the foods to be prepared by nursing staff on 1/22/23. The Administrator was notified of the Immediate Jeopardy on 2/3/23 at 9:14 AM. The facility provided the following credible allegation of compliance with a compliance date of 2/7/23. The facility provided the following credible allegation of compliance with a compliance date of 2/7/23. o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to ensure adequately trained and competent staff were on duty for meal preparation and service and failed to ensure dishes were sanitized correctly on 1/22/23. On 1/22/23, one untrained Central supply Clerk and 3 Nurse aides prepared 3 meals for 91 of 91 residents when the scheduled dietary staff did not show up for work. In addition, the one untrained Central supply Clerk and 3 Nurse aides prepared 3 meals for 91 of 91 residents without taking food temperatures, without being trained on the use of the dish machine and unaware of the 3-sink compartment dish sanitization procedure. As a result, the identified staff were unaware that the dish machine was not working properly, and dishes were not sanitized as required. On 2/3/23 the Director of Nursing, Assistant Director of Nursing, and Charge Nurses completed assessments of the current facility residents to include the 91 residents on 1/22/2023 that still remain in the facility. No signs/symptoms of foodborne illnesses were identified. On 2/3/23, the current facility residents were reviewed by the Director of Nursing and Assistant Director of Nursing to identify any changes of condition related to unsafe food preparation and the wide range of dietary restrictions and diets. The results of this failure impacted all 91 of the facility residents on 1/22/2023. The current residents are at risk as a result of this deficient practice. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete Starting 2/3/23, the nursing staff will be educated by the Director of Nursing/ designee related to identifying the signs and symptoms of foodborne illnesses. The education will continue at the beginning of each shift until each staff member receives the education by 2/6/2023. No staff member including agency staff and new hires will be permitted to work until the education is received. Starting 2/3/23, the facility staff will be educated by the Director of Nursing and Assistant Director of Nursing to call the Administrator and the Dietary Manager immediately if dietary staff is not available to prepare meals to ensure trained dietary staff to include dietary staff that are scheduled off, dietary contract staff, and dietary staff from other sister facilities can be called in to prepare, cook, and serve the meals by 2/6/2023. The Administrator and the Dietary Manager contact information will be posted at each nursing station. The Dietary Manager and the Administrator will have the dietary staff contact information to include other sister facilities contact information to assist with managing dietary call out when they are in or out of the building. The Administrator and the Dietary Manager will review the dietary staffing weekly and monthly schedule during morning report to ensure that the dietary department is adequately staff. On each Friday, the Administrator and the Dietary Manager will review the weekend dietary staffing schedule to ensure any staffing concerns have been addressed. By 2/5/2023, the Dietary Manager to include the dietary staff will be educated by the Administrator related to ensuring that the Administrator is notified of any dietary staffing concerns. The Administrator and the Dietary Manager contact information will be posted in the kitchen and on each facility nursing unit. In addition, the dietary manager will ensure the dietary staff has the dietary manager and the administrator's contact information in addition to calling the facility if they are unable to locate the contact information. Effective 2/3/2023 the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 2/07/2023 On 2/8/23 the credible allegation of IJ removal with a completion date of 2/7/23 was validated through staff interview and review of in-service training records. Staff were able to verbalize and demonstrate examples of how to prepare and serve meals, read meal tickets to ensure residents received the correct consistency of diet as ordered, able to identify symptoms of a foodborne illness and potential risk of a resident receiving the incorrect texture of food for consumption. Each were able to verbalize they were to report anytime the dietary department staff were not present in the building by the start of day shift to the Administrator and the Director of Nursing to include weekends.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, resident and staff interviews, the facility failed to provide pureed foods as ordered by the physician for 9 of 9 residents. (Resident #1, Resident #22, Resident #53, Resident #69, Resident #31, Resident #57, Resident #8, Resident #17, and Resident #26). On 01/22/23 dietary staff did not arrive for work. A central supply clerk and three nurse aides (NAs) prepared and served breakfast, lunch, and dinner to residents on pureed diets by chopping food into small pieces and not smooth consistencies. The staff had not been trained on food production and did not have skills to operate the food processor. This resulted in the high likelihood for residents to choke or aspirate. The Immediate Jeopardy (IJ) began on 1/22/23 when residents with orders for a puree diet were not served 3 of 3 meals pureed to a smooth consistency. The immediate jeopardy was removed on 2/7/23 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity E (no actual harm that is immediate jeopardy) to ensure monitoring systems are put into place are effective. The findings included: a. Resident #53 was admitted to the facility on [DATE] with diagnosis that included dementia, protein calorie malnutrition, and diabetes. A physician's order dated 9/8/22 indicated Resident #53 was to receive a puree diet with thin liquids. A quarterly MDS dated [DATE] revealed Resident #53 was cognitively intact and required set-up assistance with eating. An interview with Resident #53 was conducted on 1/26/23 at 5:25 PM which revealed she was ordered a puree diet and was delivered items such as French toast and sausage for breakfast, roast beef, sweet potato casserole, spinach and peaches for lunch, and meat loaf, squash casserole, and orange slices which she realized she could not have on her prescribed diet and was unable to eat and no other food items were available to be served on 1/22/23 which was of the puree consistency due to kitchen staff not being available. b. Resident #1 was re-admitted to the facility on [DATE] with diagnoses that included a cerebral infarction and abnormal weight loss. A physician's order dated 10/12/22 indicated Resident #1 was to receive a puree diet with thin liquids. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively impaired with short- and long-term memory problems and required extensive assistance with eating. c. Resident #22 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia. A physician's order dated 2/14/22 indicated Resident #22 was to receive a puree diet with thin liquids. A quarterly MDS dated [DATE] revealed Resident #22 was cognitively impaired with short- and long-term memory problems and required extensive assistance with eating. d. Resident #69 was admitted to the facility on [DATE] with diagnoses that included esophageal obstruction, dysphagia, and dementia. A physician's order dated 1/4/23 indicated Resident #69 was to receive a puree diet with thin liquids. A quarterly MDS dated [DATE] revealed Resident #69 was cognitively impaired and required minimal assistance with eating. e. Resident #31 was admitted to the facility on [DATE] with diagnosis that included Alzheimer's, Parkinson's disease, and malnutrition. A physician's order dated 10/7/21 indicted Resident #31 was to receive a puree diet with nectar thickened liquids. A quarterly MDS dated [DATE] revealed Resident #31 was cognitively impaired and required extensive assistance with eating. f. Resident #57 was admitted to the facility on [DATE] with diagnoses that included dementia, cerebral infarction, and abnormal weight loss. A physician's order dated 11/19/22 revealed Resident #57 was to receive a Regular diet with puree meats and thin liquids. A quarterly MDS dated [DATE] indicated Resident #57 was mildly cognitively impaired and required supervision assistance with eating. g. Resident #8 was readmitted to the facility on [DATE] with diagnosis that included functional quadriplegia, dementia, and protein calorie malnutrition. A physician's order dated 8/31/22 indicated Resident #8 was to receive a puree diet with thin liquids. A quarterly MD dated 10/29/22 indicated Resident #8 had short and long-term memory problems and required extensive assistance from staff for eating. h. Resident #17 was re-admitted to the facility on [DATE] with diagnoses that included dementia and gastrointestinal esophageal reflux disease. A physician's order dated 2/19/21 indicated Resident #17 was to receive a puree diet with thin liquids. A quarterly MDS dated [DATE] indicated Resident #17 had short- and long-term memory problems and was dependent for eating. i. Resident #26 was admitted to the facility 9/7/22 with diagnoses that include malnutrition and end of life care. A physician's order dated 12/30/22 indicated Resident #26 was to receive a mechanical soft diet with puree meats and thin liquids. A Significant Change MDS dated [DATE] indicated Resident #26 was cognitively intact and required supervision assistance for eating. A brief interview with the Regional Dietary Consultant was conducted on 1/23/23 at 10:08 AM. She indicated she was contacted on 1/22/23 by the facility Administrator who notified her that the staff from the dietary department had not shown up to prepare food on 1/22/23 and that facility nursing staff were attempting to prepare meals for all residents in the facility. The Regional Dietary Consultant stated she attempted to contact the former Dietary Manager and the Regional Dietary Manager but did not come to the facility to assist with meal service or offer instructions on how to prepare meals via phone on 1/22/23 when she gained knowledge no dietary personnel were present and was unaware kitchen equipment was unable to be properly used to mechanically alter diets as prescribed. An interview with the Administrator was conducted on 1/23/23 at 12:30 PM. The Administrator indicated he became aware staff from the dietary department had not arrived at work on the morning of 1/22/23 at approximately 8:45 AM when nursing staff and the central supply clerk discovered no meal trays had been delivered to the units and no residents had received their breakfast meal which should have been delivered beginning at 7:30 AM. He indicated he lived out of state but arrived at the facility later in the day at approximately 2-3 PM on 1/22/23 to ensure meals were delivered to residents. The Administrator had no previous dietary experience and therefore did not offer additional direction on meal service other than to follow the dietary meal tickets. The Administrator was unable to reach the Dietary Manager to determine why staff did not arrive to the facility on 1/22/23. An interview with the Central Supply clerk was conducted on 1/24/23 at 1:30 PM. The Central Supply clerk indicated he was working in the facility on 1/22/23 as a medication aide when he and other nursing staff discovered the meal trays for the breakfast meal had not arrived at the floor for distribution at around 8:45 AM. The Central Supply Clerk indicated they were able to locate the meal tickets which had been printed the day before to determine what foods would need to be prepared. The Central Supply clerk explained since he and NA #11 had some kitchen experience from a previous employment, they went to the walk-in fridge and walk-in-freezer and began pulling items they recalled were normally served to the residents for the breakfast meal and began prepping them to cook. He stated the following items were prepped and cooked: omelets, sausage patties, oatmeal, grits, scrambled eggs, and French toast sticks. The Central Supply clerk indicated they were unable to use the grinder machine that day and instead attempted to cut items in very small pieces and then mash them with a potato masher to serve to residents on mechanically altered diets such as chopped or ground meats, and puree. The Central Supply clerk described them to be more of a chopped or ground consistency. The Central Supply clerk further explained no one else from the dietary department arrived to assist with meal preparation on 1/22/23 and therefore, he and NA #11 prepared all meals for residents on that day. The Central Supply clerk verified that Dietary Aide #2 arrived at his scheduled time of 10:30 AM; however, he only washed dishes during his shift and did not assist with meal preparation on 1/22/23. The Central Supply clerk stated they prepared and served the following: lunch - roast beef, sweet potato casserole, spinach, peaches, and cornbread and for supper they served: meatloaf, mashed potatoes, squash casserole, mandarin oranges, and a biscuit. The Central Supply clerk stated the roast beef had been thawing to serve on Monday and therefore he selected that item because it was readily accessible for lunch, and they made the consistency as close to chopped and ground as possible. An interview with NA #11 on 1/25/23 at 10:45 AM revealed he worked on 1/22/23 when he was notified the dietary department had not arrived at the facility to prepare meals to the residents. NA #11 stated they were not able to use the kitchen equipment and therefore they were unable to properly prepare the texture for the puree consistency and therefore cut the items up as small as possible and then mashed them with a potato masher before serving the item to the resident on prescribed puree diets. NA #11 described the consistency of the meats to be chopped. NA #11 acknowledged they did not follow a menu on 1/22/23; they strictly looked in the walk-in-fridge and walk-in-freezer to find items that were accessible and verified they prepared the following items for residents for breakfast were: scrambled eggs, omelets, oatmeal, grits, French toast, and sausage; for lunch: roast beef, sweet potato casserole, spinach, peaches, and cornbread and for supper they served: meatloaf, mashed potatoes, squash casserole, mandarin oranges, and a biscuit. Multiple attempts were made to contact Dietary Aide #2 were unsuccessful. An interview with NA #10 on 1/24/23 at 1:59 PM revealed she worked on 1/22/23 and she was asked to help plate and serve food in the dietary department when dietary staff did not arrive at work that morning. NA #10 said she entered the kitchen along with the Central Supply clerk and 2 other NAs and began assisting to ensure the breakfast meal could be served to residents. She explained that the Central Supply clerk and NA #11 cooked the food; however, no one was able to use the grinder machine that day and therefore, they attempted to make the puree items as small and fine as possible by cutting it in very mall bites and some items were mashed using a potato masher before delivering the meal to the resident for consumption. NA #10 verified they served the following items to residents on 1/22/23 and none of the items were of the traditional puree consistency and texture: scrambled eggs, oatmeal, grits, sausage; for lunch: roast beef, sweet potato casserole, spinach, peaches, and cornbread and for supper they served: meatloaf, mashed potatoes, squash casserole, mandarin oranges, and a biscuit. NA #10 described the consistency of most items served as chopped. An interview with NA #5 on 1/25/23 at 10:30 AM revealed she worked on 1/22/23 when she learned the dietary staff members had not arrived to work and residents had not yet had breakfast at around 9 AM. NA #5 stated they did the best they could to get residents something to eat although she acknowledged she was aware they were unable to use the kitchen equipment to mechanically alter the foods for residents on a puree diet and therefore those items were cut up finely and mashed with a potato masher to get as best consistency as possible. NA #5 indicated the following items were served, but they were unable to puree them: scrambled eggs, omelets, oatmeal, grits, French toast, and sausage; for lunch: roast beef, sweet potato casserole, spinach, peaches, and cornbread and for supper they served: meatloaf, mashed potatoes, squash casserole, mandarin oranges, and a biscuit. NA #5 indicated most food items served were of a ground consistency. An interview with the Medical Director was conducted on 1/26/23 at 1:00 PM which revealed she had been notified of the residents receiving the wrong texture diet when they were prescribed a puree diet but had not been made aware of any adverse effects from not receiving a puree diet on 1/22/23 nor did she know full details of why residents did not receive the correct consistency. A follow-up interview with the Administrator on 1/26/23 at 3:00 PM revealed he was not made aware the staff were unable to use the kitchen equipment which resulted in being unable to ensure the proper textures were provided to residents with a mechanically altered consistency and indicated staff should have made administration aware before delivering meals to those residents ordered a puree diet for safety. The Administrator was notified of the Immediate Jeopardy on 2/3/23 at 9:14 AM. The facility provided the following credible allegation of compliance with a compliance date of 2/7/23. F805 o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to ensure 9 of 9 residents prescribed a puree diet received the correct texture on 1/22/2023 for 3 of 3 meals when non dietary staff were unable to utilize the kitchen equipment needed to provide residents menu items which required puree textures. On 2/3/23, the current facility residents on puree diets were reviewed by the Director of Nursing and Assistant Director of Nursing to identify any changes of condition related to unsafe food preparation and the wide range of dietary restrictions for the pureed diets with no concerns noted. On 2/3/2023, the Nurse Practitioner was made aware. The current residents on puree diets are at risk as a result of this deficient practice. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete Starting 2/3/23, All facility staff will be educated to call the Administrator and the Dietary Manager immediately if dietary staff is not available to prepare meals to ensure trained dietary staff to include dietary staff that are scheduled off, dietary contract staff, and dietary staff from other sister facilities can be called in to prepare, cook, and serve the prescribed diets to include pureed diets by 2/6/2023. Starting 2/3/23, the dietary staff will be educated by the dietary manager in food preparation and use of the kitchen equipment to puree prescribed diets to ensure residents received the prescribed pureed diets by 2/6/2023. Starting 2/3/23, the dietary staff will be educated by the Dietary Manager to ensure staff that prepare and serve food are competent in preparing all textures of diets including puree diets by 2/6/2023. Starting 2/3/23, All facility staff will be educated by the Administrator or designee related to only trained staff in safe food service preparation are allowed to prepare, cook, and serve resident prescribed diets to include pureed diets by 2/6/2023. Starting 2/3/2023, The education for the facility staff to include the dietary staff will continue at the beginning of each shift until each staff member receives the education. No staff member including agency staff, dietary and new hire will be permitted to work until the education is completed. Starting 2/6/2023, The Administrator and the Dietary Manager will review the dietary weekly and monthly staffing schedules during morning report to ensure that the dietary department is adequately staffed. On Fridays, the Administrator and the Dietary Manager will review the weekend schedule to ensure weekend staffing concerns have been addressed. By 2/6/2023, the Dietary Manager will be educated by the Administrator related to ensuring that the Administrator is notified of any dietary staffing concerns. Starting 2/6/2023, the Director of Nursing/designee will observe the current residents' meal trays that receive pureed diets at least 3 times a week for breakfast, lunch, and dinner to ensure that the residents continue to receive their prescribed pureed diets for at least 12 weeks. Effective 2/3/2023 the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 2/07/2023 On 2/8/23 the credible allegation of IJ removal with a completion date of 2/7/23 was validated through staff interview and review of in-service training records. Staff were able to verbalize and demonstrate examples of how to prepare and serve meals, how to use the dish machine and 3-in-1 sink chemical test strips, how to properly read meal tickets to ensure residents received the correct consistency of diet as ordered, able to identify symptoms of a foodborne illness and potential risk of a resident receiving the incorrect texture of food for consumption. Each were able to verbalize they were to report anytime the dietary department staff were not present in the building by the start of day shift to the Administrator and the Director of Nursing to include weekends.

Based on record review, resident, staff interviews, the facility Administration failed to provide effective leadership and oversight to ensure effective systems were in place to have trained dietary staff available to prepare meals for residents. On 1/22/23 dietary staff did not arrive to work and the Central Supply Clerk and three Nurse Aides (NAs) prepared breakfast, lunch, and dinner resident meals without serving 9 of 9 residents mechanically altered meals as ordered (Resident #1, Resident #22, Resident #53, Resident #69, Resident #31, Resident #57, Resident #8, Resident #17, and Resident #26). This led to the high likelihood of aspiration or choking. The Immediate Jeopardy (IJ) began on 1/22/23 when systems were not in place to ensure trained dietary staff were available to prepare resident meals. The immediate jeopardy was removed on 2/7/23 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity E (no actual harm that is immediate jeopardy) to ensure monitoring systems are put into place are effective. Findings included: Cross Refer to F802 Based on staff interviews and record reviews, the facility failed to have effective systems in place to ensure there were dietary staff to prepare meals when dietary staff did not arrive to work on the 1/22/23. The Central Supply Clerk and three Nurse Aides (NAs) prepared breakfast, lunch, and dinner resident meals without checking the internal temperature of cooked foods before serving, did not serve resident mechanically altered diets as ordered, and did not ensure kitchen items were sanitized. This led to the high likelihood for residents to be at risk of choking or aspiration. This situation affected 91 of 91 residents for 3 of 3 meals. Cross Refer to F805 Based on record reviews, resident and staff interviews, the facility failed to provide pureed foods as ordered by the physician for 9 of 9 residents. (Resident #1, Resident #22, Resident #53, Resident #69, Resident #31, Resident #57, Resident #8, Resident #17, and Resident #26). On 01/22/23 dietary staff did not arrive for work. A central supply clerk and three nurse aides (NAs) prepared and served breakfast, lunch, and dinner to residents on pureed diets by chopping food into small pieces and not smooth consistencies. The staff had not been trained on food production and did not have skills to operate the food processor. This resulted in the high likelihood for residents to choke or aspirate. The Administrator was notified of the Immediate Jeopardy on 2/3/23 at 9:14 AM. The facility provided the following credible allegation of compliance with a compliance date of 2/7/23. The Administration failed to ensure that an acceptable plan was implemented during the kitchen emergency of no kitchen staff. On, 1/22/2023 at about 8:45 am, the facility staff identified that there was no dietary staff in the kitchen to prepare breakfast. The Administrator was notified immediately about 9:00 am. The Administrator notified corporate leadership at 9:00 am. The Administrator also attempted to notify the dietary manager at about 9:05 am and was unable to reach the dietary manager. Dietary regional support was notified by the Administrator about 9:15am who was able to reach the dietary manager. Later that afternoon, the Administrator was made aware that the dietary manager was unable to be reached due to a personal medical emergency by the dietary regional manager. Facility leadership staff to include the Assistant Director of Nursing (ADON), the Activity Director, Maintenance and the Supply Manager were called on 1/22/2023 by the Administrator about 9:20 am and began coming to the facility to assist with resident meals about 9:35am. The identified facility leadership attempted to obtain breakfast from an outside vendor when they arrived in the building about 9:35 am. The Administrator arrived at the facility to assist with meals after lunch. On 1/22/2023, the Administrator notified the Dietary Facility Regional manager who provided assistance by phone by attempting to call the dietary staff to come to assist with the meals. This was not successful. Starting 1/23/2023 the Dietary Regional support was in the facility to provide ongoing leadership in the dietary Department to ensure the safe preparation of the residents' physician ordered diets. The facility residents on 1/22/2023 were at risk as a result of this deficient practice. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete Starting 1/22/2023, the Administrator and Maple Health Group Corporate leadership will provide ongoing follow up to ensure that the dietary department continues to be staffed as required. On 2/4/2023, the Administrator was educated by the Chief Nursing Officer on the emergency preparedness plan updates to include the dietary staffing schedule review process and that the dietary manager and the Administrator contact information will be provided to the dietary staff and posted on the nursing units and in the kitchen so that the facility will be aware of dietary staff call outs. The Administrator is aware that he is responsible for ensuring the emergency plan is being followed. Starting 2/4/2023, the Dietary Kitchen Oversight checklist which includes monitoring for dietary staffing, dietary staffing competencies completion, residents' receiving pureed diets, dish machine at appropriate temperature, and dietary supervision will be completed by the facility interdisciplinary team staff. The interdisciplinary team to include social services, Assistant Director of Nursing, Medical Records, maintenance, Business office, admissions, supply clerk, and activities were educated on the oversight checklist by the Administrator. On 2/6/2023, the facility Emergency Preparedness Plan updates will be reviewed in the Quality Improvement meeting by the Administrator to include the dietary staffing schedule review process and that the dietary manager and the Administrator contact information will be provided to the dietary staff and posted on the nursing units and in the kitchen so that the facility will be aware of dietary staff call outs. The Administrator is aware that he is responsible for ensuring the emergency plan is being followed. Starting 2/6/2023, the Maple Health Group Chief Nursing Officer or the Chief Operation Officer will complete facility rounds to include the kitchen at least monthly to ensure the updated Kitchen /dietary Emergency Preparedness Plan continues to be followed as required. Starting 2/3/23, all current dietary staff and new hire dietary staff will be required to complete the facility education related to ensuring residents receive diets as ordered, foods temps checks are completed, training on the use of the kitchen equipment, and notification of Administrator and Dietary Management with staff concerns occur by 2/6/2023 by the Regional Dietary Manager. The emergency phone numbers of the Dietary Manager and the Administrator will be posted in the kitchen and on each nursing unit by 2/6/2023. Effective 2/3/2023 the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 2/07/2023