**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews with staff, residents, and a family member, facility document review, and review of the Facility Assessment, the facility failed to ensure designated and consistent staffing was provided on one (500-Hall) of five total halls in the facility to ensure sufficient staff to provide needed care and services to the 13 residents that resided on the 500-Hall. This resulted in Immediate Jeopardy and the potential for serious injury, harm, impairment and/or death, when observations during the survey on 10/07/24 and 10/08/24 revealed times where the residents were left unattended on the 500-Hall with no staff members in the area. Staff reported there was no process in place to coordinate supervision, monitoring, or assistance for the residents on the 500-Hall. In addition, the call system on the 500-Hall only illuminated on the annunciator panel located on that hall; therefore, in the event of an emergent need, when no staff were present on the 500-Hall, the residents were not able to alert staff in other areas of the facility. Residents reported if they needed assistance, they had to utilize the elevator to go down to other floors of the facility to locate staff. Additionally, residents reported that due to no staff presence on the 500-Hall at mealtimes, residents had to retrieve their own meal trays from the food carts because no staff were available to assist. This affected 13 residents (#4, #11, #17, #26, #31, #43, #44, #56, #61, #67, #78, #82, and #90) who currently reside on the 500-Hall. The total census of the facility was 89. The Senior Administrator and Administrator were notified the Immediate Jeopardy began on 10/07/24 when the survey team observed that there were no staff present on the 500-Hall when Resident #61 activated their call light. A copy of the Immediate Jeopardy template was provided on 10/09/24 at 1:01 P.M. A removal plan was requested. The removal plan was accepted by the state survey agency on 10/10/24 at 12:24 P.M. The Immediate Jeopardy was removed on 10/09/24, after the survey team performed onsite verification that the removal plan had been implemented; however, the noncompliance remained at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings included: During the entrance conference on 10/07/24 at 9:21 A.M, the Administrator reported the facility currently had a census of 89. The facility's floor plan revealed the facility had a 100-Hall, 200-Hall, 300-Hall, 400-Hall, and 500-Hall. Review and analysis of the facility's floorplan and layout on 10/09/24 at 7:33 P.M. revealed the facility had three floors. The 100-Hall and 200-Hall were located on one side of the facility, and the 300-Hall, 400-Hall, and 500-Halls were located on the other side. The floor plan revealed that the 300-Hall was on the ground floor, and the 400-Hall and 500-Hall were each on a separate level and had to be accessed by either a stairwell or an elevator. The floor plan indicated the 300-Hall had 15 private rooms, the 400-Hall had 12 rooms (10 private and two semi-private), and the 500-Hall had 12 rooms (11 private and one semi-private). An admission Record indicated the facility admitted Resident #61 on 02/16/23. According to the admission Record, Resident #61 had a medical history that included diagnoses of Chronic Obstructive Pulmonary Disease (COPD), bronchopneumonia, hypothyroidism, anxiety, polyneuropathy, Gastro-Esophageal Reflux Disease (GERD), dementia, depression, insomnia, malignant neoplasm of the lung, iron deficiency anemia, type 2 Diabetes Mellitus (DM), hyperlipidemia, Essential Hypertension (HTN), diastolic heart failure, Peripheral Vascular Disease (PVD), and interstitial pulmonary disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/20/24, revealed Resident #61 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed Resident #61 required substantial to maximum assistance from staff with toileting hygiene, bathing, and lower body dressing, partial to moderate assistance from staff with bed to chair transfers, and supervision or touching assistance from staff with eating, oral hygiene, upper body dressing, personal hygiene, toilet transfers, bed mobility, and when transitioning from a seated position to standing or lying down. Resident #61's care plan contained a focus area, initiated 02/20/23, that indicated the resident may require assistance with Activities of Daily Living (ADLs) and may be at risk for developing complications associated with decreased ADL self-performance. Interventions indicated that the resident required assistance with ambulation, bathing, bed mobility, oral care, toileting, and transfers. Interventions also indicated that the resident required supervision with eating. During the initial pool process on 10/07/24 at 11:42 A.M., Resident #61 reported there were not always staff members working on the 500-Hall. Resident #61 further stated residents had to go to the food carts to get their own meal trays and said over the prior weekend, if their family had not been present and passed meal trays, they would not have eaten. During a telephone interview on 10/09/24 at 8:06 P.M., Resident #61's family member, Family Member #33, indicated they were at the facility on Sunday, 10/06/24, between 4:00 P.M. to 6:30 P.M. and observed there to be no staff on the 500-Hall. Family Member #33 stated when supper trays arrived there were multiple residents on the hall who got their meals independently without staff assistance. Family Member #33 indicated that when they visited the resident on weekends between the hours of 2:00 P.M. to 7:00 P.M., there were rarely staff visible. Family Member #33 stated that they had notified administration of the concern of lack of staff on the 500-Hall and was told the concern would be addressed. The family member stated they were concerned because if Resident #61 choked or fell, staff would be unaware if they were not on the hall. During an interview on 10/07/24 at 1:30 P.M., Resident #44, who also resided on the 500-Hall, stated they had to retrieve their own meal trays and hunt staff down if they needed anything. During an interview on 10/07/24 at 1:45 P.M., Resident #11, who also resided on the 500-Hall, stated that most of the time there were no staff available on the 500-Hall. Resident #11 reported residents had to go hunt and find staff on other halls of the facility. A facility document titled, Daily Nursing Staffing Sheet, dated [DATE] Monday, revealed there was not a scheduled nurse designated to work on the 500-Hall, but there was a designated State Tested Nursing Assistant (STNA) during the day shift. The staffing sheet indicated the Licensed Practical Nurses (LPNs) assigned to work the 300-Hall and 400-Hall were also responsible for the 500-Hall during the day shift. Per the staffing sheet, there was no designated nurse or STNA for the 500-Hall on the night shift, but the STNAs assigned to the 300 Right and 300 Left were also responsible for the 500-Hall. The staffing sheet did not indicate any night shift nurses were responsible for the 500-Hall. Registered Nurse (RN) #31 was listed as being assigned to the 300-Hall. During a night shift observation of the 500-Hall on 10/07/24 beginning at 8:13 P.M., RN #31 entered Resident #61's room to provide medications. RN #31 placed two medication cups containing seven total pills on the resident's over-the-bed table and informed the resident she was going downstairs to the 300-Hall to pass their medications. On 10/07/24 at 8:17 P.M., after RN #31 left the resident's room, Resident #61 said they were not sure if the medications left by the nurse were correct, and the surveyor immediately went to the nurses' station to look for RN #31. However, RN #31 was seen turning the corner to go to the elevator that led to the 300-Hall, where she indicated she was going. The surveyor then went down the hallway to locate other staff members but was unable to locate any other staff on the hallway. The surveyor returned to Resident #61's room and asked the resident if they could activate their call light so that the resident could ask staff about their medications. Resident #61 said that activating their call light was a waste of time, because after the night shift staff left the hallway, the residents did not see staff again until the following morning, unless it was a rare occasion. Resident #61 further stated they had previously been told by staff that the call lights on the 500-Hall did not go off anywhere else in the facility, so staff would not know. However, Resident #61 agreed to activate the call light. At 8:25 P.M., the Assistant Director of Nursing (ADON) arrived on the 500-Hall via the back stairwell door and was carrying her personal belongings. The ADON was headed towards her office, which was located on the same hall, when she passed Resident #61's room, with their call light still sounding. The surveyor then approached the ADON and asked who she was, because she did not answer the resident's call light as she passed. The ADON informed the surveyor of her title and said she had returned to the facility to assist the surveyors with the survey after receiving a call the survey team had re-entered the facility earlier in the evening. At 8:29 P.M., the ADON informed Resident #61 that RN #31 would come back up to speak with them about their medications, and the ADON then left the 500-Hall via the stairwell exit-door. At 8:32 P.M., RN #31 returned to Resident #61's room to address their question regarding their medications and then told the resident she was going back downstairs. Observations on 10/11/24 from 3:39 P.M. to 3:45 P.M. revealed that when the call light for room [ROOM NUMBER] was activated, the call system annunciator panel illuminated on the 500-Hall; however, observations of the annunciator panels located on the other four halls (100-, 200-, 300-, and 400-Halls) revealed they did not illuminate when call lights were activated on the 500-Hall. A facility document titled, Daily Nursing Staffing Sheet, dated [DATE] Tuesday, revealed that during the day shift, RN #32 was designated to work on the 500-Hall with a designated STNA, along with a nurse assigned to the 400-Hall that was to also assist with the 500-Hall. During an observation of the 500-Hall on 10/08/24, RN #32 left the hall via the elevator at 3:51 P.M. No other staff were able to be located on the hall. At 3:55 P.M., a housekeeping staff member was observed at the end of the 500-Hall and exited the hall via the elevator. At 3:59 P.M., RN #32 returned to the hall. During an interview on 10/08/24 at 3:59 P.M., RN #32 stated she was alone on the 500-Hall because the assigned STNA was on a break. A list provided by the facility indicated that, as of 10/07/24, 13 residents resided on the 500-Hall, of which seven residents were cognitively intact, one resident had moderate cognitive impairment, four residents had severe cognitive impairment, and one resident's cognitive status was illegible. Review of the comprehensive care plans for the 13 residents on the 500-Hall revealed each resident required assistance from staff with ADLs. In addition, the care plans indicated the resident population on the 500-Hall included residents at risk for alteration in skin integrity, alteration in comfort, alteration in nutrition and hydration status, high and low blood sugar levels, and falls, as well as residents with respiratory deficiencies and behaviors. During an interview, on 10/08/24 at 9:40 A.M., LPN #6 stated the nurses had to split the 500-Hall medication pass at times, but the STNA assigned to the 500-Hall did everything else. She stated there was normally a schedule posted that reflected which STNA was assigned to the 500-Hall. LPN #6 further stated the 500-Hall sometimes had a designated STNA the entire shift, but sometimes the schedule required the STNAs to split that responsibility, leaving no one fully assigned to the 500-Hall at all times. LPN #6 stated the staff get up there as much as they can. LPN #6 said there were times when no staff were on the 500-Hall, because staff did not coordinate with one another to ensure someone was always present on the hall. She stated that most of the time, if the residents on the 500-Hall needed something, they came down to another hall to get a staff member. During an interview on 10/08/2024 at 9:46 A.M., STNA #9 stated that her primary responsibility was providing care to residents on the 300-Hall. STNA #9 stated there were times when there were no staff on the 500-Hall. STNA #9 stated the STNAs may cross paths while transitioning between halls, but, typically, they did not know when other staff were on the 500-Hall. STNA #9 stated there was a weekend that someone was not assigned to the 500-Hall or did not come to work and a nurse provided medications, but did not communicate to the other staff that there was not an STNA on the 500-Hall, and residents received their meal trays late. STNA #9 further stated that when she was splitting the responsibility of the 500-Hall and another hall, she could not keep eyes on the residents on the 500-Hall; instead, she would ask them if they had any needs, then return downstairs. STNA #9 explained that when call lights were used by residents on the 500-Hall, they could not be seen by staff on other halls of the facility. STNA #9 reported that residents on the 500-Hall called the front desk or came downstairs to look for a staff member. During a telephone interview on 10/08/24 at 10:33 A.M., STNA #21 said that when a nurse was assigned to the 500-Hall, the nurse worked as both the nurse and the aide for the hall, but when no nurse was assigned to the 500-Hall, the STNAs from the 300-Hall and the 400-Hall split the responsibility of the 500-Hall. STNA #21 said that the STNAs who split the responsibility of the 500-Hall did not coordinate when they went to the hall. STNA #21 stated that when she was assigned Rooms 506 through 511, she checked on the residents at the beginning of her shift, then randomly checked on them throughout the night. She stated that if any resident on the 500-Hall used their call light, she would not be alerted if she was working on another hall. During a telephone interview on 10/08/24 at 10:59 A.M., STNA #15 said that the STNAs assigned to the 300-Hall and the 400-Hall split duties to each cover a portion of the 500-Hall. STNA #15 said the STNAs periodically checked on the residents on the 500-Hall, and the residents also came downstairs to let staff know when they needed something. According to STNA #15, there were no staff working on the 500-Hall multiple times a week. STNA #15 also stated that if a resident on the 500-Hall attempted to utilize their call light, staff on other halls would not be alerted. During an interview on 10/08/24 at 2:12 P.M., STNA #24 said she had frequently been assigned to work both a portion of the 400-Hall and a portion of the 500-Hall. STNA #24 stated that other times, staff were not notified until later in the shift that they needed to assist with the 500-Hall. STNA #24 stated that when breakfast trays arrived between 8:00 A.M. to 9:30 A.M., staff were notified via text message if no one was working on the 500-Hall and meal trays needed to be passed. STNA #24 said there was no organization, and the residents on the 500-Hall accessed the meal cart to get their own trays most of the time. STNA #24 further stated she did not feel comfortable working on the 400-Hall while not knowing if any call lights were activated on the 500-Hall. STNA #24 said she went up to the 500-Hall when she was able, but she took care of the residents on the 300-Hall or 400-Hall primarily, before tending to any residents on the 500-Hall. She stated the residents on the 500-Hall came down the elevator to the 300-Hall or 400-Hall to hunt down staff. STNA #24 voiced concern that the residents on the 500-Hall were dining without supervision, and staff would have no way of knowing if anyone got strangled or choked. STNA #24 said she had reported her concerns to the Scheduling Coordinator and told her she was not willing to continue attempting to work on two separate halls at the same time. STNA #24 said there should be staff designated to work the 500-Hall at all times, since there were residents that resided on that hall. During an interview on 10/09/24 at 10:20 A.M., the Scheduling Coordinator said she typically made staffing assignments by utilizing four nurses on the day shift, four nurses on night shift, eight STNAs on the day shift, and six to seven STNAs on night shift. The Scheduling Coordinator stated the 100-, 200-, and 300-Halls were scheduled with two STNAs on day shift and night shift, and the 400-Hall was scheduled with two STNAs on day shift and one STNA on night shift. She stated that if all staff showed up for their scheduled shifts, the STNAs assigned to the 300-Hall and the 400-Hall also split the 500-Hall. The Scheduling Coordinator further explained the 300-Hall nurse and the 400-Hall nurse also split the 500-Hall. She stated that if there was not a nurse or aide scheduled for the 500-Hall, then the 300-Hall nurse went to the 500-Hall after completing the 300-Hall medication administration and should remain on the hall the remainder of the shift. She stated that if a nurse had to leave the hall, staff should coordinate to ensure someone was on the hall. The Scheduling Coordinator stated she was not aware that there had been times when staff were not present on the hall. The Scheduling Coordinator stated the Director of Nursing (DON) or Administrator had to approve the facility's staffing levels based on the acuity of the residents. During an interview on 10/09/24 at 10:54 A.M., the DON said the allotted amount of staff was calculated through the corporate office to be the following: The 100-Hall was allowed one nurse and two STNAs, the 200-Hall was allowed one nurse and two STNAs, the 300-Hall was allowed one nurse and one STNA minimum but two STNAs when possible, the 400-Hall was allowed one nurse and one STNA minimum, and the 500-Hall was staffed with either a nurse or an aide when possible. The DON stated that when a staff member was not scheduled for the 500-Hall, the 300-Hall nurse should sit on the 500-Hall between medication passes and float between halls, with the 300-Hall STNA reporting to the 500-Hall when the nurse was not there. The DON said if there was a nurse assigned to the 500-Hall, the nurse was responsible for all care for the residents and completed both the nursing and STNA duties, and if there was an STNA assigned to the 500-Hall without a nurse, the 300-Hall and 400-Hall nurses split the responsibility of medication administration for the 500-Hall. The DON further stated the ADON was also on the 500-Hall during the day shift. The DON said she was unaware of any time there would be a reason for there not to be staff on the 500-Hall. During an interview on 10/11/24 at 4:41 P.M., the ADON, whose office was on the 500-Hall, stated that she was not responsible for the care of the residents on the 500-Hall. She stated that she was the unit manager for the 300-, 400-, and 500-Halls, and if nurses on those halls had concerns, they reported to her. During an interview with the Administrator and the Senior Administrator on 10/09/24 at 11:23 A.M., the Administrator said she was unsure the number of allocated staff allowed to be scheduled for the facility and stated that the numbers were managed by the Scheduling Coordinator and were calculated based on the acuity of the residents, the daily census, and the state minimum staffing requirements. She stated that adjustments were made when a resident required one-to-one supervision or when major changes occurred in the facility. The Administrator stated that nurses and STNAs on the 300-Hall and the 400-Hall split the responsibilities of covering the 500-Hall. The Senior Administrator stated that she expected staff to communicate to ensure someone was present on the 500-Hall at all times, via two-way radios, cellular phones, or there were also phones on the halls that were available for communication. She further stated there were times when there was a nurse assigned to all the duties on the 500-Hall, but they could call for help if they needed additional assistance. The Facility Assessment, dated 2024, revealed, A.1. Function- Sufficiency Analysis Summary 1. Staffing and scheduling systems: Facility staffing based on current census and resident's needs. Facility uses PPD [Per Patient Day]. Staff assigned to units to ensure continuity of care and 3. A review of individual staff assignments and systems for coordination and continuity of care for residents within and across staff assignments occur as census and resident needs adjust. 4. Staffing policies updated and reviewed and [sic] acuity and patient care needs indicate. An undated, facility document, Re [Regarding]: Staffing, revealed, Facility does not have policy on staffing, facility goes by state guidelines: The minimum number of staff required based on acuity/resident to staff ratio and current regulatory compliance, including upcoming minimum staffing requirements. On 10/10/24 at 12:24 P.M., a removal plan was submitted by the facility and accepted by the state survey agency as follows: 1. Director of Nursing (DON)/designee reviewed staffing assignments and made adjustments to the staffing assignment to ensure staffing personnel are present at all times on the 500 unit. Review completed 10/09/24 at 2 P.M. Corrective action completed on 10/09/24. 2. Licensed Nursing Home Administrator (LNHA)/designee to complete one-time audit of all staff assignments for the rest of the building to ensure appropriate staffing levels. Corrective action completed on 10/09/24. 3. IDT [Interdisciplinary team] team, consisting of LNHA, Medical Director, DON, Assistant Director of Nursing (ADON) and clinical support Registered Nurse (RN), to review facility assessment to ensure facility staffing plan is consistent with residents' care needs. Corrective action completed on 10/09/24. 4. LNHA/designee to post notice at conspicuous location in facility to notify facility staff to ensure timely communication of unit departure to ensure appropriate coverage and resident needs are met. Corrective action completed on 10/09/24. 5. LNHA/designee notified facility Medical Director regarding the Immediate Jeopardy on 10/09/24 at 2:22 P.M. via phone. 6. ADON completed assessments including vital signs and head to toe assessments on all residents residing on the 500-Hall. No residents have suffered any adverse effects related to the Immediate Jeopardy. Assessments were completed on 10/09/24. 7. Senior LNHA provided education to LNHA and DON regarding the responsibility to ensure each hall in the facility is appropriately supervised to ensure resident needs are met in accordance with each resident's plan of care. Corrective action completed on 10/09/24. 8. Facility DON/designee to educate all facility STNAs and nurses regarding their responsibility to ensure appropriate staff personnel are available to meet the needs of the residents on their designated unit and that there should always be a staff member present. The Corrective action to be completed on 10/09/24 or prior to their next scheduled shift. 9.Human Resources Director/designee to provide education to all new hire nurses and STNAs in new hire orientation prior to working their first shift. The facility does not use agency staffing. 10. Scheduler/designee to provide a laminated call sheet for staff to be posted in conspicuous areas on the 500-Hall for who to contact for relief including phone numbers reflecting day, time, and off hours. Corrective action was completed on 10/09/24. 11. LNHA/designee to monitor daily staffing assignment sheets to ensure proper staffing coverage for all units in the facility. This monitoring shall take place for 8 weeks and will be ongoing thereafter as needed as determined by the facility QAPI [Quality Assurance and Performance Improvement] committee. Additionally, any adverse findings will be shared with the facility QAPI committee and adjustments to corrective action plan will be made as needed. 12. DON/designee to monitor daily x [times] 2 weeks, then 5 x weekly x 2 weeks and then 3 x weekly x 4 weeks and ongoing thereafter as needed as determined by facility QAPI committee to ensure there is no lapse in supervision on the 500-Hall. Monitoring is to be conducted randomly and includes monitoring on off hours including evenings and weekends. Monitoring consists of conducting rounds on the 500-Hall unannounced to ensure there is always a staff member available to address any potential resident needs. Any adverse findings will be shared with the facility QAPI committee and adjustments to corrective action plan will be made as needed. The credible allegation for the Immediate Jeopardy removal was validated on 10/10/24 at 12:31 P.M. through 10/12/24 at 11:30 A.M. A review of staff in-service education records indicated staff were educated they were not to leave their units unattended without notification of another staff member. Interviews with nursing staff revealed each had been educated they were not to leave their assigned unit without notifying another staff member and that the 500-Hall was not to be left unattended at any time. The interviews also revealed a list of designated phone numbers were provided to key personnel for additional coverage of the unit. Observations were made of the postings located on the 500-Hall nurses' station, including observations of the posted information regarding staff communication about unit coverage and the laminated call sheet with contact numbers. The staffing assignments, facility audit, staffing plan, and resident head-to-toe assessments for the 500-Hall were reviewed. Staff schedules for the timeframe from 10/11/2024 to 10/25/2024 were reviewed to ensure coverage was designated for the 500-Hall on all shifts.