Every finding on record at Haven Hall Health Care Center

Based on record review, staff interviews, and facility policy review, the facility failed to ensure the Payroll-Based Journal (PBJ) report for the October 1 through December 31 reporting period was submitted accurately and within the required Centers for Medicare & Medicaid Services (CMS) timeframe for one (1) of four (4) quarters reviewed. Findings include:A record review of the policy, Reporting Direct Care Staffing Information (Payroll-Based Journal), revised August 2022, revealed, Policy Statement Direct care staffing is reported electronically to CMS (Centers for Medicare and Medicaid) through the Payroll-Based Journal System .Policy Interpretation .10. Staffing information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter.At 11:52 AM on 3/30/26 in an interview with the Administrator, she revealed it is her corporate office that handles the Payroll-Based Journal (PBJ) submission process. She has not been granted access to ensure its timely submission.At 10:35 AM on 4/1/26, in an interview with the Corporate Payroll Representative, he revealed he is solely responsible for submitting the PBJ report and ensuring its timely submission. He explained that according to the Centers for Medicare & Medicaid Services (CMS), once the PBJ submission window opens, there are 45 days to submit the report accurately. For the October 1-December 31 reporting period, the cut off date was 2/14/26. He stated he submitted the report on day 43, 2/12/26, and failed to verify the accuracy of the submission until he returned to the office on Monday, 2/16/26. At that time, he discovered he had submitted the wrong information, resulting in an error and causing the report to miss the 2/14/26 deadline. He explained that he should have verified the report was submitted correctly before the deadline, indicating the late submission was his fault. He stated he submitted the report on 2/12/26 which was day 43 and failed to verify the accuracy of the submission until he returned to the office on Monday, 2/16/26. At that time, he discovered he had submitted the wrong information, resulting in an error and causing the report to miss the 2/14/26 deadline. He explained that he should have verified the report was submitted correctly before the deadline, indicating the late submission was his fault.A record review of the email sent from the corporate compliance office revealed he submitted the report on Thursday 2/12/26. Verified a successful submission on Monday 2/16/26 after the 2/14/26 deadline.A record review of the PBJ Final File Validation Report revealed Submission Date/Time: 2/12/26 at 16:53:07 (4:53 PM).

Based on interview, record review, and facility policy review the facility failed to ensure residents received care and services in accordance with professional standards of practice and physician oversight. Specifically, the facility failed to clarify and obtain appropriate physician guidance regarding administration of blood pressure medications prior to dialysis and failed to follow safe medication administration practices, resulting in the resident receiving medications that had the potential to cause hypotension during dialysis one (1) of (1) residents reviewed for dialysis care. Resident #14Findings Include: Record review of the facility policy Administering Medications dated 2001 revealed Medications are administered in a safe and timely manner and as prescribed . 8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having a potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to express concerns. 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document not administered and the reason in the electronic record. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.In an interview on 03/31/2026 at 10:35 AM, Resident #14 stated that nurses in the facility were giving his blood pressure medications prior to his dialysis appointment even when he told them he couldn't take it because it would drop his blood pressure (BP) to an unsafe level. Resident #14 stated that he was holding the medication on dialysis days prior to his admission to the facility.In an interview with Licensed Practical Nurse (LPN) #1 at 2:19 PM on 3/31/26, she confirmed that she has cared for the resident on 3/30/26 and 3/31/26 and confirmed that her documentation on the resident's Medication Administration Record (MAR) indicated that she gave the BP meds metoprolol and furosemide prior to his dialysis appointment on 3/30, but she stated she pulled them from the pack prior to administering and held them because they could lower his BP. She stated that she must have accidentally documented it as given, but she did not give it because nurses are taught not to give BP meds prior to dialysis because of the risk of hypotension.In an interview with LPN #2 at 2:25 PM, on 3/31/26 she stated that the resident goes to dialysis on Mondays, Wednesdays, and Fridays and she took care of him on his dialysis days of 3/20/26 and 3/25/26. She confirmed that BP meds such as metoprolol and furosemide should not be given prior to dialysis due to the fear of residents bottoming out while dialyzing. She stated that she didn't give blood pressure medications on the days prior to dialysis even though she charted that she did give them. She stated she just forgot to fix the documentation because it was hectic that day. She stated she didn't know to hold them prior to pulling the medications for the residents because there was no order in the system to hold before dialysis. She stated that the resident instructed her that he would not take them and refused.In a follow up interview with Resident #14 at 2:38 PM, on 3/31/26 he stated he never pulled any drugs out when the nurses gave them to him, so he took them every time, in fact he knows for certain he took them the day that he was given his flu vaccine on 3/25/26 because they were mixed in the cup with his other meds and he couldn't pick them out. He stated that he told the nurse that could kill him because he had dialysis later that day. He stated that he had notified the dialysis nurse prior to treatment that day and they told him you know better than to take them. He said he told the nursing staff, and no one listened. In an interview at 3:31PM, on 3/31/26 with LPN#3 (she confirmed that she did give the medications metoprolol and furosemide on 3/23/26 prior to the resident's dialysis appointment. She noted that there was no order to hold the drugs although she did confirm that she knows sometimes residents blood pressures can bottom out during dialysis treatment if they receive blood pressure pills prior to the procedure.In an interview with the Director of Nursing (DON) at 4:14 PM, on 3/31/26, she stated that the provider should have been called by any one of the nurses administering the medications to Resident #14 to get a hold order or clarify the necessity of it being given. She stated that giving it prior to dialysis could have caused the resident's BP to drop to an unsafe level resulting in a possible trip to the emergency room or hospitalization. She further explained that when residents voice concern with medications being administered, nurses should investigate the manner but failed to do so in this instance. She also confirmed that medications should be accurately marked on the Medication Administration Record (MAR) to reflect whether they were given or not to avoid confusion.In an interview with Resident #14's dialysis nurse on 3/31/26 at 3:38 PM, she stated that it was reported to her one day last week (Monday) by the patient that he had taken his blood pressure medications prior to treatment. She stated that in his case, he was holding his medications prior to dialysis when he was living by himself prior to admission to the nursing home because his BP typically drops during dialysis treatment and if he takes his medications before treatment a consequence could be lower BP after treatment and difficulty getting it to come back up.In an interview at 12:09 PM on 4/1/26 with the Medical Director, he noted that while there typically has been a practice to hold BP meds prior to dialysis, there was never an established parameter that they have to be held. However, in the case of this resident, who had instructed nurses that he didn't normally take it because he had been instructed not to because he had a history of his blood pressure lowering during treatment, the nurses should have notified him to avoid lowering the resident's BP to an unsafe level and avoid complications.Record review of Resident #14's admission Record revealed the resident was admitted on [DATE] with diagnoses that included encounter for surgical aftercare following surgery on the genitourinary system.Record review of the Minimum Data Set (MDS) with an Assessment Reference (ARD) of 3/25/26 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.Record review of the March 2026 Medication Administration Record (MAR) revealed the resident had received Metoprolol 25mg and Furosemide 80mg at 8 AM prior to his 11AM dialysis appointments each time since his admission on [DATE] including the dates of 3/20/26,3/23/26, 3/25/26,3/27/26, and 3/30/26.Record review of the Order Summary Report with active orders as of 3/31/26 revealed orders dated 3/19/26 and start date of 3/20/26 for Metoprolol Succinate ER tablet Extended Release 24 Hour 25 mg (milligrams) Give 1 tablet by mouth one time a day related to Chronic Diastolic Congestive Heart Failure and Furosemide Oral Tablet 80mg give 80mg by mouth one time a day related to Chronic Diastolic Congestive Heart Failure.

Based on observation, interviews, record reviews, and facility policy review the facility failed to provide complete perineal (peri-care) for one (1) of two (2) residents observed for incontinent care. Resident #26Findings Include:Record review of the facility's policy Cather Care, Urinary dated 8/2022 revealed, .Routine Perineal Hygiene: 1. Wash basin, soap and water and washcloths; OR 2. Bathing wipes 3. Towels;4. Bed protector.Steps.1. Place the clean equipment on the bedside stand or overbed table. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Fill the basin over half (1/2) full of warm water (or if using bathing wipes, open the package). 4. Place the wash basin or wipes on the bedside stand within easy reach. 5. Put on gloves. On 03/31/2026 at 3:09 PM, during an observation of peri care provided by Certified Nursing Assistant (CNA)#1 revealed CNA #1 gathered gown, gloves and brief and knocked on the door and entered the room. She then donned (put on) a gown and gloves. CNA #1 then adjusted the bed remote with gloves on. She did not wash her hands prior to applying gloves upon entry. She did not remove gloves and perform hand hygiene after touching the remote. CNA #1 removed the soiled brief and applied a clean brief without providing peri care using peri wipes or soap and water.On 03 31/26 at 3:41 PM, in an interview CNA #1 confirmed that she did not completely do peri care. She stated she changed the brief but forgot to gather supplies to provide peri- care. She confirmed she did not perform hand hygiene upon entry, after touching the bed remote and prior to changing the brief. She confirmed that the resident's wound could get infected if he is still soiled. She stated she uses soap and water or peri wipes when doing care.On 03/31/26 at 4:08 PM, in an interview with the Director of Nursing (DON) stated CNA #1 should have washed her hands upon entry and after touching remote then applied clean gloves. She should have used soap and water or peri wipes to do care. She stated Resident #26 could get skin breakdown, wound infection, Urinary Tract Infection (UTI) and have a body odor. She stated she expects staff to give proper care.On 03/31/26 at 4:36 PM, in an interview with Registered Nurse #1/Infection Preventionist (RN)/IP stated CNA #1 should have washed hands upon entry and prior to care. She should remove gloves after touching the bed remote. She should have performed peri care with soap and water, not just apply clean brief to Resident #26. She stated it could have a negative effect on Resident #26. Resident #26 could get a UTI or infection of the sacral wound. She stated CNAs should provide high quality care.Record review of Resident #26 admission Record revealed admission date of 2/27/23 with diagnosis of Personal history of UTI's dated 1/15/26, Pressure ulcer of other site, stage 2 dated 11/18/25 and Local infection of the skin, subcutaneous tissue unspecified dated 3/26/26, Quadriplegia C1-C4 incomplete and contracture unspecified.Record review of Resident #26's Order Summary Report revealed a physician's order dated 3/24/26 to culture wound to sacrum one time only for wound healing and an order dated 3/26/26 for ceftriaxone injection solution reconstituted 1 gram intramuscularly one time a day for infection for 5 days.Record review of Resident #26's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/19/26 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Section GG revealed he is dependent for toileting and hygiene.

Based on observation, interviews, record reviews and facility policy review the facility failed to implement and maintain an effective infection prevention and control program to prevent the spread of infection, as evidenced by improperly stored and dated oxygen (O2) tubing for Resident #1, incomplete perineal care for Resident #26 and improper handling of food items for Resident #27 for two (2) of three (3) days of survey. Findings include:Record review of the facility policy Departmental (Respiratory Therapy) Prevention of Infection dated 2/2018 revealed .Infection Control Considerations.7. Store the circuit in plastic bag, marked with date and resident's name, between uses . 9. Discard the administration set up every seven (7) days. Record review of the facility's Handwashing/Hand Hygiene, dated 12/2025 revealed, Hand hygiene is the primary means for preventing healthcare associated infections and the transmission of multidrug resistant organism (MRDO). This facility requires strict adherence to evidence-based hand hygiene practices for all personnel . Indications for hand hygiene 1. Hand hygiene is indicated: a. before touching a resident, b. before .handling food.g. after touching the resident's environment or belongings (e.g. bedrails, wheelchair, etc).Record review of the facility's Infection Control Policy dated 2001 revealed Purpose: To prevent, control and reduce the spread of infection among residents, staff and visitors in the facility, ensuring a safe and healthy environment.Resident #1On 03/30/2026 at 3:22 PM, observed Resident #1 sitting in a wheelchair with oxygen tubing beside the bed. The O2 tubing was not bagged and was wrapped around the O2 machine. The tubing was dated 3/19/26. Resident #1 stated he uses O2 sometimes.On 03/30/2026 at 3:26 PM, in an interview with Licensed Practical Nurse (LPN) #2 stated the tubing should be in a bag to prevent bacteria from getting on it. She stated the nurses are responsible for changing the tubing and the tubing should be changed weekly. She confirmed the tubing was not in a bag and was dated 3/19/26. On 03/31/2026 at 2:07 PM, in an interview the Director of Nursing (DON) stated oxygen tubing is supposed to be changed weekly. It should have been changed on 3/26/26. She stated the tubing should have been a bag. She stated the reason for putting it in a bag is to keep it off the floor and prevent infection. On 03/31/2026 at 2:16 PM, in an interview with Registered Nurse #1/Infection Preventionist (RN)/IP stated the tubing is supposed to be in a bag and it is changed weekly. We change tubing every Thursday. She confirmed that by not changing O2 tubing, it could put Resident #1 at risk for infection.Record review of Resident #1's admission Record revealed an admission date of 9/24/24 with diagnoses that included cerebral palsy and pneumonia.Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference (ARD) of 3/5/26 revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicates the resident was cognitively intact. Record review of Resident #1's Order Listing Report revealed an order dated 2/24/26 Oxygen: Obtain SPO2( Peripheral capillary oxygen saturation) and apply oxygen 2L/min (liters/minute) via (by way of) nasal canula as needed to keep oxygen saturation > 92% check O2 sat(saturation) every shift.Resident #26During an observation of peri-care on 03/31/2026 at 3:09 PM, provided by Certified Nursing Assistant (CNA)#1 revealed CNA #1 gathered gown, gloves and brief and knocked on the door and entered the room. She then donned (put on) a gown and gloves. CNA #1 then adjusted the bed remote with gloves on. She did not wash her hands prior to applying gloves upon entry. She did not remove gloves and perform hand hygiene after touching the remote. CNA #1 removed the soiled brief and applied a clean brief without providing peri care using peri wipes or soap and water.During an interview on 03/31/26 at 3:41 PM, CNA #1 confirmed that she did not completely do peri care. She stated she changed the brief but forgot to gather supplies to provide peri- care. She confirmed she did not perform hand hygiene upon entry, after touching the bed remote and prior to changing the brief. She confirmed that the resident's wound could get infected if he is still soiled. She stated she uses soap and water or peri wipes when doing care.On 03/31/26 at 4:08 PM, in an interview with the Director of Nursing (DON) stated CNA #1 should have washed her hands upon entry and after touching remote then applied clean gloves. She should have used soap and water or peri wipes to do care. She stated Resident #26 could get skin breakdown, wound infection, urinary tract infection (UTI) and have a body odor. She stated she expects staff to give proper care.On 03/31/26 at 4:36 PM, in an interview with Registered Nurse #1/Infection Preventionist (RN)/IP stated CNA #1 should have washed hands upon entry and prior to care. She should remove gloves after touching bed remote. She should have performed peri care with soap and water, not just apply clean brief to Resident #26. She stated it could have a negative effect on Resident #26. Resident #26 could get another UTI or infection of the sacral wound. She stated CNAs should provide high quality care.Record review of Resident #26 admission Record revealed admission date of 2/27/23 with diagnoses that included Personal history of UTI's dated 1/15/26, Pressure ulcer of other site, stage 2 dated 11/18/25 and Local infection of the skin, subcutaneous tissue unspecified dated 3/26/26, Quadriplegia C1-C4 incomplete and contracture unspecified.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/19/26 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Section GG revealed he is dependent on toileting and hygiene.Resident #27On 03/30/26 at 12:12 PM an observation of various staff was setting up trays for residents. Medical Records (MR) staff placed a lunch tray in front of Resident #27. The tray contained mashed potatoes, green peas and a hamburger. The MR staff placed her bare left hand on his hamburger and cut it with a spoon.On 0/30/26 at 12:17 PM during an interview with MR staff she revealed she was unaware that she placed her bare hands-on Resident #27's food. She then recanted her statement and confirmed that she touched his hamburger. She stated she was trying to make sure he ate his food. She stated she should not have touched his food and that is cross contamination issue. On 03/31/26 at 2:07 PM, during an interview the Director of Nursing (DON) stated staff should never touch a resident's food with their bare hands. She stated it cross contamination issue with infection control. On 03/31/26 at 2:20 PM, in an interview with Registered Nurse #1(RN) /Infection Prevention stated staff should never touch residents' food with bare hands. She stated MR should have gotten resident another burger. She stated that it is cross contamination issue. She stated most residents are immune, compromised and this could cause the residents to get an infection.Record review of Resident #27 admission Record revealed an admission date of 10/24/25 with diagnoses that included malignant neoplasm of brain, unspecified and unspecified protein-calorie malnutrition.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/26/26 revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had sever cognitive impairment.Record review of Resident #27's Order Summary Report with active orders as of 3/31/26 revealed an order dated 10/24/25 for Regular diet, regular texture, regular/thin consistency.

Based on observation, staff interview, record review, and facility policy review the facility failed to store and replace oxygen tubing in accordance with professional standards and facility policy for one (1) of two (2) residents reviewed for oxygen use. Resident #1. Findings include: Record review of the facility policy Departmental (Respiratory Therapy) Prevention of Infection dated 2/2018 revealed .Infection Control Considerations.7. Store the circuit in plastic bag, marked with date and resident's name, between uses . 9. Discard the administration set up every seven (7) days. On 03/30/2026 at 3:22 PM, observed Resident #1 sitting in a wheelchair with oxygen tubing beside the bed. The O2 tubing was not bagged and was wrapped around the O2 machine. The tubing was dated 3/19/26. Resident #1 stated he uses O2 sometimes.On 03/30/2026 at 3:26 PM, in an interview with Licensed Practical Nurse (LPN) #2 stated the tubing should be in a bag to prevent bacteria from getting on it. She stated the nurses are responsible for changing the tubing and the tubing should be changed weekly. She confirmed the tubing was not in a bag and was dated 3/19/26. On 03/31/2026 at 2:07 PM, in an interview the Director of Nursing (DON) stated oxygen tubing is supposed to be changed weekly. It should have been changed on 3/26/26. She stated the tubing should have been a bag. She stated the reason for putting it in a bag is to keep it off the floor and prevent infection. On 03/31/2026 at 2:16 PM, in an interview with Registered Nurse #1/Infection Preventionist (RN)/IP stated the tubing is supposed to be in a bag and it is changed weekly. We change tubing every Thursday. She confirmed that by not changing O2 tubing, it could put Resident #1 at risk for infection.Record review of the Order Listing Report revealed an order dated 2/24/26 Oxygen: Obtain SPO2( Peripheral capillary oxygen saturation) and apply oxygen 2L/min (liters/minute) via (by way of) nasal canula as needed to keep oxygen saturation > 92% check O2 sat(saturation) every shift.Record review of the admission Record revealed an admission date of 9/24/24 with diagnoses that included cerebral palsy and pneumonia. Record review of the Minimum Data Set (MDS) with an Assessment Reference (ARD) of 3/5/26 revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicates the resident was cognitively intact.

Based on interview, record review, and facility policy review, the facility failed to ensure nursing staff were competent to perform duties related to safe medication administration and clinical decision making for one (1) of (1) residents reviewed for dialysis related care. Resident #14 Findings Include: Record review of the facility policy Administering Medications dated 2001 revealed Medications are administered in a safe and timely manner and as prescribed . 8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having a potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to express concerns. 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document not administered and the reason in the electronic record. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.During an interview on 03/31/2026 at 10:35 AM, Resident #14 stated that nurses in the facility were giving his blood pressure medications prior to his dialysis appointment even when he told them he couldn't take it because it would drop his blood pressure (BP) to an unsafe level. Resident #14 stated that he was holding the medication on dialysis days prior to his admission to the facility.Record review of the March 2026 Medication Administration Record (MAR) revealed the resident had received Metoprolol 25mg and Furosemide 80mg at 8 AM prior to his 11AM dialysis appointments each time since his admission on [DATE] including the dates of 3/20/26,3/23/26, 3/25/26,3/27/26, and 3/30/26.During an interview with Licensed Practical Nurse (LPN) #1 at 2:19 PM on 3/31/26, she confirmed that she has cared for the resident on 3/30/26 and 3/31/26 and confirmed that her documentation on the resident's Medication Administration Record (MAR) indicated that she gave the BP meds metoprolol and furosemide prior to his dialysis appointment on 3/30, but she stated she pulled them from the pack prior to administering and held them because they could lower his BP. She stated that she must have accidentally documented it as given, but she did not give it because nurses are taught not to give BP meds prior to dialysis because of the risk of hypotension.In an interview with LPN #2 at 2:25 PM on 3/31/26 she stated that the resident goes to dialysis on Mondays, Wednesdays, and Fridays and she took care of him on his dialysis days of 3/20/26 and 3/25/26. She confirmed that blood pressure meds such as metoprolol and furosemide should not be given prior to dialysis due to the fear of residents bottoming out while dialyzing. She stated that she didn't give blood pressure medications on the days prior to dialysis even though she charted that she did give them and just forgot to fix the documentation because it was hectic that day. She stated she didn't know to hold them prior to pulling the medications for the residents because there was no order in the system to hold before dialysis. She stated that the resident instructed her that he would not take them and refused.During a follow up interview with Resident #14 at 2:38 PM, on 3/31/26 he stated he never pulled any drugs out when the nurses gave them to him, so he took them every time, in fact he knows for certain he took them the day that he was given his flu vaccine on 3/25/26 because they were mixed in the cup with his other meds and he couldn't pick them out. He stated that he told the nurse that could kill him because he had dialysis later that day. He stated that he had notified the dialysis nurse prior to treatment that day and they told him you know better than to take them. He said he told the nursing staff, and no one listened. During an interview at 3:31PM, on 3/31/26 with LPN#3 she confirmed that she did give the medications metoprolol and furosemide on 3/23/26 prior to the resident's dialysis appointment. She noted that there was no order to hold the drugs although she did confirm that she knows sometimes residents blood pressures can bottom out during dialysis treatment if they receive blood pressure pills prior to the procedure.During an interview with Resident #14's dialysis nurse on 3/31/26 at 3:38 PM, she stated that it was reported to her one day last week (Monday) by the patient that he had taken his blood pressure medications prior to treatment. She stated that in his case, he was holding his medications prior to dialysis when he was living by himself prior to admission to the nursing home because his BP typically drops during dialysis treatment and if he takes his medications before treatment a consequence could be lower BP after treatment and difficulty getting it to come back up.During an interview with the Director of Nursing (DON) at 4:14 PM, on 3/31/26 she stated that the provider should have been called by any one of the nurses administering the medications to Resident #14 to get a hold order or clarify the necessity of it being given. She stated that giving it prior to dialysis could have caused the resident's BP to drop to an unsafe level resulting in a possible trip to the emergency room or hospitalization. She further explained that when residents voice concern with medications being administered, nurses should investigate the manner but failed to do so in this instance. She also confirmed that medications should be accurately marked on the Medication Administration Record (MAR) to reflect whether they were given or not to avoid confusion.In an interview at 12:09 PM on 4/1/26 with the Medical Director, he noted that while there typically has been a practice to hold BP meds prior to dialysis, there was never an established parameter that they have to be held. However, in the case of this resident, who had instructed nurses that he didn't normally take it because he had been instructed not to because he had a history of his blood pressure lowering during treatment, the nurses should have notified him to avoid lowering the resident's BP to an unsafe level and avoid complications.Record review of Resident #14's admission Record revealed the resident was admitted on [DATE] with diagnoses that included encounter for surgical aftercare following surgery on the genitourinary system.Record review of the Minimum Data Set (MDS) with an Assessment Reference (ARD) of 3/25/26 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.Record review of the Order Summary Report with active orders as of 3/31/26 revealed orders dated 3/19/26 and start date of 3/20/26 for Metoprolol Succinate ER tablet Extended Release 24 Hour 25 mg (milligrams) Give 1 tablet by mouth one time a day related to Chronic Diastolic Congestive Heart Failure and Furosemide Oral Tablet 80mg give 80mg by mouth one time a day related to Chronic Diastolic Congestive Heart Failure.

Based on interviews and Certification and Survey Provider Enhanced Reports (Casper) reporting data review, the provider failed to ensure their Payroll-Based Journal (PBJ) data, containing staffing hours for the appropriate care of residents, was corrected before submission to the Centers for Medicare and Medicaid Services (CMS) for one (1) of four (4) quarters in 2024. 3rd (Third) Quarter Findings Include: A review of the facility policy titled, Reporting Direct Care Staffing Information (Payroll-Based Journal), revised August 2022, revealed, . Complete and accurate direct care staffing information is reported electronically to CMS through the Payroll-Based Journal (PBJ) system in a uniform format specified by CMS . Record review of the PBJ Staffing Data Report FY (fiscal year) Quarter 3 2024 (April 1-June 30) revealed One star staffing rating and excessively low weekend staffing triggered. Triggered= Star Staffing Rating equals 1; Submitted weekend staffing data is excessively low. During an interview on 10/31/24 at 9:17 AM, the Human Resources Director explained that she does not handle anything directly related to the PBJ. She stated that her role involves compiling information that is automatically calculated within the payroll system, which she then submits to the corporate office for processing in the PBJ. During an interview on 10/31/24 at 9:23 AM, the Administrator confirmed that she does not view or process PBJ reporting, as all PBJ data is managed by the corporate office. During a phone interview on 10/31/24 at 1:33 PM, the Corporate Payroll Representative confirmed that he receives the daily staffing sheets from the facility. He reviewed the staffing grid with the State Agency (SA), selecting random dates to verify that the information submitted matched the data provided by the facility during the recertification survey. He noted that the facility's daily staffing punches are automatically uploaded to their payroll system through a second and third party. However, he acknowledged that a glitch appears to exist within either the second or third party's system, leading to discrepancies between the data extracted from the facility and what was exported to PBJ. He indicated that this issue requires resolution to ensure accurate reporting.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure care plan interventions related to Enhanced Barrier Precautions (EPB) were implemented for two (2) of three (3) residents reviewed with indwelling devices. Residents #25 and #33 Findings Include: A review of the facility's policy titled, Using the Care Plan, (undated), revealed, The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or serviced to the resident . Resident #25: A record review of Resident #25's Comprehensive Care Plan, with a date initiated of 5/26/23 revealed . receives PEG (Percutaneous Endoscopic Gastrostomy) tube feeding . Interventions . Maintain set Enhanced Based Precautions, such as washing hands, wearing a gown, wearing gloves, etc. when in resident's room when performing close contact care During an observation on 10/31/24 at 8:55 AM, Licensed Practical Nurse (LPN) #1 was observed performing PEG tube site care for Resident #25 without wearing a gown. During an interview on 10/31/24 at 9:11 AM, LPN #1 confirmed that she was aware of the EBP signage, however stated that she was uncertain of the requirement of wearing a gown. LPN #1 stated that although she had received EBP training several months prior, she could not recall specific guidelines. During an interview on 10/31/24 at 9:38 AM, the Infection Preventionist/LPN #3 confirmed that staff performing PEG tube care should wear a gown as part of EBP. A record review of the Admission Record revealed the facility admitted Resident #25 on 05/17/23. The resident's diagnoses included Aphasia related to Cerebral Infarction, Hemiplegia, and Gastrostomy Status. Resident #33: A record review of Resident 33's Comprehensive Care Plan with a date initiated of 4/24/24 revealed At risk for complications related to hx (history) Acute Renal Failure .Nephrostomy drain . Interventions: Signage to be placed on outside of residents door. Labeling as a room for EBP. Observations of the door of Resident #33 on 10/28/24 at 12:57 PM and 10/31/24 at 8:50 AM revealed there was no signage on Resident #33's door related to EBP. During an interview on 10/31/24 at 9:35 AM, Infection Preventionist/LPN #3 confirmed that Resident #33 should have EBP signage on the door due to the nephrostomy catheter. She stated that EBP signage should be maintained for residents with indwelling devices to protect against infection. During an interview on 10/31/24 at 12:14 PM, the Director of Nurses (DON) acknowledged the importance of staff following guidelines for EBP. She emphasized she expects staff to follow a resident's care plan. During an interview on 10/31/24 at 12:30 PM, the Care Plan Nurse/LPN #2 stated that the care plans are written as a guide for nursing care and that staff are expected for follow the care plans. A record review of the Admission Record revealed the facility admitted Resident #33 on 04/24/24. The resident's diagnoses included Acute Kidney Failure, Unspecified and Infection and Inflammatory Reaction Due to Nephrostomy Catheter.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed by staff when providing direct care for residents with indwelling devices for two (2) of three (3) residents reviewed with indwelling devices. Residents #18 and #25 Findings Include: A review of the facility's policy titled, Enhanced Barrier Precautions, (undated) revealed, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDROs) . Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents colonized or infected with MDRO as well as those at increased risk for MDRO acquisition (e.g., residents with wounds or indwelling medical devices) . Resident #18 During an observation of catheter care on 10/30/24 at 10:46 AM, revealed Certified Nursing Assistant (CNA) #1 or CNA #2 did not put on a gown prior to beginning catheter care. The care was completed without either CNA ever putting on a gown. During an interview on 10/30/24 at 2:05 PM, CNA #1, an agency staff member with six years of experience, stated that she had not received training on Enhanced Barrier Precautions and confirmed that she did not apply a gown before providing care. A record review of the Admission Record revealed the facility admitted Resident #18 on 06/05/24. The resident's diagnoses included Urine Retention, Unspecified. A record review of Resident #18's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/03/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Section H of the MDS was coded for Foley catheter use. Resident #25 On 10/31/24 at 8:55 AM, during an observation , Licensed Practical Nurse (LPN) #1 was observed performing PEG (Percutaneous Endoscopic Gastrostomy) tube care for Resident #25 without wearing a gown. During an interview on 10/31/24 at 9:11 AM, LPN #1 confirmed that she was aware of the EBP signage on Resident #25's door but was unsure if she was supposed to wear a gown. She stated that she had received EBP training but was uncertain of the requirements. Record review of the Order Review History Report dated 10/31/24 revealed a physician order dated 4/12/24 Enhance Barrier Precautions as of 4/1/2024 related to gastronomy status . A record review of the Admission Record revealed the facility admitted Resident #25 on 05/17/23 with diagnoses that included Aphasia related to Cerebral Infarction, Hemiplegia, and Gastrostomy Status. During an interview on 10/31/24 at 9:38 AM, the Infection Preventionist/LPN #3 confirmed that the facility had instituted EBP in March and conducted in-services. She stated that conditions requiring EBP include chronic wounds, catheters, and PEG tubes, and she expected staff to follow these guidelines. During an interview on 10/31/24 at 12:09 PM, the Director of Nursing (DON) stated that when performing resident care that involves close contact, staff are required to wear a gown in an effort to protect their uniform and the possibility of infections being transmitted to residents. The DON confirmed that CNA #1 should have worn a gown while providing catheter care to Resident #18 and that LPN #1 should have worn a gown while performing PEG tube care for Resident #25. 50751

Based on observation, staff interview, record review and facility policy review the facility failed to provide pressure ulcer treatment in a manner to prevent cross contamination and the potential for spread of infection for one (1) of six (6) sampled residents, Resident #1. Findings Include: Record review of the facility policy titled Dressings, Dry/Clean, with revised September 2013, revealed, .Steps in the Procedure .5. Wash and dry your hands thoroughly. 6. Put on clean gloves. Loosen tape and removed soiled dressing. 7. Pull glove over dressing and discard into plastic or biohazard bag. 8. Wash and dry your hands thoroughly .11. Using clean technique, open other products. 12. Wash and dry your hands thoroughly. 13. Put on clean gloves . On 3/06/24 at 3:15 PM, an observation revealed the facility Treatment Nurse provided wound care for Resident #1 for pressure ulcers on the resident's sacral area and right buttock. The Treatment Nurse removed dressings from both wounds simultaneously, removed Silver Alginate from the sacral wound then from the right buttock wound with the same gloved hand, cleansed the sacral and the right buttock wounds without performing hand hygiene and changing gloves. The Treatment Nurse used the same cotton tipped applicator to apply Silver Alginate to the sacral wound and the right buttock wound. On 3/06/24 at 4:00 PM, an interview with the Director of Nurses (DON) revealed she identified infection as a potential complication of pressure wounds. The DON stated that to provide wound care according to current standards of practice and infection prevention she expected the Treatment Nurse to provide treatment to each wound individually and change gloves and sanitize hands between contact with each wound. The DON stated that having both wounds uncovered, touching, and cleansing both wounds without changing gloves and doing hand hygiene and using the same applicator to apply treatment to both wounds could lead to cross contamination and increase the risk of infection of pressure ulcers. On 3/07/24 at 12:15 PM, during an interview with the Treatment Nurse, she confirmed that touching and cleansing both pressure wounds without changing gloves and doing hand hygiene between wounds and using the same applicator to apply treatment to both wounds could lead to contamination and an increased risk of infection of Resident #1's pressure ulcers. Record review of the Face Sheet for Resident #1 revealed the facility admitted the resident on 2/13/24, with diagnoses that included Type 2 Diabetes Mellitus, Stage 3 Pressure Ulcer of Sacral Region, Paraplegia (paralysis of the legs and lower body). Record review of the Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) 2/19/24, for Resident #1, revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Record review of the Physician Orders for Resident #1 revealed the following orders: 2/20/24 Silver Alginate cleanse Stage 3 to sacrum with normal saline, pack with silver alginate and cover with border foam as needed until healed. 2/26/24 revealed Silver Alginate cleanse Stage 2 to right ischium area with normal saline, pat dry with 4X4 (four inch by four inch) gauze and apply silver alginate to wound bed and cover with border foam dressing every day until. 2/15/24 Silver Alginate cleanse Stage 3 to sacrum with normal saline, pack with silver alginate and cover with border foam every day until healed.

Based on interviews, record review, facility policy review, and facility investigation review, the facility failed to provide adequate supervision to prevent Resident #1, who had severe cognitive impairment, from exiting the facility unnoticed and unsupervised for one (1) of four (4) residents reviewed. Resident #1 Resident #1 was able to obtain the unsecured wireless transmitter from the unmanned reception desk at the facility's front door at approximately 11:00 AM on 8/13/23 and use the transmitter to unlock the front door and exit the facility. The facility staff were unaware of Resident #1's absence until approximately 11:19 AM, when a member of staff returning from lunch observed the resident standing at a busy intersection approximately 540 feet from the facility. Resident #1 had been off the facility grounds and unsupervised for approximately 19 minutes. The facility's failure to provide supervision and ensure the front door wireless transmitter was secured properly, put Resident #1 and all other residents at risk for wandering and elopement, at risk for the likelihood of serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 8/13/23. The State Agency (SA) notified the Administrator of the IJ on 8/23/23 at 9:30 AM and provided an IJ Template. Based on the facility's implementation of corrective actions on 8/13/23, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed on 8/15/23, prior to the SA's entrance on 8/21/23. Findings include: Review of the facility policy, Wandering, Unsafe Resident, revised August 2014, revealed, The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement . Review of the facility policy, Elopements, revised December 2007, revealed, Staff shall investigate and report all cases of missing residents . Review of the Facility Investigation, completed by the Administrator, revealed on 8/13/2023, Resident #1 was seen by Certified Nurse Aide (CNA) #1 walking away from the facility on a nearby street. The CNA telephoned the facility and reported that she was returning to the facility with Resident #1. Upon return to the facility, the resident was assessed, and no signs of injury were observed. Resident #1 revealed that he was going to his grandparents' house. When the resident emptied his pockets, the facility's front door wireless transmitter fell out. The resident stated that he had taken the transmitter from behind the receptionist desk. Reportedly at that time, the resident was last seen at the facility by his aide at 11:15 AM and returned to the facility at approximately 11:30 AM. On 8/21/23 at 1:35 PM, an interview with CNA #1 revealed that she observed Resident #1 walking down the street at approximately 11:19 AM on her way back to the facility from lunch. She stated she telephoned the facility and notified them that she was assisting the resident to return to the facility. CNA #1 explained that she did not note any signs of distress or injury of Resident #1. She stated that when she and Resident #1 arrived at the facility, the resident removed the wireless transmitter from his pants pocket. On 8/22/23 at 1:42 PM, in an interview with Registered Nurse (RN) #1, she confirmed that on 8/13/23, she was notified by a CNA (she could not recall which) that CNA #1 had observed Resident #1 walking on the side of the street and was returning with the resident to the facility. She stated that she notified the Director of Nures (DON), the Administrator, the Resident's Representative (RR), and the resident's Physician. She confirmed that a Code Pink for 'Missing Resident/Elopement' had been activated and the staff used a printed census to confirm that no other resident was missing from the facility. She confirmed that all other residents were present in the facility. RN #1 revealed that as soon as CNA #1 had assisted Resident #1 to his room, she had conducted a head-to-toe body audit and found no signs or symptoms of injury, dehydration, or excessive heat. The nurse also revealed that the resident's vital signs were all within normal limits. RN #1 reported that it was determined that the last time staff observed Resident #1 prior to the elopement, was in his room at 11:00 AM, when Licensed Practical Nurse (LPN) #1 measured the resident's blood glucose. She confirmed that CNA #1 telephoned at 11:19 AM to report that she had observed the resident on a nearby street and was assisting him back to the facility. She stated that she believed CNA #1 and Resident #1 arrived at the facility at approximately 11:20 AM. The nurse noted that she observed Resident #1 remove the front door transmitter from his pocket upon return to his room. Upon notification of Resident #1's primary physician of the elopement, RN #1 stated the physician had issued new orders for increased supervision, application of a wander monitoring bracelet with monitoring. RN #1 confirmed that the facility initiated a mandatory in-service training on elopements and missing residents for all staff on 8/13/23. The nurse stated that following the incident, Resident #1 had not exhibited any further exit seeking behavior and had worn the wander monitoring bracelet, which was monitored routinely by nursing staff with documentation in the EMAR (Electronic Medication Administration Record). Record review of the Facesheet for Resident #1 revealed the resident was admitted by the facility on 12/27/22 and had diagnoses that included Cerebral Infarction (Stroke), Type 2 Diabetes Mellitus and Chronic systolic (congestive) heart failure. Record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) 6/16/23, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment. Record review of the Elopement Risk Evaluation dated 6/16/23 for Resident #1 (the most recent prior to his elopement) revealed he had a total score of 7 (seven), which indicated LOW risk for elopement. Record review of the Physician Orders for Resident #1 revealed the following orders: 8/13/2023 at 12:47 PM- Wander guard bracelet in place to left leg, check to ensure that monitor is in place every shift .8/13/2023 at 12:49 PM- Check to ensure that Wander guard to left leg is working properly- 8/14/23 at 9:35 AM- Obtain U/A (urinalysis) with culture and sensitivity related to altered mental status .8/14/23 at 5:33 PM- Monitor Hourly to ensure that Resident is in the facility at all times . antibiotic therapy order dated 8/16/23 . Record review of the Brief Interview for Mental Status (BIMS) dated 8/14/23 for Resident #1, signed by the Social Worker revealed the Social Worker conducted an interview with the resident on 8/14/23, at which time the BIMS score was 07, which indicated severe cognitive impairment. Record review of the Elopement Risk Evaluation for Resident #1 dated 8/13/23, signed by the DON confirmed that the DON performed an evaluation for elopement risk for the resident following the incident. The Evaluation rating indicated that Resident #1 was at LOW risk for elopement. Record review of the weather history according to Wunderground in conjunction/cooperation with The Weather Company and The Weather Channel at Wunderground.com, revealed the weather history for 8/13/23 in the local area of the facility was a heat advisory with a temperature at 11:00 AM of ninety-five (95) degrees Fahrenheit with zero (0) precipitation and wind speed zero to five miles per hour (0-5 MPH). On 8/24/23 at 2:15 PM, an interview with the Administrator she confirmed that there were some discrepancies between times on the Facility Investigation. She stated that based on review of the interviews with the staff working on 8/13/23, she was able to confirm that the last definite interaction between Resident #1 and staff prior to his elopement was at 11:00 AM, when LPN #1 measured his blood glucose in his room. She confirmed that the resident was observed and assisted to return to the facility at 11:19 AM and therefore, the resident was unsupervised for approximately nineteen (19) minutes. She confirmed that Resident #1 had obtained the transmitter which controlled the locking mechanism on the front door and the resident used it to unlock the front door, exit and leave the facility premises. She confirmed that she attended an emergency Quality Assurance Performance Improvement (QAPI) committee meeting on 8/14/23 at 7:00 AM along with the Medical Director and the Assistant Director of Nursing (ADON/Infection Preventionist) during which the incident was reviewed, and a systemic change was adopted to prevent the transmitter from being accessible to the residents. She stated that mandatory in-service training was provided for all staff which included the systemic change in procedure to ensure that the transmitter was always secured by staff. The Administrator also confirmed that she and the Maintenance Supervisor had observed all exit doors on 8/14/23 and that the doors and locking mechanisms were functioning correctly. Corrective Action Plan provided by the Facility: 1. On 08/13/2023, Certified Nursing Assistant (CNA) #1 observed Resident #1 walking on the side of the street at approximately 11:19 AM. CNA #1 assisted Resident #1 back to the facility. 2. On 08/13/2023, CNA #1 notified CNA #2 at the facility that Resident #1 was off campus and being assisted back to campus at approximately 11:19 AM. 3. On 08/13/2023, CNA #2 initiated a Code Pink, the emergency code for a missing resident at approximately 11:20 AM. The facility conducted a headcount with all residents accounted for except for Resident #1. 4. On 08/13/2023, RN #1 contacted Director of Nursing (DON) at 11:30 AM of Elopement. 5. On 08/13/2023, Director of Nursing notified Administrator at 11:35 AM of Elopement. 6. Registered Nurse (RN) #1 assisted resident to his room and conducted a head-to-toe assessment with no noted injuries at approximately 11:35 AM. Vital signs were within normal limits. 7. On 08/13/2023, RN #1 contacted Resident #1 Primary Care Physician at 11:40 AM. RN #1 received orders for wander monitoring bracelet, monitoring, observations, and urinalysis. Urinalysis results showed Resident #1 had Urinary Tract Infection on 08/16/23 with new orders for antibiotic. 8. RN #1 applied wander monitoring bracelet to Resident #1 left ankle on 08/13/23 at 11:40 AM. 9. On 08/13/2023, Director of Nursing notified Medical Director at 11:45 AM of Elopement. 10. On 08/13/2023, Administrator notified local Police Department at 11:50 AM of Elopement. 11. On 08/13/23 facility nursing staff conducted visual observation monitoring of Resident #1 every fifteen (15) minutes from 11:50 AM through 2:20 PM, every thirty (30) minutes from 2:35 PM through 10:45 PM, and then hourly (continues). 12. On 08/13/2023, RN #1 notified Resident Representative at 12:30 PM of Elopement. 13. On 08/13/2023, The Director of Nursing and Administrator reviewed the facility's policy on Elopement and Wandering at 12:30 PM. No policy changes were implemented. 14. On 08/13/2023, Director of Nursing notified State Agency at 12:37 PM. 15. Elopement Risk Evaluation was completed on 08/13/2023 at 12:37 PM by DON. 16. On 08/13/2023, at 12:41 PM, RN #1 conducted Pain assessment for Resident #1 with no complaints of pain. 17. Photo of Resident, Care Plan, Elopement Risk Evaluation and Face Sheet were added to the Elopement Book per Activity Director and Social Worker on 08/13/23 at 12:45 PM. 18. CNA #2 checked all exit doors to ensure they were working properly on 08/13/2023 at 12:50 PM. All doors were working properly with no issues noted. 19. A Mandatory Staff In-service was conducted on Facility's policy of Elopement, Wandering, securement of wireless door transmitter, and updated elopement books by the Assistant Director of Nursing on 08/13/2023 at 1:00 PM and completed on 08/14/23 at 5:45PM. No facility staff was allowed to work until they were educated on Facility's Policy of Elopement, Wandering, Securement of wireless door transmitter, and updated elopement books. 20. On 08/13/2023, Administrator notified Ombudsman at 1:30 PM. 21. Elopement Risk Evaluations for all residents were completed by the DON on 08/13/2023 at 2:00 PM. Two additional residents were identified and added to the Facility's Elopement Books. 22. All exit doors were checked to ensure they are working properly by the Maintenance Director and Administrator on 08/14/2023 at 6:30 AM. No issues with the exit doors were noted. 23. An Emergency Quality and Assurance Performance Improvement (QAPI) Meeting was called on 08/14/23 at 7:00 AM to discuss Resident's #1 Elopement from the facility. Those in attendance were the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing/Infection Preventionist, Unit Manager, Dietary Manager, Maintenance Director, Social Services Director, Minimum Data Nurse, Wound Care Nurse, Care Plan Nurse, and Lead Certified Nursing Assistant. QAPI reviewed facility's policy on Elopement and Wandering on August 13, 2023. No changes were made to the policy. The QAPI Committee instituted systemic change for securement of the wireless door transmitter. The wireless door transmitter will be kept in possession of facility staff at all times and/or locked in cabinet at receptionist desk. 24. On 08/14/23 at 8:43 AM, the Social Worker submitted a referral to an in facility contracted psychiatric services for talk therapy for Resident #1. 25. On 08/14/2023 at 9:05 AM, the Social Worker conducted an interview with Resident #1 which included a Brief Interview for Mental Status (BIMS). Resident #1 BIMS score is a 7. Social Worker provided reassurance of safety and psychosocial support for Resident #1. 26. Emergency Care Plan Conference with Interdisciplinary Team and Resident Representative was conducted by the Social Worker on 08/14/2023 at 9:27 AM. Care Plan reviewed for At Risk for Elopement by leaving facility unattended with interventions of place wander monitoring device on Resident #1, notify Primary Care Physician and Responsible Party of any further attempts to elope, increase group activities as resident desires, and staff to check doors to ensure they are working properly. 27. On 08/14/23, at 10:30 AM, the Director of Nursing and Care Plan Nurse reviewed and updated the Care plan for Resident #1. 28. The Codes for all exit doors was changed by the facility's contracted security provider on 08/14/2023 at 11:30 AM. 29. An Elopement Drill was conducted by the Administrator on 08/14/2023 at 12:00 PM with two more elopement drills scheduled monthly for the next two months. 30. A Medication Review for Resident #1 was completed on 08/14/2023 at 12:19 PM by the Primary Care Physician with no changes noted. 31. On 8/14/2023 at 1:15 PM, Attorney General Office was notified by Administrator. Haven Hall Healthcare Center alleged that on 08/15/2023, the Immediate Jeopardy regarding Resident #1 was removed. The SA's Validation of the Facility's Corrective Action Plan: 1. SA validated through an interview with RN #1 on 8/22/23 at 1:42 PM, record review of the Facility Investigation, and an interview with CNA #2 on 8/22/23 at 2:00 PM, that on 8/13/23 RN #1 received a telephone call at 11:19 AM from CNA #1 in which CNA #1 reported that she was assisted Resident #1 back to the facility after observation of the resident walking down the side of the street. 2. SA validated through an interview with RN #1 on 8/22/23 at 1:42 PM, record review of the Facility Investigation, and an interview with CNA #2 on 8/22/23 at 2:00 PM, On 08/13/2023, CNA #1 notified CNA #2 at the facility that Resident #1 was off campus and was assisted back to campus at approximately 11:19 AM. 3. SA validated through an interview with RN #1 on 8/22/23 at 1:42 PM, record review of the Facility Investigation that on 08/13/2023, CNA #2 initiated a Code Pink, the emergency code for a missing resident at approximately 11:20 AM. The facility conducted a headcount with all residents accounted for except for Resident #1. 4. SA validated through an interview with RN #1 on 8/22/23 at 1:42 PM, record review of the Facility Investigation, and an interview with the DON on 8/22/23 at 2:45 PM, that on 08/13/2023, RN #1 contacted the DON of the Elopement at 11:30 AM of Elopement. 5. SA validated through an interview with the DON on 8/24/23 at 2:15 PM and an interview with the Administrator On 8/24/23 at 2:15 PM that the DON notified the Administrator of the elopement on 8/13/23 at 11:35 AM. 6. SA validated through an interview with RN #1 on 8/22/23 at 1:42 PM, and record review of the Facility Investigation that Registered Nurse (RN) #1 assisted resident to his room and conducted a head-to-toe assessment with no noted injuries at approximately 11:35 AM including vital signs measured within normal limits. 7. SA validated through an interview with RN #1 on 8/22/23 at 1:42 PM, an interview with the Primary Physician for Resident #1 on 8/22/23 at 11:00 AM, and record review of the Physician Orders for August 2023 on 08/13/23 that RN #1 contacted Resident #1 Primary Care Physician at 11:40 AM and received orders for wander monitoring bracelet, monitoring, observations, and urinalysis, with new orders for antibiotic received upon receipt of the urinalysis results. 8. SA validated through an interview with RN #1 on 8/22/23 at 1:42 PM and observation of Resident #1 that RN #1 applied wander monitoring bracelet to Resident #1 left ankle on 08/13/23 at 11:40 AM. 9. SA validated through an interview with the DON on 8/24/23 at 2:15 PM and an interview with the Primary Physician for Resident #1 on 8/22/23 at 11:00 AM that on 08/13/2023, Director of Nursing notified Medical Director at 11:45 AM of elopement. 10. SA validated through an interview with the Administrator on 8/24/23 at 2:45 PM 08/13/23 that the Administrator notified local Police Department at 11:50 AM of elopement per facility policy. 11. SA validated through an interview with RN #1 on 8/22/23 at 1:42 PM and SA verified through record review of the Every 15 Minute Round Paper dated 8/13/23 documentation of facility nursing staff direct visual observations of Resident #1 every fifteen (15) minutes from 11:50 AM through 2:20 PM on 8/13/23. SA verified through record review of the Every 30 Minute Round Paper dated 8/13/23 documentation of facility nursing staff direct visual observations of Resident #1 every thirty (30) minutes from 2:35 PM through 10:45 PM on 8/13/23. SA verified through record review of the Electronic Medication Administration Record (EMAR) for Resident #1 for July 2023 documentation of hourly visual observation monitoring by nurses for Resident #1 beginning 8/13/23 and was ongoing at the time of survey. that on 08/13/23 facility nursing staff conducted visual observation monitoring of Resident #1 every fifteen (15) minutes from 11:50 AM through 2:20 PM, every thirty (30) minutes from 2:35 PM through 10:45 PM, and then hourly (continues). 12. SA validated through an interview with RN #1 on 8/22/23 at 1:42 PM and an interview with the DON on 8/24/23 at 2:15 PM, and a telephone interview on 8/23/23 at 11:03 AM with the Resident Representative (RR) for Resident #1 that on 08/13/2023, RN #1 notified the RR at 12:30 PM of the elopement. 13. SA validated through an interview with the DON on 8/24/23 at 2:15 PM and an interview with the Administrator on 8/24/23 at 2:15 PM that the DON and the Administrator reviewed the facility's policy on Elopement and Wandering at 12:30 PM, with no policy changes implemented. 14. SA validated through an interview with the DON on 8/24/23 at 2:15 PM that on 08/13/2023, the DON notified State Agency at 12:37 PM. 15. SA validated through an interview with the DON on 8/24/23 at 2:15 PM and record review of the Elopement Risk Evaluation dated 8/13/23 that an Elopement Risk Evaluation was completed on 08/13/2023 at 12:37 PM by DON and the resident scored 7 (seven), which indicated LOW risk for elopement. 16. SA validated through an interview with RN #1 on 8/22/23 at 1:42 PM that on 08/13/2023, at 12:41 PM, RN #1 conducted Pain assessment for Resident #1 with no complaints of pain noted. 17. SA validated through an interview with the Social Worker on 8/24/23 at 10:10 AM and record review that all three (3) copies of the Elopement Book that the Elopement Book's located at the reception desk and both nurses' station on 8/14/23 at 12:45 PM had been updated. 18. SA validated through an interview with CNA #2 on 8/22/23 at 2:00 PM that CNA #2 checked all exit doors to ensure they were working properly on 08/13/2023 at 12:50 PM. All doors were working properly with no issues noted. 19. SA validated through record review of In-service Sign In sheets dated 8/13/23 through 8/14/23 and an interview with the ADON/Infection Preventionist on 08/22/23 at 4:30 PM that she had conducted mandatory in-service on Facility's policy of Elopement, Wandering, securement of wireless door transmitter, and updated elopement books by the ADON on 08/13/2023 at 1:00 PM and completed on 08/14/23 at 5:45PM. The ADON confirmed that no facility staff was allowed to work until they were educated on Facility's Policy of Elopement, Wandering, Securement of wireless door transmitter, and updated elopement books. SA further validated this through an interview with CNA #2 on 8/22/23 at 2:00 PM, and RN #1 on 8/22/23 at 1:42 PM. 20. SA validated through an interview with the Administrator on 8/24/23 at 2:15 PM and through a telephone interview with the Ombudsman on 8/23/23 at 11:15 AM, that the Administrator notified Ombudsman about the elopement on 8/13/23 at 1:30 PM. 21. SA validated through an interview with the DON on 8/24/23 at 2:15 PM that Elopement Risk Evaluations for all residents were completed by the DON on 08/13/2023 at 2:00 PM. Two (2) additional residents were identified and added to the Facility's Elopement Books, Resident #2, and Resident #3. 22. SA validated through an interview with the DON on 8/24/23 at 2:15 PM and at 10:20 AM an interview and observation with the Maintenance Supervisor, that all exit doors were checked to ensure they were working properly by the Maintenance Director and Administrator on 08/14/2023 at 6:30 AM. No issues with the exit doors were noted. 23. SA validated through record review of the QAPI/Quality Assurance (QAPI) meeting minutes with attached sign-in sheet dated 8/13/23, an interview with the DON on 8/24/23 at 2:15 PM, and an interview with the Administrator on 8/24/23 at 2:15 PM that An Emergency Quality and Assurance Performance Improvement (QAPI) Meeting was called on 08/14/23 at 7:00 AM to discuss Resident's #1 Elopement from the facility. Those in attendance were the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing/Infection Preventionist, Unit Manager, Dietary Manager, Maintenance Director, Social Services Director, Minimum Data Nurse, Wound Care Nurse, Care Plan Nurse, and Lead Certified Nursing Assistant. QAPI reviewed facility's policy on Elopement and Wandering on August 13, 2023. No changes were made to the policy. The QAPI Committee instituted systemic change for securement of the wireless door transmitter. The wireless door transmitter will be always kept in possession of facility staff and/or locked in cabinet at receptionist desk. 24. SA validated through an interview with the Social Worker on 8/24/23 at 10:10 AM and record review of Social Services Progress Notes dated 8/14/23 that the Social Worker submitted a referral to an in facility contracted psychiatric services for talk therapy for Resident #1 on 8/14/23. 25. SA validated through an interview with the Social Worker on 8/24/23 at 10:10 AM and record review of the Brief Interview for Mental Status (BIMS) documentation dated 8/14/23 that on 08/14/2023 at 9:05 AM, the Social Worker conducted an interview with Resident #1 which included a BIMS. Resident #1 BIMS score is a 7. Social Worker stated she also provided reassurance of safety and psychosocial support for Resident #1 through active listening and talking with the resident. 26. SA validated through a telephone interview with the RP for Resident #1 8/23/23 at 11:03 AM, that an Emergency Care Plan Conference with Interdisciplinary Team and Resident Representative was conducted by the Social Worker on 08/14/2023 at 9:27 AM. Care Plan reviewed for At Risk for Elopement by leaving facility unattended with interventions of place wander monitoring device on Resident #1, notify Primary Care Physician and Responsible Party of any further attempts to elope, increase group activities as resident desires, and staff to check doors to ensure they are working properly. 27. SA validated through an interview with the DON on 8/24/23 at 2:15 PM and record review of the individualized Care Plan for Resident #1 that the resident's care plan was updated on 8/14/23 to address elopement and elopement risk and included appropriate interventions which included wearing a Wanderguard bracelet, daily monitoring of placement and functioning of the Wanderguard bracelet by nursing staff with documentation, and direct visual observation monitoring by nursing staff. 28. SA validated through interview with the Maintenance Supervisor on 8/24/23 at 10:20 AM that the Codes for all exit doors was changed by the facility's contracted security provider on 08/14/2023 at 11:30 AM. 29. SA validated through an interview with the Administrator on 8/24/23 at 2:15 PM and record review of sign-in sheets dated 8/24/23 that an Elopement Drill was conducted by the Administrator on 08/14/2023 at 12:00 PM with two more elopement drills scheduled monthly for the next two months. 30. SA validated through an interview with the Primary Physician for Resident #1 on 8/22/23 at 11:00 AM, that a Medication Review for Resident #1 was completed on 08/14/2023 at 12:19 PM by the Primary Care Physician with no changes noted. 31. SA validated through an interview with the Administrator on 8/24/23 at 2:15 PM that on 8/14/2023 at 1:15 PM, Attorney General Office was notified by Administrator. The SA validated on 8/24/23 that all corrective actions to remove the Immediate Jeopardy were completed as of 8/15/23, prior to entrance.

Based on observation, interviews, record review, and facility policy review, the facility failed to prevent the possible spread of infection by not placing supplies outside the residents door and by not posting appropriate signage to alert staff and visitors of necessary precautions for one (1) of two (2) residents observed for Transmission-Based Precautions (TBP). Resident #68. Findings include: Review of the facility's policy titled, Isolation-Initiating Transmission-Based Precautions, with a revised date of January 2012, revealed Transmission-Based Precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease. Transmission-Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions . When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee) shall: a. Ensure that protective equipment (i.e., gloves, gowns, mask, etc.) is maintained near the resident's room so that everyone entering the room can access what they need; b. Post the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel will be aware that they must first see a nurse to obtain additional information about the situation before entering the room . d. Place necessary equipment and supplies in the room that will be needed during the period of Transmission -Based Precautions . On 06/25/23 at 11:22 AM, an observation of the room of Resident #68 revealed there were two red barrels in the room. There was no sign on the door for isolation nor was there any Personal Protective Equipment (PPE) near the resident's room. An interview of 6/25/23 at 11:25 AM, revealed Certified Nursing Assistant (CNA) #1 did not know why there were red barrels located inside Resident #68's room. However, the CNA stated she would check with the nurse. Within a few minutes, CNA #1 returned and stated that the nurse informed her that Resident #68 had Methicillin Resistant Staphylococcus Aureus (MRSA). On 06/25/23 at 3:13 PM, in an interview with the Infection Preventionist (IP), she revealed there two (2) residents in the facility currently on Transmission-Based Precautions (TBP). The IP confirmed that Resident #68 was diagnosed over a week ago with MRSA, however, there was no notice on the resident's door indicating that the resident was on TBP or PPE close to the resident's room for access prior to entering the resident's room. On 06/27/23 at 3:00 PM, in an interview with Director of Nursing (DON), she revealed that she was aware that Resident #68 had MRSA and there should have been a sign on the door for contact precautions, as well as PPE by the door. The DON stated PPE is used to prevent the spread of infection to staff and other residents and the IP nurse is responsibility for making sure that the sign, as well as the PPE are made available. On 06/27/23 at 4:15, in an interview with IP nurse, she confirmed she is responsible for making sure signage is on the door and PPE is by the door. On 06/28/23 at 9:20 AM, in an interview with CNA #1, she confirmed she did not have Resident #68 on 06/25/23, however, she had provided care for Resident #68 earlier in the week without wearing PPE. She stated there was no sign on the door or PPE at the door and at the time she was assigned to the resident, she did not know the resident had MRSA. On 06/28/23 at 9:40 AM, in an interview with CNA #2, she confirmed she had provided care for Resident #68 on 06/25/23 without wearing PPE, as she was unaware that the resident had MRSA. She explained that there was no sign on the door or PPE beside the door, so she was unaware that the resident was on contact precautions and needed to wear PPE while providing care. On 06/28/23 11:59 AM, an interview and observation of Resident #68, revealed a sign on door indicating Contact Precautions and PPE beside the door. The resident stated staff are now wearing PPE when they come into her room, but earlier in the week, some staff did not wear any type of PPE while providing care. A record review of the Face Sheet for Resident #68, revealed an admitted [DATE], with diagnoses that included Pressure Ulcer of Sacral Region, stage 3 onset date of 05/26/23, Pressure ulcer of left buttock, stage 3 onset date 06/14/23 and Methicillin Resistant Staphylococcus Aureus infection, with an onset date of 06/8/23. A record review of the Physician's Telephone Orders, revealed an order on 6/8/23, for contact isolation related to MRSA in wound bed. A record review of the Laboratory Specimen Reports for Resident #68, dated 06/07/23, revealed a Grams Stain Final report for moderate Gram-Positive Cocci and an Aerobic Culture Final report for Methicillin Resistant Staph Aureus. A Laboratory Specimen Report dated 06/27/23, revealed a Gram Stain Final report for rare Gram-Positive Cocci, with an Aerobic Culture report pending. A record review of the Admission Minimum Data Set (MDS) for Resident #68, with the Assessment Reference Date (ARD) of 05/26/23, revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicates the resident is cognitively intact.

Based on record review, policy review, and interviews, the facility failed to ensure that residents were treated with dignity and respect for one (1) of five (5) sampled residents. Resident #1 Findings include: Record review of the Facility Investigation, dated 2/09/22 (related to MS# ) revealed that on 2/05/22 at 10:55 PM, Certified Nurse Aide (CNA) #1 reported to Licensed Practical Nurse (LPN) #1 an exchange between herself and Resident #1. The CNA stated that when Resident #1 became agitated during care and cursed at her, she cursed at Resident #1 in response. LPN #1 reported the incident to Administration and the facility removed the CNA from duty pending results of an investigation. The facility's investigation concluded that the behavior of CNA #1 was unacceptable, and CNA #1 was terminated. The facility reported CNA's inappropriate behavior to the State Agency (SA), Attorney General's Office (AGO), and the CNA registry. On 8/10/22 at 8:05 PM, an interview with the Administrator revealed that on 2/05/22 at 10:55 PM, an incident that involved Resident #1 and CNA #1 resulted in the failure of CNA #1 to treat the resident with respect and dignity. CNA #1's behavior resulted in the termination of her employment. The Administrator stated that Resident Rights were included in the orientation of all new employees and that the facility provided ongoing education to all staff regarding Resident Rights and the importance of treating residents with respect and dignity. The Administrator stated that the CNA's verbal response constituted failure to treat Resident #1 with dignity. In addition to terminating CNA #1, the Administrator confirmed that the facility reported CNA's inappropriate behavior to the SA, AGO, and the CNA registry. Record review of an educational program entitled Behavior Management Strategies was electronically signed by CNA #1, indicating that she had received a copy of the training on 10/13/20. Review of the facility's employee policy, The Rights & Care of Residents (undated), revealed Abide by all the Resident's Rights under federal law given to me upon my hiring. Specific Rights: .to dignity, respect, and freedom, was electronically signed by CNA #1 on 9/14/20. Review of the facility's policy Policy and Procedures on Resident's Rights (undated) stated The facility shall protect and promote the rights of each resident .The resident has the right to a dignified existence . It was noted that a copy of the policy was signed by CNA #1 on 9/14/20. Record review of the Admission Record for Resident #1 revealed she was admitted by the facility on 7/09/21 with diagnoses that included Diabetes, [CONDITION(S)], and Dementia. Record review of the Quarterly Minimum Data Set (MDS) with Assessment Reference date of (ARD) 6/30/22, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated moderate cognitive impairment. Further review of the MDS revealed the resident required limited one-person assistance for dressing and was independent or needed supervision for all other Activities of Daily Living. On 8/11/22 at 11:00 AM, observation and an interview with Resident #1 revealed she was sitting on the edge of her bed in her room with the television on. She appeared neat, clean, and appropriately dressed, alert and oriented, and able to communicate without difficulty. The Resident initially stated she did not recall an incident with staff, then stated I did have a problem with one nurse's aide. She had a bad attitude. She stated she could not recall what was said. She said the incident had not affected her in a negative way and denied any lingering effects. She stated, I feel safe here and denied that any staff had been abusive toward her. On 8/11/22 at 12:18 PM, a telephone interview with the Responsible Party (RP) for Resident #1 revealed she had forgotten the incident and voiced no complaints related to the resident's care. On 8/11/22 at 1:19 PM, an interview with the facility's Social Worker, revealed she was involved in the investigation of the incident involving Resident #1. She confirmed the facility investigation determined that CNA #1 failed to treat Resident #1 with respect and dignity at the time of the verbal disagreement. She revealed that both she and the Administrator had visited Resident #1 in her room on multiple occasions following the incident and noted no residual adverse effects. A licensed psychologist had also been notified of the incident and had conducted a psychosocial assessment of Resident #1 following the incident. The psychologist did not verify any resulting negative psychosocial effects. The Social Worker stated that the facility routinely provided staff with in-service training regarding the care of residents with dementia and difficult behaviors. She stated Resident #1's care plan was updated on 2/10/22, to include a goals related to the recent incident. Review of Resident #1's Care Plan revealed that on 2/10/22, the Care Plan was updated to include goals and interventions to ensure that the resident would not have decline in mood and will feel safe from verbal abuse. Interventions included additional social service visits to offer emotional support and the reassurance of safety, staff in-services addressing verbal abuse, the allowance of Resident #1 to talk about her feelings, and to encourage continuation of normal activities and daily routine. On 8/11/22 at 3:40 PM, an interview with LPN #1 confirmed that on 2/05/22 she was assigned to the care of Resident #1. Stated that CNA #1 came out of Resident #1's room from measuring vital signs and reported a verbal exchange in which CNA #1 responded to the resident's calling her and her mother an offensive name, by responding in kind. She said the CNA #1 was upset and recognized that her response to the resident was not appropriate or acceptable. The LPN said she telephoned the Director of Nursing (DON) and was instructed to send CNA #1 home immediately, pending investigation. The LPN said she completed an incident report which initiated monitoring and assessments of Resident #1 every shift for seventy-two (72) hours. She stated Resident #1 had no adverse reaction or response to the incident. She stated that upon interview of the resident approximately twenty (20) minutes following the report from CNA #1, the resident confirmed calling CNA #1 an offensive name, but denied that the CNA had called her any names. The LPN confirmed the facility routinely provided in-service training regarding the care of residents with dementia and those with difficult behaviors. She reported the failure of CNA #1 to respect the rights of the resident to be treated with dignity, resulted in the termination of CNA #1.

Based on observation, resident interview, staff interview, record review, and facility policy review, the facility failed to develop and implement a Comprehensive Care Plan related to Resident #214's [MEDICAL CONDITION] (trach) care or the resident's [MEDICAL CONDITION] and interventions to ensure Registered Nurse (RN) or Respiratory Therapist (RT) coverage 24 hours per day seven (7) days per week to provide deep tracheal suctioning or emergency [MEDICAL CONDITION] care if needed, and to implement Resident #50's Care Plan related to Activities of Daily Living (ADL) for two (2) of 19 Comprehensive Care Plans reviewed. Resident #214 was admitted by the facility from the hospital, on 01/24/2020, with a [MEDICAL CONDITION] she had been providing [MEDICAL CONDITION] for at home. Resident #214 was admitted to the hospital on [DATE] due to alteration in mental status, and the assessment by the physician was Acute Metabolic [MEDICAL CONDITION]. Resident #214 had previously been hospitalized from [DATE] to 01/14/2020 for Pneumonia. Her husband reported since she was discharged from the hospital, on 01/14/2020, she was sleeping a lot and when she was awake, she was confused. Resident #214's Baseline Care Plan, dated 01/24/2020, revealed the facility did [MEDICAL CONDITION] to be done daily, but the care plan did not address Resident #214 performing [MEDICAL CONDITION] or the need for RN and/or RT coverage 24 hours per day seven (7) days per week to provide deep tracheal suctioning and possible emergency [MEDICAL CONDITION] care. Resident #214 had a physician's orders [REDACTED]. The facility's failure to develop and implement a Comprehensive Care Plan to address Resident #214'[MEDICAL CONDITION] and [MEDICAL CONDITION], and providing coverage 24 hours per day seven (7) days per week for the RN and/or RT roles to provide deep tracheal suctioning and possible [MEDICAL CONDITION] emergency care placed Resident #214 and other residents with tracheostomies at risk for serious injury, harm, impairment or death. On 02/17/2020 at 7:50 PM, the SA notified the facility's Administrator and Director of Nurses (DON) of the Immediate Jeopardy (IJ). The facility submitted an acceptable Immediate Jeopardy Removal Plan, on 02/19/2020, in which the facility alleged all corrective actions were completed on 02/19/2020, and the IJ was removed on 02/19/2020. The SA validated the facility's Immediate Jeopardy Removal Plan, on 02/20/2020, and determined the IJ was removed on 2/19/2020, prior to the SA's exit. Findings include: A review of the facility's policy titled Care Plans, Comprehensive Person-Centered, with a revision date of (MONTH) (YEAR), revealed 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain the resident's highest practicable physical, mental, and psychological well-being; g. Incorporate identified problem areas; l. Identify the professional services that are responsible for each element of care; o. Reflect currently recognized standards of practice for problem areas and conditions. 10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS/Minimum Data Set). 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. Review of the facility's policy titled, Resident Assessment Instrument, revised (MONTH) 2010, revealed a comprehensive assessment of a resident's needs shall be made within fourteen (14) days of the resident's admission. The Policy Interpretation and Implementation revealed: 3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. 4. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. 6. Within seven (7) days of the completion of the resident assessment, a comprehensive care plan will be developed. Review of the facility's policy titled, Suctioning the Lower Airway (Endotracheal (ET) or [MEDICAL CONDITION]), with a revised date of (MONTH) 2010, revealed the training was addressed for in-servicing on the policy and demonstrated competency in the procedure is required on hire, and at least annually for Registered Nurses. Resident #214 Review of Resident #214's Care Plans revealed a Baseline Care Plan, dated 01/24/2020, where the facility identified a Skin Care Need and Special Treatments/Procedures [MEDICAL CONDITION] care and oxygen (O2) at five liters per minute (5L/M) via [MEDICAL CONDITION]. The Baseline Care Plan also identified [MEDICAL CONDITION] care to be done daily. The Baseline Care Plan did not address Resident #214's [MEDICAL CONDITION] and the need for RN and/or RT roles to provide deep tracheal suctioning and possible [MEDICAL CONDITION] emergency care. The facility did not develop a Comprehensive Care Plan regarding these concerns until the SA identified them on 02/17/2020. Resident #214 also had a physician's orders [REDACTED]. Review of Resident #214's Comprehensive Care Plan revealed the facility developed the following Problem/Needs, dated 02/17/2020: (1) The Potential for Complications related to (r/t) [MEDICAL CONDITION]. The Interventions included: Deep suctioning as needed (PRN) for thick copious amounts of secretions resident is unable to expel. If resident becomes decannulated, cannula to be replaced using sterile technique. Respiratory Therapist to assess the resident each visit to facility and will be available for consultation PRN. Assess for signs and symptoms (s/s) of respiratory distress to include, but not limited to labored breathing, rapid breathing, cyanosis, low blood pressure, restlessness, dyspnea, decreased O2 (oxygen), rattling breath sounds PRN (as needed), and notify the MD (Medical Doctor) of any negative findings. The Roles for these interventions was assigned to the RN/RT. (2) At Risk for Aspiration r/t [MEDICAL CONDITION]. The Interventions included: Assess for s/s of respiratory distress. Assess for s/s of aspiration to include but not limited to fever, cough, shortness of breath (SOB), fatigue PRN and notify the MD of any negative findings. The Roles were assigned to the RN/RT. (3) Resident Prefers To Perform [MEDICAL CONDITION]. The Interventions included: Allow resident to perform [MEDICAL CONDITION]. Honor resident's right to perform [MEDICAL CONDITION]. RN staffing 24 hours per day seven (7) days per week in case of [MEDICAL CONDITION]. Encourage resident to notify Licensed Practical Nurse (LPN) or RN prior to [MEDICAL CONDITION]. An interview, on 02/19/2020 at 3:55 PM, revealed Licensed Practical Nurse (LPN) #5/Care Plan Nurse, stated she was responsible for the care plans. LPN #5 stated the facility uses the admission assessment to develop the care plan, and the MDS Nurse was responsible to check the care plan and make sure it is done and accurate. LPN #5 stated the facility has a new computer charting system that started in (MONTH) 2019, and the system caused her to get behind on the care plans. LPN #5 stated the nurses are supposed to let her know of any changes in the residents so she can update the care plans. Review of Resident #214's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/30/2020, revealed the Special Treatments/Programs section was checked for oxygen (O2) use and [MEDICAL CONDITION] care. Suctioning was not checked. Resident #214's Basic Interview for Mental Status (BIMS) score was 11, which indicated moderate cognitive impairment. The MDS also revealed Resident #214 did not have any vision, hearing or speech deficits, and was able to make herself understood to others, and she was able to understand others. On 02/17/2020 at 3:55 PM, an observation revealed Resident #214 was lying in bed, awake, alert, and oriented times four (X 4), which indicated the resident was aware of her place, time, date, and situation. Resident #214 had a [MEDICAL CONDITION] intact. No distress was noted. An interview, on 02/17/2020 at 4:09 PM, revealed Resident #214 stated the facility told her she would have to take care of her [MEDICAL CONDITION]. Review of Resident #214's Medical Record revealed there were no assessments regarding the resident's ability to perform [MEDICAL CONDITION] until the Departmental Notes-Respiratory Therapy, dated 02/18/2020 at 9:07 PM, late entry for 6:30 PM, for [MEDICAL CONDITION] Self Performance, revealed Resident #214 is performing [MEDICAL CONDITION] for herself to a seven (7) year established trach. The RT explains due to the resident's report of being sick at her stomach and not wanting to move [MEDICAL CONDITION] very much right now, they agreed for her to demonstrate and describe how she provided [MEDICAL CONDITION]. The RT also documented she had asked the resident if she wanted the RT to get the nurse, but the resident reported the nurse had already given her something for the nausea. The RT documented Resident #214's demonstration showed the resident was comfortable and competent to provide her [MEDICAL CONDITION], and the RT's opinion was that Resident #214 was very competent in doing her [MEDICAL CONDITION]. An interview, on 02/19/2020 at 5:20 PM, revealed the Director of Nurses (DON) stated she should have observed Resident #214 perform [MEDICAL CONDITION] to ensure she was doing it correctly. On 02/17/20 at 4:00 PM, an interview with Director of Nursing (DON) and Administer revealed they do not have a Register Nurse 24 hours a day seven (7) days a week at the facility. They stated Resident #214 takes care of [MEDICAL CONDITION], and the resident has had it for seven years. The Administrator and DON both agreed Resident #214 knows how to take care of it herself and she prefers to take care it herself. On 02/18/2020 at 1:55 PM, an interview with Licensed Practical Nurse (LPN) #4, revealed to the best of her knowledge the LPN and RN does [MEDICAL CONDITION]. The LPN does the suctioning and deep suctioning is done by the RN. On 02/18/2020 at 3:00 PM, an interview with the DON and Administer revealed the DON stated she just did not think about the 24 hour RN/RT care. The DON said it would take the ambulance five (5) minutes to get here and two (2) minutes to get to the hospital. It would be seven (7) minutes total time, and that could cause brain damage to the resident. On 02/18/2020 at 3:26 PM, an interview with LPN #3 revealed she has been employed at the facility for nine (9) years, and this is the [MEDICAL CONDITION] since she has been here. LPN #3 stated Resident #214 does her [MEDICAL CONDITION]. Review of Resident #214's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/20/2020, revealed the resident required extensive assistance with one person physical assist for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. Resident #50 A review of Resident #50's Comprehensive Care Plan revealed the facility failed to provide Resident #50's nail care. The Care Plan revealed the Problem/Need, dated 06/14/2017, the resident requires assistance with Activities of Daily Living (ADL) related to (r/t) impaired mobility and requires one person extensive assistance with personal hygiene. The Care Plan addressed the Problem/Need, dated 01/09/2020, Psoriasis to the left lower leg and the Approaches included keep nails clean and trimmed. Staff responsible was listed as Nursing/CN[NAME] An observation and interview, on 02/17/2020 at 12:15 PM, revealed Resident #50's Family Member #1 was clipping the resident's toenails. Family Member #1 stated she was trimming the resident's nails because the facility staff would never do it. Family Member #1 said she had already trimmed the resident's fingernails. Family Member #1 stated the facility told her someone comes once a year to take care of the toenails. The resident stated she didn't ask for staff to do it because she didn't want to bother anyone. An interview, on 02/17/2020 at 12:30 PM, with Certified Nurse Assistant (CNA) #1 revealed she stated hospice does the resident's nails, and that the CNAs were supposed to check the resident's nails during their bath time. CNA #1 said she had been on A Hall off and on the past couple of weeks but had not notified the nurse or her partner Resident #50's nails needed to be trimmed. CNA #1 said when she sees long nails she tells her partner. CNA #1 said she had noticed the long nails, but she did not like to cut the nails because she cuts to low, to short, all the way down. CNA #1 said when she sees long nails she tells her partner. On 02/17/2020 at 12:35 PM, an observation and interview with the Assistant Director of Nurses (ADON) revealed the ADON measured Resident #50's left great toenail and right great toenails at 0.5 centimeters (cm). The ADON also observed the smaller toenails were curling around the end of the toes on the right foot. The ADON stated the CNAs tell the nurses about the toenails, and there is a communication book, but usually they tell the nurses. An interview, on 02/19/2020 at 3:08 PM, with LPN #1 revealed Resident's #50's care plan was not followed if her nails were not kept trimmed. LPN #1 reported Resident #50 required assistance with cutting her nails. LPN #1 stated she would ensure tasks were done according to the care plan by making rounds to see if CNAs had completed tasks assigned or doing the tasks herself. LPN #1 stated sometimes the CNAs would ask the nurse to assist in completing nail care and that dependent residents relied on staff to complete hygiene tasks. LPN #1 stated she had not been informed Resident #50's nails needed trimming by anyone, but the CNAs generally trimmed the nails or asked the nurse to. During an interview and review of the care plan, on 02/19/2020 at 4:00 PM, the DON stated nurses don't usually trim toenails and CNAs were generally responsible for trimming nails. The DON stated that if the care plan stated CNAs or nursing were listed as responsible for trimming nails, and the resident's nails were not trimmed, the care plan was not followed. An interview, on 02/19/2020 at 2:50 PM, revealed CNA #2 said Resident #50 required total care assistance. CNA #1 stated she knows the resident's care needs because the resident's ADL care is listed in the Kiosk (computer system). CNA #1 stated nail care is provided during the resident's bath. On 02/19/2020 at 4:00 PM, an interview with the DON revealed the weekly skin assessments and body audits do not specifically address fingernails and toenails. The skin assessments and body audits address whether skin is intact or not intact. The DON stated the staff just knows nail care should be done, it is a part of what they should be doing. The DON reported a Podiatrist visits the facility every three (3) months to provide nail care also. Review of Resident #50's last Podiatry Note, dated 05/28/2019, revealed Resident #50 was examined by the Podiatrist and would need to be seen again as needed or per physician's orders [REDACTED]. Review of the Face Sheet revealed Resident #50 was admitted by the facility, on 10/27/2010, and re-admitted on [DATE], with the included [DIAGNOSES REDACTED]. Review of Resident #50 Quarterly MDS, with an ARD of 01/20/2020, revealed a BIMS score of 4, which indicated severe cognitive impairment. The MDS further revealed Resident #50 required extensive assistance with two person physical assist with bed mobility, transfers, dressing and toileting. Resident #50 required extensive assistance with one person physical assist with locomotion on and off the unit, and was totally dependent on staff for bathing. Resident #50 only required limited assistance with one person physical assist with eating. Resident #50's vision was impaired and she could only see large print, but not regular print in newspapers or magazines. The resident's speech and hearing was not impaired, and she was able to make herself understood to others and she was able to understand others. The facility's accepted Immediate Jeopardy Removal Plan: Haven Hall Healthcare Center Administrator and Director of Nursing were notified of Immediate Jeopardy and Substandard Quality of Care on, 2/17/2020 at 7:50 p.m. related to the facility admitting Resident #214 on 1/24/2020 with a [MEDICAL CONDITION] and (1) Failure to assess resident during routine [MEDICAL CONDITION] care performed per resident, (2) Failure to develop and implement a care plan for the care of resident's [MEDICAL CONDITION], and (3) Failure to provide around the clock Registered Nurse (RN) or Respiratory Therapist (RT) coverage to provide deep suctioning and emergency [MEDICAL CONDITION] care, placed the resident at risk for serious injury, harm, impairment. Immediately upon notification: The Director of Nursing put in place for Registered Nurse coverage to be 24/7. An emergency Quality Assurance meeting was called on 2/17/2020 at 8:14 PM to discuss (1) Failure to assess resident during routine [MEDICAL CONDITION] care performed per resident, (2) Failure to develop and implement a care plan for the care of resident's [MEDICAL CONDITION], and (3) Failure to provide around the clock Registered Nurse (RN) or Respiratory Therapist (RT) coverage to provide deep suctioning and emergency [MEDICAL CONDITION] care, placed the resident at risk for serious injury, harm, impairment. Those in attendance were the Medical Director, Administrator, Director of Nursing, Nurse Consultant, Assistant Director of Nursing, Minimal- Data Set Nurse, Care Plan Nurse, Social Worker, and Admissions/Medicare Nurse. Policy and Procedure on [MEDICAL CONDITION] Care was reviewed on 2/17/20, by the Director of Nursing with no policy changes implemented. This policy was revised 8/2013. Facility identified through record review by the Director of Nursing on 2/17/20 at 9:00 P.M., that Resident #214 is the only resident in the facility that has a [MEDICAL CONDITION], Review of Resident# 214's Care Plan was conducted by the Director of Nursing and the Care Plan Nurse developed a plan of care on 2/17/20 at 8:00 p.m, to include specific needs and staff involved to. provide needed services according to the resident's wishes. (1) Potential for complications related to [MEDICAL CONDITION]: Deep suction as needed for thick or copious amounts of secretions the resident is unable to expel, per Registered Nurse or Respiratory Therapist. If resident becomes de-cannulated, cannula to be replaced using sterile technique, per Registered Nurse or Respiratory Therapist. Respiratory Therapist to assess resident each visit to the facility and will be available for consultation as needed. Assess for signs and symptoms of respiratory distress to include but not limited to labored breathing, cyanosis, low blood pressure, restlessness, dyspnea, decreased oxygen saturations, rattling breath sounds, etcetera, as needed per Registered Nurse or Respiratory Therapist. Notify Medical Director of any negative findings, per Nurse. Keep Ambu bag at bedside, per Nurse or Registered Nurse. Keep oxygen saturation monitor at bedside, per Nurse. Keep suction machine at bedside, per Nurse. (2) At risk for aspiration related to [MEDICAL CONDITION]:: Change out [MEDICAL CONDITION] tubing and mask weekly on Thursday, per Nurse. Suction [MEDICAL CONDITION] as needed using aseptic technique, Resident to perform as needed for increased secretions, per Resident. [MEDICAL CONDITION] care, using aseptic technique every shift, per Resident, Registered Nurse to be in room in case of complications, Registered Nurse. Change out [MEDICAL CONDITION] tubing and mask weekly, on Thursday, per Nurse. Resident is to be maintained in an upright or sitting position while eating, per Nurse. Assess for signs and symptoms of respiratory distress to include but not limited to labored breathing, rapid breathing, cyanosis, low blood pressure, restlessness, dyspnea, decreased oxygen saturation, rattling breath sounds, etcetera, as needed per Registered Nurse and/or Respiratory Therapist. Assess for signs and symptoms of aspirations to include but not limited to fever, cough, shortness of breath, fatigue, etcetera, as needed, per Registered Nurse and Respiratory Therapist. Notify Medical Doctor of any negative findings, per Nurse. Keep Ambu bag at bedside, per Nurse or Registered Nurse. Keep oxygen saturation monitor at bedside, per Nurse. Keep suction machine at bedside, per Nurse. Oxygen saturation taken, every shift, and notify Physician if oxygen saturation is less than 90 percent, per Nurse. (3) Resident prefers to perform her own [MEDICAL CONDITION] care, per Resident. Allow Resident to perform own [MEDICAL CONDITION] care, as desired, with Registered Nurse present, per resident. Honor Residents right to perform own [MEDICAL CONDITION] care, per Nurse. Registered Nurse staffing 24 hours 7 days a week in case of emergency [MEDICAL CONDITION] care needed, per Nurse. Encourage Resident to notify Licensed Practical Nurse or Registered Nurse prior to performing [MEDICAL CONDITION] care, per Nurse. Review of Registered Nurse scheduling was done on 2/17/20 at 8 :30 P.M. by the Director of Nursing to ensure that the facility had 24/7 Registered Nurse coverage. We will continue to hire Registered Nurses. While we are in the process of hiring the Registered Nurses to cover the around the clock Registered Nurse positions, we will reach out and utilize the resources of our Nurse Consultant (Registered Nurse), Director of Clinical Service (Registered Nurse), or our Clinical Respiratory Therapist, in the event one of the Registered Nurses are unable to perform their duties. We have a Contract in place, effective 2/18/2020, with a Staffing Agency for Registered Nurse coverage. The initial date they will be on site for Registered Nurse coverage is, Friday, 2/21/2020, 3/11 shift. They will be trained prior to working on the floor, Friday 2/21/2020, on facility Policies related to [MEDICAL CONDITION] Care and Deep Suctioning by the Director of Nursing. Registered Nurses (6 Registered Nurses) in-serviced per Director of Nursing on 2/17/2020 at 9:00 P.M. on policy for assessing the residents for self care related to [MEDICAL CONDITION] care and suctioning. No nurse will be allowed to work until they have received the above in-service education. Care plan nurse re-in-serviced per Director of Nursing on 2/17/2020 at 9:45 P.M. on the policy for completing comprehensive care plans. This nurse was not allowed to work until she had received the above in-service education. Resident was assessed to ensure that she is able to perform her own [MEDICAL CONDITION] care on 2/18/2020 at 6:30 P.M. per Respiratory Therapist. Respiratory Therapist was able to confirm that Resident #214's ability to safely perform her own [MEDICAL CONDITION] care. In-services were initiated on 2/18/2020 at 7 :22 p.m. by the Assistant Director of Nursing with Certified Nursing Assistants (17 Certified Nursing Assistants), Licensed Practical Nurses (10 Licensed Practical Nurses), and Registered Nurses (6 Registered Nurses) on the signs and symptoms of respiratory distress. The information reviewed was provided to them. No Certified Nursing Assistant or Nurse will be allowed to work until they have received the above in-service education. Staff in-services initiated, 2/18/2020, at 7 :30 p.m. by the Director of Nursing with Nursing, Housekeeping, Laundry, Dietary, Maintenance, and Administrative Staff (69 employees), related to Immediate Jeopardy citations and signs and symptoms of Respiratory Distress. In-service education and competency training was provided on 2/18/2020 at 9:20 p.m., by the Respiratory Therapist, on the policy for deep suctioning with Registered Nurse (6 Registered Nurses) and [MEDICAL CONDITION] care with Licensed Practical Nurses and Registered Nurses (12 Licensed Practical Nurses and 6 Registered Nurses) and copy of the policies and procedures reviewed to ensure that nursing staff will be provided this information. No nurse will be allowed to work until they have received the above in-service education Haven Hall Healthcare Center alleges that, on 2/19/2020, the Immediate Jeopardy regarding Resident #214 has been removed. SA VALIDATIONS The State Agency (SA) validated by record review of the Registered Nurses (RN) schedule dated 02/19/20 revealed RN coverage twenty-four hours a day seven (7) days a week. The SA validated the Quality Assurance meeting was held on 02/17/20 by record review of sign in sheet contained containing the following signatures for: Medical Director, Director of Nursing, Assistant Director of Nursing, Minimum Data Set Nurse, Care Plan Nurse, Nurse Consultant, Social Worker, and Admission/Medicare Nurse. The SA validated no changes in the facility policy by record review with a revision date of 8/2013. The SA validated the current matrix and census by record review revealed there was no other [MEDICAL CONDITION] residents in the facility. The SA validated by record review a comprehensive care plan was developed for Resident #214, dated 02/17/20, with interventions for [MEDICAL CONDITION] care, resident's [MEDICAL CONDITION] and RN/RT coverage 24 hours a day seven (7) days a week. The SA validated, on 02/20/20 ,by interview the Medical Director revealed that staff was informed to contact the Medical Director for any negative findings. The SA validated that Resident #214 room contained the Ambu bag, oxygen saturation monitor, and the suction machine was at bedside by observation. The SA validated agency contract by record review, dated 02/18/20, with an initial start date 02/21/20 on the 3-11 shift. The SA validated the Resident #214 declined observation [MEDICAL CONDITION] care, on 02/20/20, by interview with the DON. The SA validated by interview and record review the Respiratory Therapist assessed Resident #214, on 02/18/20 at 6:30 PM, and determined the resident was competent and comfortable to perform her [MEDICAL CONDITION]. The SA validated by record review of the Medication Administration Record the change out of the tubing and mask is to be done on Thursdays. The SA validated all residents (Resident #214 was the [MEDICAL CONDITION] in the facility) at risk for aspiration related to [MEDICAL CONDITION] by interview and record review of the MAR and person- centered care comprehensive care plan. The SA validated by interview that the RT is available for consultation as needed. The SA validated that Resident #214 was capable of performing [MEDICAL CONDITION] by interview with the RT. The SA validated six (6) RN's was in-serviced by record review of sign in sheet on [MEDICAL CONDITION] care, signs and symptoms of respiratory distress. The SA validated 10 Licensed Practical Nurses was in-serviced on [MEDICAL CONDITION] care, signs and symptoms, of respiratory distress by interview and sign in sheet and interview. The SA validated thirteen Certified Nursing Assistance was in-serviced on Respiratory Distress signs and symptoms by interview and in-service attendance sign sheet. The SA validated interview and review of in-service attendance sign in sheet that six (6) Housekeeping/Laundry staff were in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet two (2) Human Resources staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet one (1) Occupational Therapist in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet one (1) Account Payable Staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet one (1) lawn service staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet two (2) Maintenance staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet two (2) Activities staff was in-serviced on Respiratory Distress sign and symptoms. The SA validated by interview and attendance sign in sheet one (1) Medical Record staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet one (10 Physical Therapist Assistant was in-serviced on Respiratory Distress sign and symptoms. The SA validated by interview and attendance sign in sheet one (1) Speech Language Pathologist was in-serviced on Respiratory Distress sign and symptoms.

Based on observation, staff and resident interview, facility policy review, and review of the Mississippi (MS) State Board of Nursing website, the facility failed to ensure qualified staff, a Registered Nurse (RN) and/or Respiratory Therapist (RT), were available 24 hours a day seven days a week to provide deep suctioning or emergency [MEDICAL CONDITION] (trach) care for one of one (1 of 1) residents reviewed with [MEDICAL CONDITION] the only resident in the facility with a trach. Resident #214 was admitted to the facility, on [DATE], with an established [MEDICAL CONDITION]. Observations and interviews, with Resident #214 on [DATE] and [DATE] revealed Resident #214 had a [MEDICAL CONDITION], and she stated the facility told her she would have to provide her [MEDICAL CONDITION]. Review of the facility's nursing schedule, RN time cards, and daily staffing sheets from [DATE] to [DATE], revealed 23 days out of the 24 days did not have RN/RT coverage 24 hours per day seven days per week to provide deep suctioning or other possible [MEDICAL CONDITION] if needed. The lack of RN/RT coverage was identified on all shifts, 7 AM to 3 PM, 3 PM to 11 PM and 11 PM to 7 AM. The facility's failure to provide 24 hour per day seven days per week RN/RT coverage to provide deep suctioning and other possible emergency [MEDICAL CONDITION] care placed Resident #214 and other possible [MEDICAL CONDITION] residents at risk for serious harm, injury, impairment, or death. The SA identified Immediate Jeopardy (IJ) which began on [DATE], and was present until [DATE], due to the facility did not provide RN or RT coverage 24 hours per day seven days per week. The SA notified the Administrator and the Director of Nurses of the IJ, on [DATE] at 7:50 PM. The facility submitted an acceptable Immediate Jeopardy Removal Plan on [DATE], in which the facility alleged all corrective actions were completed on [DATE], and the IJ was removed as of [DATE]. The SA validated the Immediate Jeopardy Removal Plan on [DATE] and determined the IJ was removed prior to exit on [DATE]. Findings include: Review of the facility's policy titled, Competency of Nursing Staff, revised (MONTH) 2019, revealed that all nursing staff must meet the specific competency requirements of their respective licensures and certification requirements defined by state law. The policy's Interpretation and Implementation included: 1. Is designated to train nursing staff to deliver individualized, safe, quality of care and services for the residents. 2. The following factors are considered in the creation of the competency-based staff development and training program included-Specialized skills or training needed based on the resident population. 4. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as: d. Person centered care; f. Basic nursing skills; l. Identification of changes in condition. Review of the Mississippi State Board of Nursing (BON) website, revealed frequently asked questions (FAQ's). The BON's statement regarding the LPN's scope of practice with [MEDICAL CONDITION] care revealed: It is within the scope of practice of the LPN to [MEDICAL CONDITION] and suction secretions from [MEDICAL CONDITION]. However, it is not within the scope of practice for the LPN to perform deep right main stem suctioning. If deep suctioning is required for a patient, a Registered Nurse (RN) must perform the procedure. A review of the facility's policy titled Care Plans, Comprehensive Person-Centered, with a revision date of (MONTH) (YEAR), revealed 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain the resident's highest practicable physical, mental, and psychological well-being; g. Incorporate identified problem areas; l. Identify the professional services that are responsible for each element of care; o. Reflect currently recognized standards of practice for problem areas and conditions. 10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS/Minimum Data Set). 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. Review of the Face Sheet revealed Resident #214 was admitted by the facility, on [DATE], with the included [DIAGNOSES REDACTED]. Review of Resident #214's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed the Special Treatments/Programs section was checked for oxygen (O2) use and [MEDICAL CONDITION] care. Suctioning was not checked. Resident #214's Basic Interview for Mental Status (BIMS) score was 11, which indicated moderate cognitive impairment. The MDS also revealed Resident #214 did not have any vision, hearing or speech deficits, and was able to make herself understood to others, and she was able to understand others. Review of Resident #214's Comprehensive Care Plan revealed the facility did not address Resident #214's [MEDICAL CONDITION] care regarding her [MEDICAL CONDITION] or RN/RT requirements to provide deep suctioning and other possible [MEDICAL CONDITION]. The Baseline Care Plan dated, [DATE], [MEDICAL CONDITION] daily, but did not identify who was to provide [MEDICAL CONDITION] or designate specific staff roles in [MEDICAL CONDITION]. The facility did not develop a care plan regarding resident #214's [MEDICAL CONDITION], or the need for a RN/RT to provide the deep suctioning and other possible [MEDICAL CONDITION] until [DATE], when the SA identified the IJ regarding no RN/RT coverage 24 hours per day seven days per week. Review of Resident #214's physician's orders [REDACTED]. Review of the facility's nursing staff schedule, from [DATE] to [DATE], revealed 23 of the 24 days, the facility did not have RN and/or RT coverage for all shifts, 7 AM to 3 PM, 3 PM to 11 PM or 11 PM to 7 AM to provide deep tracheal suctioning or [MEDICAL CONDITION] if needed for Resident #214. Review of the facility's Daily Nurse Staffing sheets, from [DATE] to [DATE], revealed one Registered Nurse (RN) was scheduled for the day shift - 6 AM to 2 PM and 7 AM to 3 PM, and there was no RN scheduled for the evening shift - 2 PM to 10 PM and 3 PM to 11 PM or the night shift - 10 PM to 6 AM and 11 PM to 7 AM. Review of the hospital's admission notes by the Physician revealed, on [DATE], Resident #214 was brought to the hospital by her husband due to alteration in mental status, and the assessment by the physician was Acute Metabolic [MEDICAL CONDITION]. Resident #214 was previously hospitalized for [REDACTED]. Resident #214's husband brought her back to the hospital, on [DATE] because she was sleeping a lot, and was confused when she was awake since she was discharged on [DATE]. The hospital Physician's History Note, dated [DATE], revealed Resident #214 had a [MEDICAL CONDITION] in 2007, and has paralysis of her bilateral vocal cords and larynx. On [DATE] at 4:09 PM, an interview and observation revealed Resident #214 said the facility had told her she would have to provide her [MEDICAL CONDITION]. Resident #214 had a [MEDICAL CONDITION] in place, and there was no distress noted. Resident #214 also said she had taken care of [MEDICAL CONDITION] many years. The Administrator and the Director of Nurses (DON) was interviewed on [DATE] at 4:00 PM, and they both confirmed the facility did not have RN coverage 24 hours per day seven days per week in the event Resident #214 required deep suctioning or [MEDICAL CONDITION]. The DON stated Resident #214 was providing her [MEDICAL CONDITION] at home and had been for several years. The DON also stated Resident #214 preferred to do her [MEDICAL CONDITION], and had been providing it at the facility. On [DATE] at 3:00 PM, an interview with the Administrator and the DON revealed the DON just did not realize they needed a RN/RT scheduled 24 hours per day seven days a week for a [MEDICAL CONDITION] resident. She had not thought about it since Resident #214 was admitted . The DON also stated in the event Resident #214 needed deep suctioning and the RN was not here, the LPN would have to call for an ambulance to transfer her to the hospital, which would take five (5) minutes to get to the facility and another two (2) minutes to get to the hospital, that would be seven (7) minutes, and could result in possible brain damage. The Medical Director's interview, on [DATE] at 5:30 PM, revealed he had no knowledge the facility did not have RN coverage to provide deep suctioning if it was needed. The Medical Director did confirm he would expect the RN to provide deep suctioning if it was needed, and he just assumed they would have coverage that was required. The Medical Director stated he was trusting the staff to do what was needed to provide care for Resident #214. The Medical Director also revealed he knew the resident was admitted to the facility from the hospital with a [MEDICAL CONDITION] and Pneumonia, which could cause further respiratory issues. An interview, on [DATE] at 4:34 PM, revealed the Assistant Director of Nurses (ADON) said she was aware Resident #214 was admitted with a [MEDICAL CONDITION]. The ADON stated the DON makes the nursing schedules and decides who to admit to the facility. The ADON said without 24 hour a day seven (7) days a week RN coverage the resident was at risk for death. An interview, on [DATE] at 5:17 PM, with LPN #2, revealed she had not received any training from the facility [MEDICAL CONDITION] since she has been employed at the facility. LPN #2 said she did [MEDICAL CONDITION] training in nursing school. LPN #2 stated the RN provided supervision when she's here and the LPNs and RNs are charge nurses. On [DATE] at 4:05 PM, an interview with Licensed Practical Nurse (LPN) #2, revealed she would not do anything that was not in her scope of practice. LPN #2 said if Resident #214 needed deep suctioning she would provide some type of care to keep the resident alive until the paramedics got to the facility. LPN #2 said she would check the oxygen level, raise the head of the bed, and she would suction around [MEDICAL CONDITION] didn't work and stay at the resident's bed side until help arrived. LPN #2 said she would call the medical doctor after she got the resident's vital signs. LPN #2 said if the cannula came out, she would keep the airway open and keep the resident [MEDICATION NAME] until the paramedics arrived. LPN #2 did not mention notifying the RN. An interview, on [DATE] at 3:26 PM, revealed LPN #3 works the 7 AM to 3 PM shift on the West Wing and sometimes to 7 PM. LPN #3 stated she has been employed at the facility for nine (9) years, and there has not been [MEDICAL CONDITION] here until now. LPN #3 said Resident #214 does her [MEDICAL CONDITION]. LPN #2 said no one [MEDICAL CONDITION] here, and Resident #214 does her [MEDICAL CONDITION]. LPN #3 reported she has not received any training by the facility [MEDICAL CONDITION] and there has not been any training provided by the facility [MEDICAL CONDITION]. LPN #3 said if Resident #214 needed deep suctioning she would notify the RN if she was here, if the RN was not here she would call the RN and see if she wanted her to send Resident #214 out. On [DATE] at 1:55 PM, an interview with LPN #4, revealed the last training [MEDICAL CONDITION] was provided by the corporate nurse back in (MONTH) or (MONTH) of last year. They watched the corporate nurse and then did a return demonstration. LPN #4 stated the LPNs can suction, but only the RNs can deep suction the trachs. LPN #4 stated if the resident exhibited signs and symptoms (s/s) of respiratory distress such as facial grimacing, she would try to get them to calm down, get their Oxygen Saturation (O2 Sat), and get their vital signs (v/s). LPN #4 stated if the resident needed deep suctioning and the RN was not here, she would suction the resident, keep the airway open, and call 911. On [DATE] at 4:17 PM, an interview with the DON revealed the corporate respiratory therapist trained the staff on care of a [MEDICAL CONDITION] about a couple of weeks ago. Record review revealed the only In-Service Attendance Sheet the facility provided [MEDICAL CONDITION], suctioning the upper airway, oxygen therapy and administration and [MEDICAL CONDITIONS] was dated (MONTH) 10, 2019. The sign in sheet revealed the signature of one person. The training was provided by the RT. On [DATE] at 1:50 PM, an interview with RN #1/Minimum Data Set (MDS) Nurse, revealed she was aware the LPNs could not deep suction trachs. RN #1 also stated if a resident needed deep suctioning and did not get it, the resident could die. RN #1 also reported she did not have anything to do with the nurse staffing or scheduling to ensure RN coverage 24 hours per day seven (7) days per week to provide deep suctioning [MEDICAL CONDITION] care if needed. RN #1 stated the Director of Nurses (DON) does the nursing staff schedule. RN #1 also said it would take about seven (7) minutes for the ambulance to get here and the resident could die in seven (7) minutes. RN #1 said she has had training for [MEDICAL CONDITION] care. She stated the last training prior to survey was around (MONTH) 2019, and she also had training by the DON on [DATE]. Certified Nursing Assistant (CNA) #3 was interviewed, on [DATE] at 3:46 PM. CNA #3, stated she has been employed at the facility since (MONTH) of 2019, and she works swing shift, she works 2 PM to 10 PM on the weekends and 6 AM to 2 PM the other days. CNA #3 revealed she has not worked with a resident with [MEDICAL CONDITION], however Resident #214 was assigned to her today, and nor has she had any prior training to take care of a resident with a trach. CNA #3 stated she was currently Cardiopulmonary Resuscitation (CPR) certified. CNA #3 said she did know the resident did everything for herself. CNA #3 said however if Resident #214 was having respiratory difficulty the first thing she would do is call for help, she would not leave her. If the resident was gasping for breath or not breathing she would call for help, shake her to see if she was OK and then call for help. The facility's accepted Immediate Jeopardy Removal Plan: Haven Hall Healthcare Center Administrator and Director of Nursing were notified of Immediate Jeopardy and Substandard Quality of Care on, [DATE] at 7:50 p.m. related to the facility admitting Resident #214 on [DATE] with a [MEDICAL CONDITION] and (1) Failure to assess resident during routine [MEDICAL CONDITION] care performed per resident, (2) Failure to develop and implement a care plan for the care of resident's [MEDICAL CONDITION], and (3) Failure to provide around the clock Registered Nurse (RN) or Respiratory Therapist (RT) coverage to provide deep suctioning and emergency [MEDICAL CONDITION] care, placed the resident at risk for serious injury, harm, impairment. Immediately upon notification: The Director of Nursing put in place for Registered Nurse coverage to be ,[DATE]. An emergency Quality Assurance meeting was called on [DATE] at 8:14 PM to discuss (1) Failure to assess resident during routine [MEDICAL CONDITION] care performed per resident, (2) Failure to develop and implement a care plan for the care of resident's [MEDICAL CONDITION], and (3) Failure to provide around the clock Registered Nurse (RN) or Respiratory Therapist (RT) coverage to provide deep suctioning and emergency [MEDICAL CONDITION] care, placed the resident at risk for serious injury, harm, impairment. Those in attendance were the Medical Director, Administrator, Director of Nursing, Nurse Consultant, Assistant Director of Nursing, Minimal- Data Set Nurse, Care Plan Nurse, Social Worker, and Admissions/Medicare Nurse. Policy and Procedure on [MEDICAL CONDITION] Care was reviewed on [DATE], by the Director of Nursing with no policy changes implemented. This policy was revised ,[DATE]. Facility identified through record review by the Director of Nursing on [DATE] at 9:00 P.M., that Resident #214 is the only resident in the facility that has a [MEDICAL CONDITION]. Review of Resident# 214's Care Plan was conducted by the Director of Nursing and the Care Plan Nurse developed a plan of care on [DATE] at 8:00 p.m, to include specific needs and staff involved to provide needed services according to the resident's wishes. (1) Potential for complications related to [MEDICAL CONDITION]: Deep suction as needed for thick or copious amounts of secretions the resident is unable to expel, per Registered Nurse or Respiratory Therapist. If resident becomes de-cannulated, cannula to be replaced using sterile technique, per Registered Nurse or Respiratory Therapist. Respiratory Therapist to assess resident each visit to the facility and will be available for consultation as needed. Assess for signs and symptoms of respiratory distress to include but not limited to labored breathing, cyanosis, low blood pressure, restlessness, dyspnea, decreased oxygen saturations, rattling breath sounds, etcetera, as needed per Registered Nurse or Respiratory Therapist. Notify Medical Director of any negative findings, per Nurse. Keep Ambu bag at bedside, per Nurse or Registered Nurse. Keep oxygen saturation monitor at bedside, per Nurse. Keep suction machine at bedside, per Nurse. (2) At risk for aspiration related to [MEDICAL CONDITION]: Change out [MEDICAL CONDITION] tubing and mask weekly on Thursday, per Nurse. Suction [MEDICAL CONDITION] as needed using aseptic technique, Resident to perform as needed for increased secretions, per Resident. [MEDICAL CONDITION] care, using aseptic technique every shift, per Resident, Registered Nurse to be in room in case of complications, Registered Nurse. Change out [MEDICAL CONDITION] tubing and mask weekly, on Thursday, per Nurse. Resident is to be maintained in an upright or sitting position while eating, per Nurse. Assess for signs and symptoms of respiratory distress to include but not limited to labored breathing, rapid breathing, cyanosis, low blood pressure, restlessness, dyspnea, decreased oxygen saturation, rattling breath sounds, etcetera, as needed per Registered Nurse and/or Respiratory Therapist. Assess for signs and symptoms of aspirations to include but not limited to fever, cough, shortness of breath, fatigue, etcetera, as needed, per Registered Nurse and Respiratory Therapist. Notify Medical Doctor of any negative findings, per Nurse. Keep Ambu bag at bedside, per Nurse or Registered Nurse. Keep oxygen saturation monitor at bedside, per Nurse. Keep suction machine at bedside, per Nurse. Oxygen saturation taken, every shift, and notify Physician if oxygen saturation is less than 90 percent, per Nurse. (3) Resident prefers to perform her own [MEDICAL CONDITION] care, per Resident. Allow Resident to perform own [MEDICAL CONDITION] care, as desired, with Registered Nurse present, per resident. Honor Residents right to perform own [MEDICAL CONDITION] care, per Nurse. Registered Nurse staffing 24 hours 7 days a week in case of emergency [MEDICAL CONDITION] care needed, per Nurse. Encourage Resident to notify Licensed Practical Nurse or Registered Nurse prior to performing [MEDICAL CONDITION] care, per Nurse. Review of Registered Nurse scheduling was done on [DATE] at 8:30 P.M. by the Director of Nursing to ensure that the facility had ,[DATE] Registered Nurse coverage. We will continue to hire Registered Nurses. While we are in the process of hiring the Registered Nurses to cover the around the clock Registered Nurse positions, we will reach out and utilize the resources of our Nurse Consultant (Registered Nurse), Director of Clinical Service (Registered Nurse), or our Clinical Respiratory Therapist, in the event one of the Registered Nurses are unable to perform their duties. We have a Contract in place, effective [DATE], with a Staffing Agency for Registered Nurse coverage. The initial date they will be on site for Registered Nurse coverage is, Friday, [DATE], ,[DATE] shift. They will be trained prior to working on the floor, Friday [DATE], on facility Policies related to [MEDICAL CONDITION] Care and Deep Suctioning by the Director of Nursing. Registered Nurses (6 Registered Nurses) in-serviced per Director of Nursing on [DATE] at 9:00 P.M. on policy for assessing the residents for self care related to [MEDICAL CONDITION] care and suctioning. No nurse will be allowed to work until they have received the above in-service education. Care plan nurse re-in-serviced per Director of Nursing on [DATE] at 9:45 P.M. on the policy for completing comprehensive care plans. This nurse was not allowed to work until she had received the above in-service education. Resident was assessed to ensure that she is able to perform her own [MEDICAL CONDITION] care on [DATE] at 6:30 P.M. per Respiratory Therapist. Respiratory Therapist was able to confirm that Resident #214's ability to safely perform her own [MEDICAL CONDITION] care. In-services were initiated on [DATE] at 7 :22 p.m. by the Assistant Director of Nursing with Certified Nursing Assistants (17 Certified Nursing Assistants), Licensed Practical Nurses (10 Licensed Practical Nurses), and Registered Nurses (6 Registered Nurses) on the signs and symptoms of respiratory distress. The information reviewed was provided to them. No Certified Nursing Assistant or Nurse will be allowed to work until they have received the above in-service education. Staff in-services initiated, [DATE], at 7:30 p.m. by the Director of Nursing with Nursing, Housekeeping, Laundry, Dietary, Maintenance, and Administrative Staff (69 employees), related to Immediate Jeopardy citations and signs and symptoms of Respiratory Distress. In-service education and competency training was provided on [DATE] at 9:20 p.m., by the Respiratory Therapist, on the policy for deep suctioning with Registered Nurse (6 Registered Nurses) and [MEDICAL CONDITION] care with Licensed Practical Nurses and Registered Nurses (12 Licensed Practical Nurses and 6 Registered Nurses) and copy of the policies and procedures reviewed to ensure that nursing staff will be provided this information. No nurse will be allowed to work until they have received the above in-service education Haven Hall Healthcare Center alleges that, on [DATE], the Immediate Jeopardy regarding Resident #214 has been removed. SA VALIDATIONS The State Agency (SA) validated by record review of the Registered Nurses (RN) schedule dated [DATE] revealed RN coverage twenty-four hours a day seven (7) days a week. The SA validated the Quality Assurance meeting was held on [DATE] by record review of sign in sheet contained containing the following signatures for: Medical Director, Director of Nursing, Assistant Director of Nursing, Minimum Data Set Nurse, Care Plan Nurse, Nurse Consultant, Social Worker, and Admission/Medicare Nurse. The SA validated no changes in the facility policy by record review with a revision date of ,[DATE]. The SA validated the current matrix and census by record review revealed there was no other [MEDICAL CONDITION] residents in the facility. The SA validated by record review a comprehensive care plan was developed for Resident #214, dated [DATE], with interventions for [MEDICAL CONDITION] care, resident's [MEDICAL CONDITION] and RN/RT coverage 24 hours a day seven (7) days a week. The SA validated, on [DATE] ,by interview the Medical Director revealed that staff was informed to contact the Medical Director for any negative findings. The SA validated that Resident #214 room contained the Ambu bag, oxygen saturation monitor, and the suction machine was at bedside by observation. The SA validated agency contract by record review, dated [DATE], with an initial start date [DATE] on the ,[DATE] shift. The SA validated the Resident #214 declined observation [MEDICAL CONDITION] care, on [DATE], by interview with the DON. The SA validated by interview and record review the Respiratory Therapist assessed Resident #214, on [DATE] at 6:30 PM, and determined the resident was competent and comfortable to perform her [MEDICAL CONDITION]. The SA validated by record review of the Medication Administration Record the change out of the tubing and mask is to be done on Thursdays. The SA validated all residents (Resident #214 was the [MEDICAL CONDITION] in the facility) at risk for aspiration related to [MEDICAL CONDITION] by interview and record review of the MAR and person- centered care comprehensive care plan. The SA validated by interview that the RT is available for consultation as needed. The SA validated that Resident #214 was capable of performing [MEDICAL CONDITION] by interview with the RT. The SA validated six (6) RN's was in-serviced by record review of sign in sheet on [MEDICAL CONDITION] care, signs and symptoms of respiratory distress. The SA validated 10 Licensed Practical Nurses was in-serviced on [MEDICAL CONDITION] care, signs and symptoms, of respiratory distress by interview and sign in sheet and interview. The SA validated thirteen Certified Nursing Assistance was in-serviced on Respiratory Distress signs and symptoms by interview and in-service attendance sign sheet. The SA validated interview and review of in-service attendance sign in sheet that six (6) Housekeeping/Laundry staff were in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet two (2) Human Resources staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet one (1) Occupational Therapist in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet one (1) Account Payable Staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet one (1) lawn service staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet two (2) Maintenance staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet two (2) Activities staff was in-serviced on Respiratory Distress sign and symptoms. The SA validated by interview and attendance sign in sheet one (1) Medical Record staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet one (10 Physical Therapist Assistant was in-serviced on Respiratory Distress sign and symptoms. The SA validated by interview and attendance sign in sheet one (1) Speech Language Pathologist was in-serviced on Respiratory Distress sign and symptoms.

Based on observation, resident interview, staff interview, family interview, record review, Mississippi (MS) State Board of Nursing website review, the Nurse Practice Act review and facility policy review, the facility failed to assess Resident #214's competency to perform self [MEDICAL CONDITION] (trach) care, for one (1) out of one (1) residents observed with a [MEDICAL CONDITION]. Resident #214 was the only resident with [MEDICAL CONDITION] the facility. The facility also failed to provide qualified personnel, a Registered Nurse (RN) and/or a Respiratory Therapist (RT) in the facility 24 hours a day seven (7) days a week to provide deep tracheal suctioning or [MEDICAL CONDITION] if needed. The State Agency (SA) identified by review of the facility's staffing schedule from [DATE] to [DATE], interviews and record review, the facility did not provide RN or RT coverage 24 hours per day seven (7) days per week, on all shifts, for 23 out of 24 days. Resident #214 was admitted by the facility from the hospital, on [DATE], with a [MEDICAL CONDITION] she had been providing self care for at home. Resident #214 was admitted to the facility with a [DIAGNOSES REDACTED].#214 had a physician's orders [REDACTED]. The facility's failure to assess Resident #214's competency for [MEDICAL CONDITION] and providing coverage 24 hours per day seven (7) days per week services of an RN and/or RT to provide deep tracheal suctioning and possible [MEDICAL CONDITION] emergency care placed Resident #214 and other possible residents with tracheostomies at risk for serious injury, harm, impairment or death. The SA identified the situation as an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), on [DATE], when the facility admitted Resident #214 with [MEDICAL CONDITION] [DATE] and did not assess Resident #214's competency to provide [MEDICAL CONDITION] and to provide RN and/or RT coverage 24 hours per day seven (7) days per week for 23 of the 24 days of the days from the admitted until the SA's survey entrance date. On [DATE] at 7:50 PM, the SA notified the facility's Administrator and Director of Nurses (DON) of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). The facility submitted an acceptable Immediate Jeopardy Removal Plan, on [DATE], in which the facility alleged all corrective actions were completed on [DATE], and the IJ was removed on [DATE]. The SA validated the facility's Immediate Jeopardy Removal Plan, on [DATE], and determined the IJ was removed on [DATE], prior to the SA's exit on [DATE]. Findings include: Review of the facility's policy titled, Suctioning the Lower Airway (Endotracheal (ET) or [MEDICAL CONDITION]), with a revised date of (MONTH) 2010, revealed the training was addressed for in-servicing on the policy and demonstrated competency in the procedure is required on hire, and at least annually for Registered Nurses. The Purpose of this procedure revealed is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract. Review of the facility's policy titled, [MEDICAL CONDITION] Care, with a revision date of (MONTH) 2013, revealed the purpose of the procedure is to guide [MEDICAL CONDITION] care and cleaning of reusable [MEDICAL CONDITION] cannulas. The Training stated in-servicing on the policy and demonstrated competency in this procedure is required on hire and at least annually for Registered Nurses and Licensed Practical Nurses. The Equipment and Supplies included [MEDICAL CONDITION] care kit, suction catheter, suction machine, pulse oximeter, gloves, sterile water or normal saline, hydrogen peroxide, and extra gauze. The General Guidelines included: 1. Aseptic technique must be used during cleaning and sterilization of reusable [MEDICAL CONDITION]; during all dressing changes until the [MEDICAL CONDITION] wound has healed and during [MEDICAL CONDITION] changes or disposable. 2. Sterile gloves must be worn during aseptic procedures. 4. [MEDICAL CONDITION] care must be provided as often as needed, at least once daily for old, established tracheostomies, and at least every eight (8) hours for residents with unhealed tracheostomies. 7. A suction machine, supply of suction catheters, exam sterile gloves, and flush solution, must be left at the bedside at all times. Review of the facility's policy titled, Resident Assessment Instrument, revised (MONTH) 2010, revealed a comprehensive assessment of a resident's needs shall be made within fourteen (14) days of the resident's admission. The Policy Interpretation and Implementation revealed: 3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. 4. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. 6. Within seven (7) days of the completion of the resident assessment, a comprehensive care plan will be developed. Review of the Mississippi State Board of Nursing (BON) website, revealed frequently asked questions (FAQs): The BON's statement regarding the LPN's scope of practice with [MEDICAL CONDITION] care revealed, It is within the scope of practice of the LPN to [MEDICAL CONDITION] and suction secretions from [MEDICAL CONDITION]. However, it is not within the scope of practice for the LPN to perform deep right main stem suctioning. If deep suctioning is required for a patient, a Registered Nurse (RN) must perform the procedure. Review of the Mississippi (MS) Board of Nursing Laws and Rules Administrative Code Part 2830 Practice of Nursing Title 30: Professions and Occupations Chapter 2, Functions of the Licensed Practical Nurse, (LPN) revealed: Rule 2. 1-LPN Supervision, The LPN gives nursing care which does not require the specialized skill, judgement, and knowledge required of an RN. Advanced Practice Registered Nurse (APRN), Licensed Physician, or Licensed Dentist. Review of the facility's nursing staff schedule, from [DATE] to [DATE], revealed 23 of the 24 days, the facility did not have RN and/or RT coverage for all shifts, 7 AM to 3 PM, 3 PM to 11 PM or 11 PM to 7 AM to provide deep tracheal suctioning or [MEDICAL CONDITION] if needed for Resident #214. Review of the facility's Daily Nurse Staffing sheets, from [DATE] to [DATE], revealed one Registered Nurse (RN) was scheduled for the day shift - 6 AM to 2 PM and 7 AM to 3 PM, and there was no RN scheduled for the evening shift - 2 PM to 10 PM and 3 PM to 11 PM or the night shift - 10 PM to 6 AM and 11 PM to 7 AM. Review of the hospital's admission notes by the Physician revealed, on [DATE] revealed Resident #214 was brought to the hospital by her husband due to alteration in mental status, and the assessment by the physician was Acute Metabolic [MEDICAL CONDITION]. Resident #214 was previously hospitalized for [REDACTED]. Resident #9's husband brought her back to the hospital, on [DATE] because she was sleeping a lot, and was confused when she was awake since she was discharged on [DATE]. The hospital Physician's History Note, dated [DATE], revealed Resident #214 had a [MEDICAL CONDITION] in 2007, and has paralysis of her bilateral vocal cords and larynx. On [DATE] at 4:00 PM, an interview with the Director of Nursing (DON) and Administer revealed they do not have RN coverage 24 hours per day seven days per week to provide deep suctioning or [MEDICAL CONDITION] if needed for Resident #214. The DON stated the resident provided [MEDICAL CONDITION] at home for years and was providing it herself at the facility. The DON stated Resident #214 prefers to take care of it herself. An interview, on [DATE] at 3:00 PM, with the Administrator and the DON, revealed the DON did say that if Resident #214 required deep suctioning and the RN was not here, the LPN would have to call for an ambulance to transfer her to the hospital. The DON said it would take the ambulance five (5) minutes to get to the facility and another two (2) minutes to get to the hospital, that would be seven (7) minutes, and could result in possible brain damage. The DON stated she just did not think about 24 hour a day RN coverage at the time Resident #214 was admitted to provide deep suctioning or [MEDICAL CONDITION] if needed. An interview, on [DATE] at 5:30 PM, revealed the Medical Director stated he did not know Resident #214 prior to admission to the facility, and he was aware Resident #214 was admitted to the facility with a [MEDICAL CONDITION]. The Medical Director stated it was possible Resident #214 could have more respiratory issues with a history of Pneumonia and [MEDICAL CONDITIONS]. The Medical Director stated he was not aware the facility did not have RN coverage to provide deep suctioning if it was needed. The Medical Director said he assumed they would have coverage that was required. He further stated he would expect the RN to perform the deep suctioning as needed. The Medical Director also said he would expect the facility to assess the resident to ensure she was able to provide [MEDICAL CONDITION] safely. The Medical Director said he knew the resident was admitted to the facility from the hospital with Pneumonia and she was here for physical therapy for weakness. The Medical Director stated he was trusting the staff to do what was needed to provide care for Resident #214. The Medical Director stated he did not have any concerns regarding Resident #214 being mentally unstable. On [DATE] at 3:55 PM, an observation revealed Resident #214 was lying in bed, with a [MEDICAL CONDITION] intact. No distress was noted. On [DATE] at 4:08 PM, an observation of Resident #214's room revealed there was no suction machine, suction catheter kit, or [MEDICAL CONDITION] care kit. There was an oxygen concentrator machine and humidifier in the room that was just sitting there, not connected to anything. On [DATE] at 4:09 PM, an interview with Resident #214 revealed they (the facility) told her she would have to take care of [MEDICAL CONDITION]. Resident #214 said she had managed to care for [MEDICAL CONDITION] home for many years and could do it here at the nursing home. Resident #214 said she suctioned herself as needed and had not required a nurse to suction her since she has been there. Resident #214 stated she does [MEDICAL CONDITION] every day. Resident #214 stated she did have suction equipment over there, pointing to the nightstand, that they (the facility) had brought it in. The facility had brought [MEDICAL CONDITION] supplies, however there were no suction supplies observed at this time. Resident #214 was at the nursing home for therapy and planned to return home. Review of Resident #214's physician's orders [REDACTED].#214 to provide her [MEDICAL CONDITION] and suction [MEDICAL CONDITION] needed to remove excess secretions. Review of Resident #214's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed the Special Treatments/Programs section was checked for oxygen (O2) use and [MEDICAL CONDITION] care. Suctioning was not checked. Resident #214's Basic Interview for Mental Status (BIMS) score was 11, which indicated moderate cognitive impairment. The MDS also revealed Resident #214 did not have any vision, hearing or speech deficits, and was able to make herself understood to others, and she was able to understand others. The DON revealed during an interview, on [DATE] at 5:20 PM, she should have observed Resident #214 perform [MEDICAL CONDITION] to ensure she was doing it correctly. Review of Resident #214's Medical Record revealed there were no assessments regarding the resident's ability to perform [MEDICAL CONDITION] until the Departmental Notes-Respiratory Therapy, dated [DATE] at 9:07 PM, late entry for 6:30 PM, for [MEDICAL CONDITION] Self Performance, revealed Resident #214 is performing [MEDICAL CONDITION] for herself to a seven (7) year established trach. The RT explains due to the resident's report of being sick at her stomach and not wanting to move [MEDICAL CONDITION] very much right now, they agreed for her to demonstrate and describe how she provided [MEDICAL CONDITION]. The RT also documented she had asked the resident if she wanted the RT to get the nurse, but the resident reported the nurse had already given her something for the nausea. The RT documented Resident #214's demonstration showed the resident was comfortable and competent to provide her [MEDICAL CONDITION], and the RT's opinion was that Resident #214 was very competent in doing her [MEDICAL CONDITION]. Resident #214 declined for the surveyor to observe her perform [MEDICAL CONDITION]. An interview, on [DATE] at 10:15 AM, revealed Resident #214's Family Member #2/husband, said the resident came to the nursing home for therapy. Resident #214's husband stated the resident had been taking care of [MEDICAL CONDITION] home for a long time without any problems. The husband confirmed Resident #214 had been hospitalized twice due to Pneumonia and [MEDICAL CONDITION]. The husband reported the nursing home did know about [MEDICAL CONDITION] Resident #214 went there. The husband also reported Resident #214 has long term memory problems at times. An interview, on [DATE] at 5:17 PM, with LPN #2, revealed the RN provided supervision when she's here and the LPNs and RNs are charge nurses. LPN #2 reported she had not received any training from the facility [MEDICAL CONDITION] since she has been employed at the facility. LPN #2 said she did [MEDICAL CONDITION] training in nursing school. LPN #2 reported the emergency supplies, suction, and crash cart was kept in the clean utility room behind the nursing station in a locked room. The room has a key pad lock, and all nursing staff has the code to the room. LPN #2 said the nurses check the crash cart each shift. LPN #2 stated the nursing staff changes out the oxygen concentrator tubing weekly. LPN #2 did not reveal how or who was monitoring Resident #214 to ensure she was providing [MEDICAL CONDITION] and suctioning as needed, ensuring the resident was [MEDICAL CONDITION] supplies as needed, or the bedside equipment such as a suction machine, suction catheter, [MEDICAL CONDITION], that may be required in case if an emergency arose such as the need for deep suctioning or decannulation. On [DATE] at 4:05 PM, an interview with Licensed Practical Nurse (LPN) #2, revealed Resident #214 preferred to take care of her own [MEDICAL CONDITION] because she had been doing it for years at home. LPN #2 stated if Resident #214 needed deep suctioning she would provide some type of care to keep the resident alive until the paramedics got to the facility, but she would not do anything not in her scope of practice. LPN #2 said she would check the oxygen level, raise the head of the bed, and she would suction around [MEDICAL CONDITION] didn't work and stay at the resident's bed side till help arrived. LPN #2 said she would call the medical doctor after she got the resident's vital signs. LPN #2 said if the cannula came out, she would keep the airway open and keep the resident [MEDICATION NAME] till the paramedics arrived. LPN #2 said tracheal suctioning is a sterile procedure. LPN #2 said she would oxygenate the resident and suction no longer than 10 seconds, oxygenate and repeat suction. LPN #2 stated when the suction equipment was not in use it was kept in a zip lock bag and changed weekly, they date and initial the bag. LPN #2 stated they change the oxygen concentrator tubing weekly. An interview, on [DATE] at 3:26 PM, revealed LPN #3 stated no one [MEDICAL CONDITION] here. LPN #3 said Resident #214 does her [MEDICAL CONDITION]. LPN #3 said if Resident #214 had any problems breathing, she would go get the RN. LPN #3 stated if [MEDICAL CONDITION] came out the resident would be at risk for infection. LPN #3 further stated she would do nothing else if the resident could still breathe, and she would go get the RN, and if the RN was not there she would call the RN and see if she wanted her to send the resident out. LPN #3 reported she works the 7 AM to 3 PM shift on the West Wing and sometimes to 7 PM. LPN #3 stated she has been employed at the facility for nine (9) years, and there has not been [MEDICAL CONDITION] here until now. LPN #3 said the RNs would have to do [MEDICAL CONDITION]. LPN #3 said she has not received any training by the facility [MEDICAL CONDITION] and there has not been any training provided by the facility [MEDICAL CONDITION]. LPN #3 did not confirm how the facility was monitoring to be sure Resident #214 was [MEDICAL CONDITION] and suctioning as needed, or ensure the resident had the [MEDICAL CONDITION] supplies, or emergency equipment kept at the bedside. On [DATE] at 1:55 PM, an interview with LPN #4, revealed the RNs and LPNs provide resident care. LPN #4 stated the RNs were in charge of [MEDICAL CONDITION]. LPN #4 stated the LPNs can suction, but only the RNs can deep suction the trachs. LPN #4 stated if the resident exhibited signs and symptoms (s/s) of respiratory distress such as facial grimacing, she would try to get them to calm down, get their Oxygen Saturation (O2 Sat), and get their vital signs (v/s). LPN #4 stated if the resident needed deep suctioning and the RN was not here, she would suction the resident, keep the airway open, and call 911. LPN #4 stated the crash cart is kept in the clean utility room. The door is kept locked, but all the nurses know the code. LPN #4 reported the last training [MEDICAL CONDITION] was provided by the corporate nurse back in (MONTH) or (MONTH) of last year. They watched the corporate nurse and then did a return demonstration. LPN #4 stated if there were any changes in a resident she would report it to the RN and the physician. LPN #4 said she has not worked the West Wing since Resident #214 has been here, and she worked the West Wing two months ago, but we can be pulled to work any hall. LPN #4 did not confirm how the facility was monitoring to be sure Resident #214 was [MEDICAL CONDITION] and suctioning as needed, or ensure the resident had the [MEDICAL CONDITION] supplies, or emergency equipment kept at the bedside. On [DATE] at 4:17 PM, an interview with the DON revealed the corporate respiratory therapist trained the staff on care of a [MEDICAL CONDITION] about a couple of weeks ago. Record review revealed the only In-Service Attendance Sheet the facility provided [MEDICAL CONDITION], suctioning the upper airway, oxygen therapy and administration and [MEDICAL CONDITIONS] was dated (MONTH) 10, 2019. The sign in sheet revealed the signature of one person. The training was provided by the RT. On [DATE] at 1:50 PM, an interview with RN #1/Minimum Data Set (MDS) Nurse, revealed she does not have anything to do with the nurse staffing or scheduling to ensure RN coverage 24 hours per day seven (7) days per week to provide deep suctioning [MEDICAL CONDITION] care if needed. RN #1 stated the Director of Nurses (DON) does the nursing staff schedule. RN #1 stated Resident #1 provided her [MEDICAL CONDITION] and suctioning. RN #1 confirmed she had not [MEDICAL CONDITION] or deep suctioning for Resident #214. RN #1 confirmed she was aware the LPNs could not deep suction trachs. RN #1 also stated if a resident needed deep suctioning and did not get it, the resident could die. RN #1 also said it would take about seven (7) minutes for the ambulance to get here and the resident could die in seven (7) minutes. RN #1 said she has had training for [MEDICAL CONDITION] care. She stated the last training prior to survey was around (MONTH) 2019, and she also had training by the DON on [DATE]. On [DATE] at 3:46 PM, an interview with Certified Nursing Assistant (CNA) #3, revealed she has been employed at the facility since (MONTH) of 2019, and she has not had any prior training to take care of a resident with a trach. CNA #3 stated she was currently Cardiopulmonary Resuscitation (CPR) certified. CNA #3 said she works swing shift, she works 2 PM to 10 PM on the weekends and 6 AM to 2 PM the other days. CNA #3 said she has not worked with a resident with [MEDICAL CONDITION], however Resident #214 was assigned to her today. CNA #3 said she did know the resident did everything for herself. CNA #3 said she has not received any training on taking care of a resident with a trach. If Resident #214 was having respiratory difficulty CNA #3 said the first thing she would do is call for help, she would not leave her. If the resident was gasping for breath or not breathing she would call for help, shake her to see if she was OK and then call for help. Review of the Face Sheet revealed Resident #214 was admitted by the facility, on [DATE], with the included [DIAGNOSES REDACTED]. Review of Resident #214's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed the resident required extensive assistance with one person physical assist for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. The facility's accepted Immediate Jeopardy Removal Plan: Haven Hall Healthcare Center Administrator and Director of Nursing were notified of Immediate Jeopardy and Substandard Quality of Care on, [DATE] at 7:50 p.m. related to the facility admitting Resident #214 on [DATE] with a [MEDICAL CONDITION] and (1) Failure to assess resident during routine [MEDICAL CONDITION] care performed per resident, (2) Failure to develop and implement a care plan for the care of resident's [MEDICAL CONDITION], and (3) Failure to provide around the clock Registered Nurse (RN) or Respiratory Therapist (RT) coverage to provide deep suctioning and emergency [MEDICAL CONDITION] care, placed the resident at risk for serious injury, harm, impairment. Immediately upon notification: The Director of Nursing put in place for Registered Nurse coverage to be ,[DATE]. An emergency Quality Assurance meeting was called on [DATE] at 8:14 PM to discuss (1) Failure to assess resident during routine [MEDICAL CONDITION] care performed per resident, (2) Failure to develop and implement a care plan for the care of resident's [MEDICAL CONDITION], and (3) Failure to provide around the clock Registered Nurse (RN) or Respiratory Therapist (RT) coverage to provide deep suctioning and emergency [MEDICAL CONDITION] care, placed the resident at risk for serious injury, harm, impairment. Those in attendance were the Medical Director, Administrator, Director of Nursing, Nurse Consultant, Assistant Director of Nursing, Minimal- Data Set Nurse, Care Plan Nurse, Social Worker, and Admissions/Medicare Nurse. Policy and Procedure on [MEDICAL CONDITION] Care was reviewed on [DATE], by the Director of Nursing with no policy changes implemented. This policy was revised ,[DATE]. Facility identified through record review by the Director of Nursing on [DATE] at 9:00 P.M., that Resident #214 is the only resident in the facility that has a [MEDICAL CONDITION]. Review of Resident# 214's Care Plan was conducted by the Director of Nursing and the Care Plan Nurse developed a plan of care on [DATE] at 8:00 p.m, to include specific needs and staff involved to provide needed services according to the resident's wishes. (1) Potential for complications related to [MEDICAL CONDITION]: Deep suction as needed for thick or copious amounts of secretions the resident is unable to expel, per Registered Nurse or Respiratory Therapist. If resident becomes de-cannulated, cannula to be replaced using sterile technique, per Registered Nurse or Respiratory Therapist. Respiratory Therapist to assess resident each visit to the facility and will be available for consultation as needed. Assess for signs and symptoms of respiratory distress to include but not limited to labored breathing, cyanosis, low blood pressure, restlessness, dyspnea, decreased oxygen saturations, rattling breath sounds, etcetera, as needed per Registered Nurse or Respiratory Therapist. Notify Medical Director of any negative findings, per Nurse. Keep Ambu bag at bedside, per Nurse or Registered Nurse. Keep oxygen saturation monitor at bedside, per Nurse. Keep suction machine at bedside, per Nurse. (2) At risk for aspiration related to [MEDICAL CONDITION]: Change out [MEDICAL CONDITION] tubing and mask weekly on Thursday, per Nurse. Suction [MEDICAL CONDITION] as needed using aseptic technique, Resident to perform as needed for increased secretions, per Resident. [MEDICAL CONDITION] care, using aseptic technique every shift, per Resident, Registered Nurse to be in room in case of complications, Registered Nurse. Change out [MEDICAL CONDITION] tubing and mask weekly, on Thursday, per Nurse. Resident is to be maintained in an upright or sitting position while eating, per Nurse. Assess for signs and symptoms of respiratory distress to include but not limited to labored breathing, rapid breathing, cyanosis, low blood pressure, restlessness, dyspnea, decreased oxygen saturation, rattling breath sounds, etcetera, as needed per Registered Nurse and/or Respiratory Therapist. Assess for signs and symptoms of aspirations to include but not limited to fever, cough, shortness of breath, fatigue, etcetera, as needed, per Registered Nurse and Respiratory Therapist. Notify Medical Doctor of any negative findings, per Nurse. Keep Ambu bag at bedside, per Nurse or Registered Nurse. Keep oxygen saturation monitor at bedside, per Nurse. Keep suction machine at bedside, per Nurse. Oxygen saturation taken, every shift, and notify Physician if oxygen saturation is less than 90 percent, per Nurse. (3) Resident prefers to perform her own [MEDICAL CONDITION] care, per Resident. Allow Resident to perform own [MEDICAL CONDITION] care, as desired, with Registered Nurse present, per resident. Honor Residents right to perform own [MEDICAL CONDITION] care, per Nurse. Registered Nurse staffing 24 hours 7 days a week in case of emergency [MEDICAL CONDITION] care needed, per Nurse. Encourage Resident to notify Licensed Practical Nurse or Registered Nurse prior to performing [MEDICAL CONDITION] care, per Nurse. Review of Registered Nurse scheduling was done on [DATE] at 8 :30 P.M. by the Director of Nursing to ensure that the facility had ,[DATE] Registered Nurse coverage. We will continue to hire Registered Nurses. While we are in the process of hiring the Registered Nurses to cover the around the clock Registered Nurse positions, we will reach out and utilize the resources of our Nurse Consultant (Registered Nurse), Director of Clinical Service (Registered Nurse), or our Clinical Respiratory Therapist, in the event one of the Registered Nurses are unable to perform their duties. We have a Contract in place, effective [DATE], with a Staffing Agency for Registered Nurse coverage. The initial date they will be on site for Registered Nurse coverage is, Friday, [DATE], ,[DATE] shift. They will be trained prior to working on the floor, Friday [DATE], on facility Policies related to [MEDICAL CONDITION] Care and Deep Suctioning by the Director of Nursing. Registered Nurses (6 Registered Nurses) in-serviced per Director of Nursing on [DATE] at 9:00 P.M. on policy for assessing the residents for self care related to [MEDICAL CONDITION] care and suctioning. No nurse will be allowed to work until they have received the above in-service education. Care plan nurse re-in-serviced per Director of Nursing on [DATE] at 9:45 P.M. on the policy for completing comprehensive care plans. This nurse was not allowed to work until she had received the above in-service education. Resident was assessed to ensure that she is able to perform her own [MEDICAL CONDITION] care on [DATE] at 6:30 P.M. per Respiratory Therapist. Respiratory Therapist was able to confirm that Resident #214's ability to safely perform her own [MEDICAL CONDITION] care. In-services were initiated on [DATE] at 7 :22 p.m. by the Assistant Director of Nursing with Certified Nursing Assistants (17 Certified Nursing Assistants), Licensed Practical Nurses (10 Licensed Practical Nurses), and Registered Nurses (6 Registered Nurses) on the signs and symptoms of respiratory distress. The information reviewed was provided to them. No Certified Nursing Assistant or Nurse will be allowed to work until they have received the above in-service education. Staff in-services initiated, [DATE], at 7 :30 p.m. by the Director of Nursing with Nursing, Housekeeping, Laundry, Dietary, Maintenance, and Administrative Staff (69 employees), related to Immediate Jeopardy citations and signs and symptoms of Respiratory Distress. In-service education and competency training was provided on [DATE] at 9:20 p.m., by the Respiratory Therapist, on the policy for deep suctioning with Registered Nurse (6 Registered Nurses) and [MEDICAL CONDITION] care with Licensed Practical Nurses and Registered Nurses (12 Licensed Practical Nurses and 6 Registered Nurses) and copy of the policies and procedures reviewed to ensure that nursing staff will be provided this information. No nurse will be allowed to work until they have received the above in-service education Haven Hall Healthcare Center alleges that, on [DATE], the Immediate Jeopardy regarding Resident #214 has been removed. SA VALIDATIONS The State Agency (SA) validated by record review of the Registered Nurses (RN) schedule dated [DATE] revealed RN coverage twenty-four hours a day seven (7) days a week. The SA validated the Quality Assurance meeting was held on [DATE] by record review of sign in sheet contained containing the following signatures for: Medical Director, Director of Nursing, Assistant Director of Nursing, Minimum Data Set Nurse, Care Plan Nurse, Nurse Consultant, Social Worker, and Admission/Medicare Nurse. The SA validated no changes in the facility policy by record review with a revision date of ,[DATE]. The SA validated the current matrix and census by record review revealed there was no other [MEDICAL CONDITION] residents in the facility. The SA validated by record review a comprehensive care plan was developed for Resident #214, dated [DATE], with interventions for [MEDICAL CONDITION] care, resident's [MEDICAL CONDITION] and RN/RT coverage 24 hours a day seven (7) days a week. The SA validated, on [DATE], by interview the Medical Director revealed that staff was informed to contact the Medical Director for any negative findings. The SA validated that Resident #214 room contained the Ambu bag, oxygen saturation monitor, and the suction machine was at bedside by observation. The SA validated agency contract by record review, dated [DATE], with an initial start date [DATE] on the ,[DATE] shift. The SA validated the Resident #214 declined observation [MEDICAL CONDITION] care, on [DATE], by interview with the DON. The SA validated by interview and record review the Respiratory Therapist assessed Resident #214, on [DATE] at 6:30 PM, and determined the resident was competent and comfortable to perform her [MEDICAL CONDITION]. The SA validated by record review of the Medication Administration Record the change out of the tubing and mask is to be done on Thursdays. The SA validated all residents (Resident #214 was the [MEDICAL CONDITION] in the facility) at risk for aspiration related to [MEDICAL CONDITION] by interview and record review of the MAR and person- centered care comprehensive care plan. The SA validated by interview that the RT is available for consultation as needed. The SA validated that Resident #214 was capable of performing [MEDICAL CONDITION] by interview with the RT. The SA validated six (6) RN's was in-serviced by record review of sign in sheet on [MEDICAL CONDITION] care, signs and symptoms of respiratory distress. The SA v

Based on observation, resident interview, staff interview, record review, review of the Mississippi State Board of Nursing website and the Nurse Practice Act, the facility failed to provide qualified, consistent and sufficient staff, a Registered Nurse (RN) and/or a Respiratory Therapist (RT), 24 hours per day seven (7) days per week to provide deep tracheal suctioning and [MEDICAL CONDITION] if needed to ensure respiratory care for one of one (1 of 1) residents reviewed with a [MEDICAL CONDITION] (trach), Resident #214. Review of the facility's nursing staff schedule from 01/24/2020 to 02/17/2020 revealed the facility did not have 24 hours per day seven (7) days per week RN or RT coverage for 23 of the 24 days on the 7 AM to 3 PM, 3 PM to 11 PM, and 11 PM to 7 AM shifts. Resident #214 was admitted from the hospital to the facility, on 01/24/2020, with [DIAGNOSES REDACTED]. Resident #214 was admitted for therapy for [REDACTED]. Resident #214 had a physician's orders [REDACTED]. The hospital records revealed Resident #214 had a [MEDICAL CONDITION] in 2007 and has paralysis of her bilateral vocal cords and larynx. The facility's failure to provide 24 hour per day RN and/or RT staffing, for possible deep suctioning and other emergency [MEDICAL CONDITION] care, placed Resident #214 and other possible [MEDICAL CONDITION] residents at risk for serious harm, injury, impairment or death. The State Agency (SA) identified the Immediate Jeopardy (IJ), on 02/17/2020, when the facility failed to ensure qualified staff, a RN and/or RT, were present 24 hours per day seven (7) days per week to provide deep tracheal suctioning and [MEDICAL CONDITION] if needed for Resident #214. The SA notified the facility's Administrator and Director of Nurses (DON) of the IJ on 02/17/2020 at 7:50 PM. The facility submitted an acceptable Immediate Jeopardy Removal Plan on 02/19/2020. The facility alleged all corrective actions were completed on 02/19/2020 and the IJ was removed on 02/19/2020. The SA validated the Immediate Jeopardy Removal Plan on 02/20/2020 and determined the IJ was removed prior to exit on 02/20/2020. Findings Include: The facility did not have a policy specific to sufficient staffing or adequate staffing. Review of the facility's policy titled, Competency of Nursing Staff, dated revised (MONTH) 2019, revealed that all nursing staff must meet the specific competency requirements of their respective licensures and certification requirements defined by state law. The policy's Interpretation and Implementation included: 1. Is designated to train nursing staff to deliver individualized, safe, quality of care and services for the residents. 2. The following factors are considered in the creation of the competency-based staff development and training program included-Specialized skills or training needed based on the resident population. 4. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as: d. Person centered care; f. Basic nursing skills; l. Identification of changes in condition. Review of the Mississippi State Board of Nursing (BON) website, revealed frequently asked questions (FAQs): The BON's statement regarding the LPN's scope of practice with [MEDICAL CONDITION] care revealed, It is within the scope of practice of the LPN to [MEDICAL CONDITION] and suction secretions from [MEDICAL CONDITION]. However, it is not within the scope of practice for the LPN to perform deep right main stem suctioning. If deep suctioning is required for a patient, a Registered Nurse (RN) must perform the procedure. Review of the Mississippi (MS) Board of Nursing Laws and Rules Administrative Code Part 2830 Practice of Nursing Title 30: Professions and Occupations Chapter 2, Functions of the Licensed Practical Nurse, (LPN) revealed: Rule 2. 1-LPN Supervision, The LPN gives nursing care which does not require the specialized skill, judgement, and knowledge required of an RN. Advanced Practice Registered Nurse (APRN), Licensed Physician, or Licensed Dentist. Review of the facility's nursing staff schedule, from 01/24/2020 to 02/17/2020, revealed 23 of the 24 days, the facility did not have RN and/or RT coverage for all shifts, 7 AM to 3 PM, 3 PM to 11 PM or 11 PM to 7 AM to provide deep tracheal suctioning or [MEDICAL CONDITION] if needed for Resident #214. Review of the facility's Daily Nurse Staffing sheets, from 02/10/2020 to 02/16/2020, revealed one Registered Nurse (RN) was scheduled for the day shift - 6 AM to 2 PM and 7 AM to 3 PM, and there was no RN scheduled for the evening shift - 2 PM to 10 PM and 3 PM to 11 PM or the night shift - 10 PM to 6 AM and 11 PM to 7 AM. Review of the hospital's admission notes by the Physician revealed, on 01/18/2020, Resident #214 was brought to the hospital by her husband due to alteration in mental status, and the assessment by the physician was Acute Metabolic [MEDICAL CONDITION]. Resident #214 was previously hospitalized for [REDACTED]. Resident #9's husband brought her back to the hospital, on 01/18/2020 because she was sleeping a lot, and was confused when she was awake since she was discharged on [DATE]. The hospital Physician's History Note, dated 01/18/2020, revealed Resident #214 had a [MEDICAL CONDITION] in 2007, and has paralysis of her bilateral vocal cords and larynx. On 02/17/2020 at 4:09 PM, an interview and observation revealed Resident #214 had a [MEDICAL CONDITION], and Resident #214 reported they (the facility) told her she would have to take care of [MEDICAL CONDITION], and she had taken care of [MEDICAL CONDITION] home for many years. Review of Resident #214's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/30/2020, revealed the Special Treatments/Programs section was checked for oxygen (O2) use and [MEDICAL CONDITION] care. Suctioning was not checked. Resident #214's Basic Interview for Mental Status (BIMS) score was 11, which indicated moderate cognitive impairment. The MDS also revealed Resident #214 did not have any vision, hearing or speech deficits, and was able to make herself understood to others, and she was able to understand others. During an interview with the Administrator and the Director of Nurses (DON), on 02/17/2020 at 4:00 PM, they confirmed the facility did not have RN coverage 24 hours per day seven days per week in the event Resident #24 required deep suctioning or [MEDICAL CONDITION]. The DON stated Resident #214 prefers to take care of [MEDICAL CONDITION], and she was doing [MEDICAL CONDITION] at home for years and was providing it herself at the facility. On 02/18/2020 at 3:00 PM, an interview with the Administrator and the DON, confirmed in the event that Resident #214 needed deep suctioning and the RN was not here, the LPN would have to call for an ambulance to transfer her to the hospital. The DON also confirmed it would take the ambulance five (5) minutes to get to the facility and another two (2) minutes to get to the hospital, that would be seven (7) minutes, and could result in possible brain damage. The DON said when Resident #214 was admitted and since her admission she just did not think about 24 hour a day RN coverage to provide deep suctioning or [MEDICAL CONDITION] if needed. An interview, on 02/19/2020 at 5:30 PM, revealed the Medical Director was not aware the facility did not have RN coverage to provide deep suctioning if it was needed and that he just assumed they would have coverage that was required. He further stated he would expect the RN to perform the deep suctioning as needed. The Medical Director stated he was trusting the staff to do what was needed to provide care for Resident #214. The Medical Director also revealed he knew the resident was admitted to the facility from the hospital with a [MEDICAL CONDITION] and Pneumonia, which could cause further respiratory issues. An interview, on 02/19/2020 at 4:34 PM, revealed the Assistant Director of Nurses (ADON) stated the DON makes the nursing schedules and decides who to admit to the facility. The ADON said she was aware Resident #214 had a [MEDICAL CONDITION], and without 24 hour a day seven (7) days a week RN coverage the resident was at risk for death. Review of the Face Sheet revealed Resident #214 was admitted by the facility, on 01/24/2020, with the included [DIAGNOSES REDACTED]. Review of Resident #214's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/20/2020, revealed the resident required extensive assistance with one person physical assist for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. The facility's accepted Immediate Jeopardy Removal Plan: Haven Hall Healthcare Center Administrator and Director of Nursing were notified of Immediate Jeopardy and Substandard Quality of Care on, 2/17/2020 at 7:50 p.m. related to the facility admitting Resident #214 on 1/24/2020 with a [MEDICAL CONDITION] and (1) Failure to assess resident during routine [MEDICAL CONDITION] care performed per resident, (2) Failure to develop and implement a care plan for the care of resident's [MEDICAL CONDITION], and (3) Failure to provide around the clock Registered Nurse (RN) or Respiratory Therapist (RT) coverage to provide deep suctioning and emergency [MEDICAL CONDITION] care, placed the resident at risk for serious injury, harm, impairment. Immediately upon notification: The Director of Nursing put in place for Registered Nurse coverage to be 24/7. An emergency Quality Assurance meeting was called on 2/17/2020 at 8:14 PM to discuss (1) Failure to assess resident during routine [MEDICAL CONDITION] care performed per resident, (2) Failure to develop and implement a care plan for the care of resident's [MEDICAL CONDITION], and (3) Failure to provide around the clock Registered Nurse (RN) or Respiratory Therapist (RT) coverage to provide deep suctioning and emergency [MEDICAL CONDITION] care, placed the resident at risk for serious injury, harm, impairment. Those in attendance were the Medical Director, Administrator, Director of Nursing, Nurse Consultant, Assistant Director of Nursing, Minimal- Data Set Nurse, Care Plan Nurse, Social Worker, and Admissions/Medicare Nurse. Policy and Procedure on [MEDICAL CONDITION] Care was reviewed on 2/17/20, by the Director of Nursing with no policy changes implemented. This policy was revised 8/2013. Facility identified through record review by the Director of Nursing on 2/17/20 at 9:00 P.M., that Resident #214 is the only resident in the facility that has a [MEDICAL CONDITION]. Review of Resident# 214's Care Plan was conducted by the Director of Nursing and the Care Plan Nurse developed a plan of care on 2/17/20 at 8:00 p.m, to include specific needs and staff involved to. provide needed services according to the resident's wishes. (1) Potential for complications related to [MEDICAL CONDITION]: Deep suction as needed for thick or copious amounts of secretions the resident is unable to expel, per Registered Nurse or Respiratory Therapist. If resident becomes de-cannulated, cannula to be replaced using sterile technique, per Registered Nurse or Respiratory Therapist. Respiratory Therapist to assess resident each visit to the facility and will be available for consultation as needed. Assess for signs and symptoms of respiratory distress to include but not limited to labored breathing, cyanosis, low blood pressure, restlessness, dyspnea, decreased oxygen saturations, rattling breath sounds, etcetera, as needed per Registered Nurse or Respiratory Therapist. Notify Medical Director of any negative findings, per Nurse. Keep Ambu bag at bedside, per Nurse or Registered Nurse. Keep oxygen saturation monitor at bedside, per Nurse. Keep suction machine at bedside, per Nurse. (2) At risk for aspiration related to [MEDICAL CONDITION]:: Change out [MEDICAL CONDITION] tubing and mask weekly on Thursday, per Nurse. Suction [MEDICAL CONDITION] as needed using aseptic technique, Resident to perform as needed for increased secretions, per Resident. [MEDICAL CONDITION] care, using aseptic technique every shift, per Resident, Registered Nurse to be in room in case of complications, Registered Nurse. Change out [MEDICAL CONDITION] tubing and mask weekly, on Thursday, per Nurse. Resident is to be maintained in an upright or sitting position while eating, per Nurse. Assess for signs and symptoms of respiratory distress to include but not limited to labored breathing, rapid breathing, cyanosis, low blood pressure, restlessness, dyspnea, decreased oxygen saturation, rattling breath sounds, etcetera, as needed per Registered Nurse and/or Respiratory Therapist. Assess for signs and symptoms of aspirations to include but not limited to fever, cough, shortness of breath, fatigue, etcetera, as needed, per Registered Nurse and Respiratory Therapist. Notify Medical Doctor of any negative findings, per Nurse. Keep Ambu bag at bedside, per Nurse or Registered Nurse. Keep oxygen saturation monitor at bedside, per Nurse. Keep suction machine at bedside, per Nurse. Oxygen saturation taken, every shift, and notify Physician if oxygen saturation is less than 90 percent, per Nurse. (3) Resident prefers to perform her own [MEDICAL CONDITION] care, per Resident. Allow Resident to perform own [MEDICAL CONDITION] care, as desired, with Registered Nurse present, per resident. Honor Residents right to perform own [MEDICAL CONDITION] care, per Nurse. Registered Nurse staffing 24 hours 7 days a week in case of emergency [MEDICAL CONDITION] care needed, per Nurse. Encourage Resident to notify Licensed Practical Nurse or Registered Nurse prior to performing [MEDICAL CONDITION] care, per Nurse. Review of Registered Nurse scheduling was done on 2/17/20 at 8:30 P.M. by the Director of Nursing to ensure that the facility had 24/7 Registered Nurse coverage. We will continue to hire Registered Nurses. While we are in the process of hiring the Registered Nurses to cover the around the clock Registered Nurse positions, we will reach out and utilize the resources of our Nurse Consultant (Registered Nurse), Director of Clinical Service (Registered Nurse), or our Clinical Respiratory Therapist, in the event one of the Registered Nurses are unable to perform their duties. We have a Contract in place, effective 2/18/2020, with a Staffing Agency for Registered Nurse coverage. The initial date they will be on site for Registered Nurse coverage is, Friday, 2/21/2020, 3/11 shift. They will be trained prior to working on the floor, Friday 2/21/2020, on facility Policies related to [MEDICAL CONDITION] Care and Deep Suctioning by the Director of Nursing. Registered Nurses (6 Registered Nurses) in-serviced per Director of Nursing on 2/17/2020 at 9:00 P.M. on policy for assessing the residents for self care related to [MEDICAL CONDITION] care and suctioning. No nurse will be allowed to work until they have received the above in-service education. Care plan nurse re-in-serviced per Director of Nursing on 2/17/2020 at 9:45 P.M. on the policy for completing comprehensive care plans. This nurse was not allowed to work until she had received the above in-service education. Resident was assessed to ensure that she is able to perform her own [MEDICAL CONDITION] care on 2/18/2020 at 6:30 P.M. per Respiratory Therapist. Respiratory Therapist was able to confirm that Resident #214's ability to safely perform her own [MEDICAL CONDITION] care. In-services were initiated on 2/18/2020 at 7:22 p.m. by the Assistant Director of Nursing with Certified Nursing Assistants (17 Certified Nursing Assistants), Licensed Practical Nurses (10 Licensed Practical Nurses), and Registered Nurses (6 Registered Nurses) on the signs and symptoms of respiratory distress. The information reviewed was provided to them. No Certified Nursing Assistant or Nurse will be allowed to work until they have received the above in-service education. Staff in-services initiated, 2/18/2020, at 7:30 p.m. by the Director of Nursing with Nursing, Housekeeping, Laundry, Dietary, Maintenance, and Administrative Staff (69 employees), related to Immediate Jeopardy citations and signs and symptoms of Respiratory Distress. In-service education and competency training was provided on 2/18/2020 at 9:20 p.m., by the Respiratory Therapist, on the policy for deep suctioning with Registered Nurse (6 Registered Nurses) and [MEDICAL CONDITION] care with Licensed Practical Nurses and Registered Nurses (12 Licensed Practical Nurses and 6 Registered Nurses) and copy of the policies and procedures reviewed to ensure that nursing staff will be provided this information. No nurse will be allowed to work until they have received the above in-service education. Haven Hall Healthcare Center alleges that, on 2/19/2020, the Immediate Jeopardy regarding Resident #214 has been removed. SA VALIDATIONS The State Agency (SA) validated by record review of the Registered Nurses (RN) schedule dated 02/19/2020 revealed RN coverage twenty-four hours a day seven (7) days a week. The SA validated the Quality Assurance meeting was held on 02/17/2020 by record review of sign in sheet contained containing the following signatures for: Medical Director, Director of Nursing, Assistant Director of Nursing, Minimum Data Set Nurse, Care Plan Nurse, Nurse Consultant, Social Worker, and Admission/Medicare Nurse. The SA validated no changes in the facility policy by record review with a revision date of 8/2013. The SA validated the current matrix and census by record review revealed there was no other [MEDICAL CONDITION] residents in the facility. The SA validated by record review a comprehensive care plan was developed for Resident #214, dated 02/17/2020, with interventions for [MEDICAL CONDITION] care, resident's [MEDICAL CONDITION] and RN/RT coverage 24 hours a day seven (7) days a week. The SA validated, on 02/20/2020 ,by interview the Medical Director revealed that staff was informed to contact the Medical Director for any negative findings. The SA validated that Resident #214 room contained the Ambu bag, oxygen saturation monitor, and the suction machine was at bedside by observation. The SA validated agency contract by record review, dated 02/18/2020, with an initial start date 02/21/2020 on the 3-11 shift. The SA validated the Resident #214 declined observation [MEDICAL CONDITION] care, on 02/20/2020, by interview with the DON. The SA validated by interview and record review the Respiratory Therapist assessed Resident #214, on 02/18/2020 at 6:30 PM, and determined the resident was competent and comfortable to perform her [MEDICAL CONDITION]. The SA validated by record review of the Medication Administration Record the change out of the tubing and mask is to be done on Thursdays. The SA validated all residents (Resident #214 was the [MEDICAL CONDITION] in the facility) at risk for aspiration related to [MEDICAL CONDITION] by interview and record review of the MAR and person- centered care comprehensive care plan. The SA validated by interview that the RT is available for consultation as needed. The SA validated that Resident #214 was capable of performing [MEDICAL CONDITION] by interview with the RT. The SA validated six (6) RN's was in-serviced by record review of sign in sheet on [MEDICAL CONDITION] care, signs and symptoms of respiratory distress. The SA validated 10 Licensed Practical Nurses was in-serviced on [MEDICAL CONDITION] care, signs and symptoms, of respiratory distress by interview and sign in sheet and interview. The SA validated thirteen Certified Nursing Assistance was in-serviced on Respiratory Distress signs and symptoms by interview and in-service attendance sign sheet. The SA validated interview and review of in-service attendance sign in sheet that six (6) Housekeeping/Laundry staff were in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet two (2) Human Resources staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet one (1) Occupational Therapist in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet one (1) Account Payable Staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet one (1) lawn service staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet two (2) Maintenance staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet two (2) Activities staff was in-serviced on Respiratory Distress sign and symptoms. The SA validated by interview and attendance sign in sheet one (1) Medical Record staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet one (10 Physical Therapist Assistant was in-serviced on Respiratory Distress sign and symptoms. The SA validated by interview and attendance sign in sheet one (1) Speech Language Pathologist was in-serviced on Respiratory Distress sign and symptoms.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure staff wore hair coverings during meal preparation and to ensure gaskets and doors of the refrigeration equipment were maintained in a sanitary condition to prevent possible cross contamination of food products, for three (3) of four (4) kitchen observations. This deficient practice had the potential to affect all residents who were served food from the kitchen. Findings include: Review of the facility's policy titled, Cleaning Instructions Refrigerator, dated 09/2004, revealed the equipment was to be maintained in a clean and sanitary condition and included specifically, Clean gaskets to remove dirt and mildew. Review of the facility's policy titled, Employee Work Practices, with a revision date of 10/2017, revealed food service employees were to follow sanitary practices to prevent the spread of food borne illness. The procedure of the policy included that employees were to maintain their hair to prevent the transfer of pathogens to food and employees and were to wear a clean hat or other hair restraint in the food production area. The restraint was to cover all hair to prevent the hair from contacting exposed food. An observation, with the Dietary Manager (DM), on 02/17/2020 at 10:45 AM, revealed the DM had on a hair net that did not cover all of her hair as she walked through the food preparation areas and Dietary Staff (DS) #6's hair net did not completely cover her hair while preparing beverages for the lunch meal in the food preparation area. Further observation revealed the entire length of the gasket (seals) and the edge of the door of the walk-in cooler (refrigerator) had a thick black buildup appearing substance. The walk-in freezer had an area approximately 17 inches in length along the gasket and edge of the door of a thick black buildup appearing substance. An observation of the facility's kitchen, on 02/18/2020 at 9:03 AM, revealed the DM was wearing a hair net that did not cover all of her hair, while in the food preparation area. The DM and DS #1 proceeded to stock the walk in-cooler and freezer with a shipment of food supplies. The entire length of the gasket (seals) and the edge of the door of the walk-in cooler (refrigerator) had a thick black buildup appearing substance, and the walk-in freezer had an area approximately 17 inches in length along the gasket and edge of the door of a thick black buildup appearing substance. While stocking the walk-ins both staff were touching the discolored black gaskets and sides of the walk-ins. The DM and DS #1 were observed holding doors open while removing a cart of beverages, and stocking food into the walk-ins. An observation of the facility kitchen, on 02/18/2020 at 11:30 AM, revealed DS #1 was wearing a hair net with a hole approximately 6 centimeters (cm) x 6 cm with hair clearly visible and uncovered in the food preparation area, and the Dietary Manager was wearing a hair net that did not cover all of her hair in the food preparation area. The gaskets on the walk-in freezer and walk-in refrigerator had not been cleaned. A review of the facility's Cleaning Schedule documentation revealed the walk-in refrigerator and the walk-in cooler were to be cleaned on Saturdays by Cook C. The documentation included handwritten tasks on separate notebook paper starting on 11/19/2019, that were initialed by the kitchen staff. Cleaning the walk-in cooler and freezer were not documented or initialed in the handwritten tasks. During an observation and interview, on 02/18/2020 at 12:45 PM, with the DM and DS#1, DS#2, DS#3, DS#4, DS#5, DS#6, and DS#7, revealed the DM, DS#1, and DS#3 had hair coverings that did not completely cover their hair. All eight staff agreed the hair coverings worn by the DM, DS #1, and DS #3, did not adequately cover their hair. The walk-in cooler and walk-in freezer were observed by all staff at this time and DS#1 and DS#4 stated the blackened areas on the gaskets and edge of the doors appeared to be mold. The DM stated it looked like mildew. All staff agreed the amount of the black buildup most likely happened over a period of time, more than a month. No staff recalled the last time they cleaned the doors or gaskets, but all stated they had cleaned the walk in-cooler and freezer. DS #4 stated, we usually concentrate on the inside. The DM stated the black buildup could contaminate the food and cause residents to get sick. DS #4 stated that the cleaning schedules for the kitchen equipment were posted on the bulletin board and that everyone who worked in the kitchen was responsible for cleaning the walk-in refrigerator and freezer. The DM confirmed this by stating the cleaning schedule rotates. All staff stated they had not noticed the doors or gaskets needing to be cleaned. An interview, on 02/20/2020 at 11:25 AM, with the DM confirmed the hair nets were not adequately covering dietary staff's hair, including her own. The DM stated that normally hair is adequately covered by the hair coverings available to staff, however, several staff members including herself had gotten their hair styled for the Valentine's Day holiday and the hair coverings weren't large enough to cover the extra braids and hair up-dos with braids and buns. The DM stated she didn't think the hair would fall out into the food. The DM stated she was responsible for making sure the cleaning schedules were done and she would check by observation. The DM stated she had honestly not checked to make sure each cleaning schedule task was written and initialed on the notebook paper staff were using to document their cleaning tasks. The DM stated she had told staff in a recent in-service on the cleaning schedule that if the cleaning task wasn't documented it didn't count. She felt that looking behind the staff was adequate to ensure tasks were done and she had not really had time to check the handwritten tasks with staff initials. The DM stated she had just not noticed doors or seals being dirty. The DM stated she did not recall having an in-service on hair coverings since she had started working at the facility six months ago. A review of the in-services completed in the past year confirmed there was an in-service in (MONTH) 2019 with the subject of Cleaning Schedule but no in-services with a topic of ensuring hair was adequately covered.

Based on observation, resident interview, family interview, staff interview, record review and facility policy review, the facility failed to provide nail care for a dependent resident for one of four (1 of 4) residents reviewed, Resident #50. Findings include: Review of the facility's policy titled, Care of Fingernails/Toenails, revised (MONTH) (YEAR), revealed the purpose of this procedure is to clean the nail bed to keep nails trimmed and to prevent infections. The General Guidelines included nail care includes daily checking and regular trimming. The policy Steps in the Procedure included: Date and time of nail care. Name and title of person who provided the nail care. The condition of the nail and nail bed. Any difficulties in cutting the resident's nails. Any problems or complaints made by the resident with his/her hands or feet or related to the procedure. If the resident refuses the treatment, state why and interventions taken. On 02/17/2020 at 12:15 PM, an observation revealed Resident #50's Family Member #1was trimming the resident's toe nails. Family Member #1 also said she had done the resident's fingernails. Family Member #1 said she cut the resident's nails because the staff does not cut them. Resident #50's Family Member #1 stated she was told by the facility that someone comes once a year to provide the nail care. On 02/27/2020 at 12:30 PM, Certified Nursing Assistant (CNA) #1 was interviewed and stated that hospice does Resident #50's nails. CNA #1 also stated the CNAs check the resident's nails during the bed baths. CNA #1 reported she has been assigned to the A Hall off and on the past couple of weeks, but has failed to notify the nurse or her partner that Resident #50's nails needed to be trimmed. CNA #1 said she did not like to cut the residents' nails because she always cuts the nails to short or to low all the way down. CNA #1 said she would tell her partner to cut the nails. CNA #1 did say when she sees lengthy nails she tells her partner. A review of Resident #50's Comprehensive Care Plan, dated 06/14/2017, revealed the resident required assistance with Activities of Daily Living (ADL) related to (r/t) impaired mobility and requires one person extensive assistance with personal hygiene. The Care Plan addressed the Problem/Need, dated 01/09/2020, Psoriasis to the left lower leg and the Approaches included keep nails clean and trimmed. Staff responsible was listed as Nursing/CN[NAME] On 02/17/20 at 12:35 PM, an observation revealed the Assistant Director of Nursing (ADON) measured Resident #50's left great toenail at 0.5 centimeter (cm) and the right great toenail at 0.5 cm. The ADON also observed the resident's smaller toe toenails were curling around the end of the toes on the right foot. An interview at this time with the ADON revealed they have a communication book, but the CNAs usually just tell the nurses of any concerns or observations they may have. Review of Resident #50's ADL Assistance and Support sheet from (MONTH) 1, 2020 to (MONTH) 17, 2020, revealed documentation the facility staff provided personal hygiene daily and bathing seven (7) out of the 17 days reviewed. The form did not specifically address nail care. During the follow up interview, with Resident #50, on 02/17/2020 at 12:54 PM, she reported her toes feel better since having her toenails trimmed and that before being trimmed, the long toenails were bothering her, she stated, they didn't feel good. CNA #2 was interviewed, on 02/19/2020 at 2:50 PM. CNA #2 said she worked the 2 PM to 10 PM shift and Resident #50 required assistance with her ADLs. CNA #2 stated total care in reference to the level of care the resident required and that Resident #50 was able to tell you what she wanted or needed. CNA #2 stated nail care should be done during the morning care (AM care). CNA #2 said there is a Rounds Sheet on the closet door, and the ADL care is listed in the Kiosk (computer system). CNA #2 also reported the bath, meals and hygiene are documented in the Kiosk. CNA #2 said when a resident refuses care we just accept it and come back later and try again or maybe get someone else to try and report it to the nurse. CNA #2 stated Resident #50 never refuses care. CNA #2 said we provide nail care anytime we go in and see they need grooming and then record it on the Kiosk. Licensed Practical Nurse (LPN) #1 was interviewed, on 02/19/2020 at 3:08 PM. LPN #1 revealed she worked the 2 PM to 10 PM shift. LPN #1 revealed she has the opportunity to observe the resident's feet on a daily basis. LPN #1 also said the CNAs come to the nurses for any questions or concerns with the residents. On 02/19/2020 at 4:00 PM, the Director of Nurses' (DON) interview revealed fingernails and toenails are not addressed on the weekly skin assessments/body audits. The DON said these audits are done for each resident weekly. The DON stated It's (nail care) not in there. It's intact or not intact (skin)''. The DON said nail care is part of what the staff are supposed to do. The DON stated a Podiatrist makes rounds and does nail care every three months. Review of Resident #50s last Podiatrist Note, dated 05/28/2019, revealed the podiatrist examined Resident #50's feet, and recommended return visit as needed or ordered by physician. Review of the Face Sheet revealed Resident #50 was admitted by the facility, on 10/27/2010, and re-admitted on [DATE], with the included [DIAGNOSES REDACTED]. Review of Resident #50 Quarterly MDS, with an ARD of 01/20/2020, revealed a BIMS score of 4, which indicated severe cognitive impairment. The MDS further revealed Resident #50 required extensive assistance with two person physical assist with bed mobility, transfers, dressing and toileting. Resident #50 required extensive assistance with one person physical assist with locomotion on and off the unit, and was totally dependent on staff for bathing. Resident #50 only required limited assistance with one person physical assist with eating. Resident #50's vision was impaired and she could only see large print, but not regular print in newspapers or magazines. The resident's speech and hearing was not impaired, and she was able to make herself understood to others and she was able to understand others.

Based on observation, interview, and policy review, it was determined the facility failed to ensure biologicals, medications, and other medical care supplies stored in two (2) of two (2) medication rooms were not expired. This had the potential to affect the census of 114 residents in the facility, who specifically have lab drawn, Intravenous (IV) therapy, or use catheters. Findings include: Review of the facility's undated policy, titled Storage of Medications, revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Additional review of the policy revealed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. The Administrator provided a written statement dated 04/11/19, that explained the facility did not have a policy and procedure related to the checking and removing of expired supplies. The facility's failure to remove expired medications, medical supplies, and biologicals allowed for the potential decrease in the effectiveness, sterility and safety of the items. 1. Observation, on 04/11/19 at 8:20 AM, of the Medication Room for the North, East, and South hallways, revealed two (2), 5-milliliter (ml) filled syringes labeled [MEDICATION NAME] Lock Flush, USP 500 units in 0.9% Sodium Chloride, which were stored in a red plastic caddy. Both filled syringes had an expiration date of 03/2019. There were six (6) additional 5-ml filled syringes labeled [MEDICATION NAME] Lock Flush, USP 500 units in 0.9 % Sodium Chloride, that were labeled with an expiration date of 12/2018. Continued observation revealed eight (8) green top specimen tubes, labeled BD vacutainer PST Gel and [MEDICATION NAME] Medium, stored in a plastic bag in another cabinet in the medication room. Each of the tubes were labeled with the expiration date of 01/31/19. In addition, there was one (1) unopened plastic bottle of Arthritis and Sports Penetrating Heat Rub, with no patient identifier, but with an expiration date of 11/2018. In the same cabinet there was one (1) [MEDICATION NAME] HFA inhaler, with no patient identifier, but with an expiration date of 09/2016. Interview on 04/11/19 at 8:22 AM, with the Assistant Director of Nursing (ADON), revealed the red plastic caddy supplies were used at a resident's bedside if there were orders to draw a blood specimen or for other types of Intravenous (IV) care. The ADON said the vacutainer tubes were for drawing blood samples for testing. She said she thought the green top tubes were used for drawing a sample for testing the resident's [MEDICAL CONDITION] Stimulating Hormone (TSH) level. Continued interview, on 04/11/19 at 8:30 AM, with the ADON, revealed blood work drawn at the facility would be processed at the local hospital, and blood work supplies such as vacutainers were supplied by the hospital. She said facility nursing staff would need to notify the local hospital when the facility needed those supplies replenished. She stated if a resident had an order for [REDACTED]. 2. Observation, on 04/11/19 at 8:45 AM, of the Medication Room for the West hall, revealed a Steri-Gear/Fig Leaf Brand Leg Bag for attachment to an indwelling catheter was stored in the medication room. The leg bag had an expiration date of 12/2018. In a drawer in the medication room, there were two (2) vials of Assure Dose High and Normal Level Control Solutions used for a Prime Blood Glucose Monitoring Systems (Glucometer used to test blood sugar). Both vials of control solution were labeled with the expiration date of 12/31/18. Interview, on 04/11/19 at 8:55 AM, with the Admissions Nurse present during the West hall Medication room observation, revealed she did not think the glucometer and control solutions stored in the drawer had been used, but she said they should not be in the medication room, and available for use. She said the nursing staff would not want to use expired control solutions to test a glucometer because the product could be faulty and result in an inaccurate reading when testing a glucometer's accuracy for measuring a resident's blood sugar. The Admissions Nurse stated she would not want to use any expired supplies for resident care, and that would include an item such as the expired urine collection bag (leg bag). She said the medication room should not contain any expired medications or supplies as they may no longer be effective for resident care. She said she was not sure who was responsible for stocking the medication rooms, or for disposing of expired products. Interview, on 04/11/19 at 10:50 AM with the Director of Nursing (DON), revealed nurses were supposed to discard expired supplies when found. She said before obtaining a medication or items needed to perform resident care, the nurse should always check the item's expiration date to prevent use of outdated products. She further explained there had not been a certain staff person assigned to routinely inspect the medication rooms and remove expired biologicals, medications, or other resident care supplies. However, she said there had been discussion about making that one of the assigned duties of the facility's Treatment Nurse. The DON stated every administrative nurse, which included the ADON, Minimum Data Set (MDS) Coordinator, the Care Plan nurse, and the Lead Charge Nurse were to make daily rounds in assigned areas of the facility, and the rounding responsibility included monitoring the medication rooms. She said if the nurses found expired medications, biologicals or supplies, they should remove them from the medication room(s). The DON said administrative nurses were not required to complete a check list or document the findings of their rounds, but they would verbally report any findings of concern. The DON said she was concerned that expired items were found in the medication rooms because if a nurse picked up an expired item such as a vacutainer tube, a syringe for flushing an IV line, or any other expired supply, the nurse should take time to go through all similar items, check the expiration dates, and remove any or all that were expired.

Based on record review, staff interview and facility policy review, the facility failed to discontinue the administration of [MEDICATION NAME] for a resident with a high [MEDICATION NAME] (PT)/ International Normalized Ratio (INR) for one (1) of four (4) residents reviewed for [MEDICATION NAME] therapy, Resident #5. Resident #5 received [MEDICATION NAME] four (4) days after a significantly high INR result and two (2) days after a verbal order to discontinue the [MEDICATION NAME]. Resident #5 was admitted to the hospital and received IV fluids and blood [MEDICAL CONDITION]. Findings included: A review of the facility policy Identifying and Managing Medication Errors and Adverse Consequences revealed the staff and practitioner would try to prevent medication errors and adverse medication consequences by determining the resident has no condition, history or sensitivities that would preclude use of that medication. Review of Resident #5's December 2015 physician's orders revealed an order for [REDACTED]. A review of Resident #5's lab report, dated 12/11/15, revealed an INR of 5.27. The identified normal results for prevention of [MEDICAL CONDITION] range from 2.0-3.0. The results of the INR were faxed to Attending Physician's office on Saturday morning, 12/12/15, but was not reviewed until Monday, 12/14/15. The faxed lab report revealed orders were documented (and called) to the facility by phone on 12/14/15 to hold [MEDICATION NAME] 12/14/15 and 12/15/15 and repeat the PT/INR on Wednesday, 12/16/15. A review of Resident #5's Medication Administration Record [REDACTED]. A review of Resident #5's hospital admission History and Physical (H & P) dated 12/27/15 revealed [DIAGNOSES REDACTED]. The H & P revealed Resident #5 was treated with blood and blood product [MEDICAL CONDITION] and intravenous (IV) fluids. In an interview on 02/04/15 at 1:45 PM, the Director of Nurses (DON) confirmed Resident #5 had received four (4) doses of [MEDICATION NAME] while INR was reported at a high level of 5.27 on 12/12/15. The DON said the lab results were not addressed until Monday, 12/14/15, but the orders were not written (on physician's orders) in the chart so the [MEDICATION NAME] was not held on 12/14/15 or 12/15/15. Interview with Resident #5's Attending Physician's Nurse on 2/5/16 at 9:10 AM confirmed she received orders from the physician and notified the facility to hold Resident #5's [MEDICATION NAME] for 12/14/15 and 12/15/15 and to repeat the INR on 12/16/15. A phone interview on 02/05/16 at 9:10 AM with Resident #5's Attending Physician revealed he had the facility send Resident #5 to the hospital because her lab results indicated volume depletion as well as blood loss. The Attending Physician stated Resident #5 had numerous problems but you can only assume the elevated PT/INR contributed to the GI bleed. Review of the facility's face sheet revealed the facility admitted Resident #5 on 12/04/12. Resident #5's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/08/15 revealed Resident #5's Brief Interview for Mental Status (BIMS) score was nine (9)indicating Resident #5 had moderate cognitive impairment.

Based on record review, staff interview and facility policy review, the facility failed to write, note, and follow a physician's verbal telephone order to hold [MEDICATION NAME] (a blood thinner) and repeat a laboratory (lab) test for one (1) of four (4) records reviewed for residents receiving [MEDICATION NAME] therapy, Resident #5. Resident #5 received [MEDICATION NAME] two (2) days after the verbal order to hold the medication was received. Resident #5 was later admitted to the hospital with [REDACTED]. Findings included: A review of the undated facility policy titled Telephone Orders revealed verbal telephone orders may be received by licensed personnel (Registered Nurse, Licensed Practical Nurse, Licensed Vocational Nurse, Pharmacist or Physician). The policy also revealed that orders must be reduced to writing by the person receiving the order and recorded in the resident's medical record. A review of the Mississippi Nursing Practice Act, dated 07/01/2010, revealed, Nursing Practice includes, but is not limited to, administration, teaching, counseling, delegation and supervision of nursing, and execution of the medical regimen, including the administration of medications and treatments prescribed by any licensed or legally authorized physician or dentist. A review of Resident #5's lab report for a PT ([MEDICATION NAME] time) and INR (International Normalized Ratio), dated 12/11/15, revealed the INR was 5.27 and identified by the lab as High. (The lab report indicated normal limits to prevent embolism ranged 2.0-3.0)The report revealed Licensed Practical Nurse (LPN) #1 documented the result was faxed on Saturday morning, 12/12/15, (to the resident's attending physician's closed office). The lab report revealed handwritten physician instructions that read orders given per phone today, hold [MEDICATION NAME] today 12/14 and tomorrow 12/15, repeat INR Wed (Wednesday), call us w/ (with) results. A review of the nurses' notes dated 12/12/15 did not reveal the abnormal high INR had been reported by phone to the attending physician. A review of Resident #5's Physician's Telephone Orders revealed no written orders dated 12/12/15 or 12/14/15. A review of a hospital admission History and Physical (H & P) dated 12/27/15 for Resident #5 revealed [DIAGNOSES REDACTED]. The H & P revealed the hospital treated Resident #5 with blood and blood product [MEDICAL CONDITION] and intravenous (IV) fluids. In an interview on 02/05/15 at 9:45 AM, LPN #1 confirmed she had not called the Attending Physician to report Resident #5's high INR level but had faxed the lab report on Saturday morning to the Attending Physician's closed office. LPN #1 said, I only call the high critical values to the doctor; Gamma lab calls the facility if it is a high critical. LPN #1 said she was not familiar with PT/INR lab values. In an interview on 02/04/16 at 1:45 PM, the Director of Nursing (DON) confirmed no written Physician's Telephone Orders dated 12/12/15 or 12/14/15 for Resident #5. The DON confirmed the abnormal high INR had not been called to Attending Physician and the orders on the lab report had not been reduced in writing and transferred to Resident #5's Physician's Telephone Orders. The DON said the Attending Physician's Nurse had called the facility on Wednesday, 12/16/15, to get the results of the PT/INR. The DON said the Attending Physician's Nurse said the telephone orders were given to a nurse named (Registered Nurse #3's name). The DON stated, We had a nurse (Registered Nurse #3's name) but she does not work here anymore; she resigned but did not work out her notice. The DON confirmed the INR result of 5.27 (reported on 12/11/15) was not addressed until Monday (12/14/16) and confirmed the facility continued to administer Resident #5's [MEDICATION NAME] 5 milligrams (mg) on 12/12/15, 12/13/15, 12/14/15 and 12/15/15. Interview with Resident #5's Attending Physician's Nurse on 2/5/16 at 9:10 AM confirmed Resident #5's labs were reviewed on 12/14/15. The Nurse stated she received orders from the physician and notified the facility to hold Resident #5's [MEDICATION NAME] for 12/14/15 and 12/15/15 and to repeat the INR on 12/16/16. The Nurse stated the facility should have called the physician with the elevated INR and not faxed the results. In an interview on 02/05/16 at 12:30 PM, the DON stated the information for lab values are on the lab reports and any abnormal lab should be easily recognized; a system is in place and that PT/INR for Resident #5 should have been called in (to the physician) but the true breakdown happened when the order did not get written to hold the [MEDICATION NAME] and repeat the lab. On 02/05/16 at 9:10 AM a phone interview with Resident #5's Attending Physician revealed that he gave orders for the facility to send Resident #5 to the hospital (on 12/27/15)because the lab results indicated volume depletion as well as blood loss. The Attending Physician said Resident #5 had numerous problems but assumed the elevated PT/INR contributed to the GI bleed. The Physician stated an INR of 5+ should be called to him or the physician on call. Review of the facility's face sheet revealed the facility admitted Resident #5 on 12/04/12. Resident #5's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/08/15 revealed Resident #5's Brief Interview for Mental Status (BIMS) score was nine (9) indicating Resident #5 had moderate cognitive impairment.

Based on record review, staff interview and facility policy review, the facility failed to follow the care plan for [MEDICATION NAME] therapy for one (1) of four (4) records reviewed for residents receiving [MEDICATION NAME] therapy, Resident #5. Resident #5's laboratory (lab) test, dated 12/11/15, indicated a high/abnormal INR (International Normalized Ratio) and the physician was not notified per phone and did not receive results of the test for two (2) days. As a result of not following the care plan and notifying the physician with the abnormal results, Resident #5 continued to receive [MEDICATION NAME] therapy. Resident #5 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Findings included: A review of the facility policy Care Plans-Comprehensive, revised August 2006, revealed an individualized Comprehensive Care plan was developed for each resident to meet the resident's medical, nursing mental and psychological needs. The care plan was designed to incorporate identified problem areas and risk factors associated with identified problems. A review of Resident #5's care plan, dated 12/14/12, revealed Resident #5 was at risk for bleeding/bruising related to [MEDICATION NAME] therapy. Approaches to the [MEDICATION NAME] therapy included to obtain [MEDICATION NAME] Time (PT) and International Normalized Ratio (INR) as ordered by the physician and to notify the physician of any negative findings. A review of Resident #5's lab report, dated 12/11/15, revealed an abnormally high INR of 5.27. Licensed Practical Nurse (LPN) #1 documented she faxed this report (to Attending Physician's office) on Saturday morning, 12/12/15, but did not notify Attending Physician by phone on 12/12/15 of the high lab result. The lab report revealed the physician did not review the results until 12/14/15, when orders were documented on the report to hold the [MEDICATION NAME] for 12/14/15 and 12/15/15 and repeat the PT/INR on 12/16/15. Review of Resident #5's Electronic Medication Administration Record [REDACTED]. A review of a hospital admission History and Physical (H & P) dated 12/27/15 for Resident #5 revealed [DIAGNOSES REDACTED]. The H & P revealed the hospital treated Resident #5 with blood and blood product [MEDICAL CONDITION] and intravenous (IV) fluids. On 02/05/16 at 9:10 AM a phone interview with Resident #5's Attending Physician revealed an INR of 5+ should be called to him or the physician on call. The Attending Physician said Resident #5 had numerous problems but assumed the elevated PT/INR contributed to the GI bleed because the lab results indicated volume depletion as well as blood loss. An interview on 02/05/15 at 2:35 PM LPN #4 said she did not refer to the care plan about lab reports. LPN #4 said, It's nursing 101 to call the doctor if the lab is abnormal. LPN #4 said the nurses could call the attending physician anytime and most of the time the physicians call back right away. LPN #4 said if the attending physicians did not call back right away, the medical director was always available. Review of the facility's face sheet revealed the facility admitted Resident #5 on 12/04/12. Resident #5's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/08/15 revealed Resident #5's Brief Interview for Mental Status (BIMS) score was nine (9)indicating Resident #5 had moderate cognitive impairment.

Based on record review, staff interview and facility policy review, the facility failed to provide [MEDICATION NAME] therapy in a manner to reduce risks of bleeding for one (1) of four (4) residents reviewed for [MEDICATION NAME] (blood thinner) therapy, Resident #5. Resident #5 received [MEDICATION NAME] four (4) days after abnormal laboratory (lab) results were received and two (2) days after the physician had given verbal orders to hold the [MEDICATION NAME]. Resident #5 was later admitted to the hospital with [REDACTED]. Findings included: A review of the facility policy Identifying and Managing Medication Errors and Adverse Consequences revealed in the event of a clinically significant medication consequence, nursing staff would implement and follow physician's orders, monitor and document the resident's condition and response to any corrective interventions for at least 24 hours or as otherwise directed. Review of Resident #5's December 2015 physician's orders revealed an order for [REDACTED]. A review of Resident #5's lab report for a PT ([MEDICATION NAME] Time) and INR (International Normalized Ratio), dated 12/11/15, revealed the INR was 5.27 and identified by the lab as High. Licensed Practical Nurse (LPN) #1 documented she faxed the report (to Attending Physician's closed office) on Saturday morning, 12/12/15, but failed to notify the Attending Physician by phone. The lab report revealed the Attending Physician reviewed the PT/INR report on Monday, 12/14/15 with documented orders (the Attending Physician's Nurse phoned the facility) to hold [MEDICATION NAME] 12/14/15 and 12/15/15, obtain a PT/INR on Wednesday 12/16/15, and call the results to the Attending Physician's office. A review of the Physician's Telephone Orders for Resident #5 revealed no written orders dated 12/14/16 to hold the [MEDICATION NAME] 12/14/15, 12/15/15 and obtain a PT/INR on 12/16/15. Review of Resident #5's Electronic Medication Administration Record [REDACTED]. A review of Resident #5's Physician's Telephone Orders dated 12/26/15 revealed an order to obtain a Complete Metabolic Profile, Complete Blood Count, [MEDICAL CONDITION] Stimulating Hormone, PT/INR, Uric Acid as diagnostic lab tests to determine the cause of excessive weight loss and change of consciousness. Review of Resident #5's telephone orders dated 12/27/15 revealed an order to send Resident #5 to the local hospital related to abnormal lab values obtained on 12/26/15. A review of Resident #5's hospital admission History and Physical (H & P) dated 12/27/15 revealed the Attending Physician's evaluation of Dehydration, Acute or [MEDICAL CONDITION], Gastrointestinal (GI) bleeding and severe [MEDICAL CONDITION] related to the other findings. Review of the H & P revealed Resident #5 was treated with blood and blood product [MEDICAL CONDITION] and intravenous (IV) fluids. Interview with Resident #5's Attending Physician's Nurse on 2/5/16 at 9:10 AM confirmed the lab results for Resident #5's PT/INR was reviewed on 12/14/16 per fax. The Nurse stated she received orders from the physician and notified the facility to hold Resident #5's [MEDICATION NAME] for 12/14/15 and 12/15/15 and to repeat the INR on 12/16/16. The Nurse stated the facility should have called the physician with the elevated INR and not faxed the results. In an interview on 02/04/16 at 1:45 PM Director of Nursing (DON) confirmed the INR result of 5.27 was not addressed until Monday, 12/14/16, and said the phone order was not written as a telephone order in Resident #5's medical record. The DON confirmed Resident #5 received [MEDICATION NAME] 5 milligrams (mg) on 12/12/15, 12/13/15, 12/14/15 and 12/15/15. During a phone interview on 02/05/16 at 9:10 AM, the Attending Physician said when he reviewed Resident #5's lab reports he had the facility send Resident #5 to the hospital because her lab results indicated volume depletion as well as blood loss. The Attending Physician said Resident #5 had numerous problems but you can only assume the elevated PT/INR contributed to the GI bleed. The Attending Physician said he had treated Resident #5 for over [AGE] years and it was probable Resident #5 had required blood [MEDICAL CONDITION] in the past but he could not verify it without reviewing her records. Review of the facility's face sheet revealed the facility admitted Resident #5 on 12/04/12. Resident #5's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/08/15 revealed Resident #5's Brief Interview for Mental Status (BIMS) score was nine (9)indicating Resident #5 had moderate cognitive impairment.

CI MS # Based on interviews, records review, and facility policy review, the facility failed to provide the necessary care and services required during a diabetic emergency to ensure the highest practicable physical well-being based for one (1) of four (4) sampled residents (Resident #1). This was evidenced when staff failed to adequately assess Resident 1's acute change in condition. This resulted in her prolonged exposure to critically low blood glucose level, a facial droop, altered mental status, and the need for emergency medical care, with the likelihood of continued medical decline if left untreated. Findings include: According to a review of the American Diabetic Associations website (<http://diabetes.niddk.nih.gov/dm/pubs/[DIAGNOSES REDACTED]>) on 02/19/2014, "[DIAGNOSES REDACTED] is a condition characterized by abnormally low blood glucose," usually defined by a blood glucose level of less than 70 milligrams per deciliter (mg/dL). Further, when left untreated, severe [DIAGNOSES REDACTED] can cause [MEDICAL CONDITION], coma, and even death. Review of the facility's policy entitled "Change in a Resident's Condition or Status", with a revised date of 04/2007, revealed "if a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted." Resident #1 Review of the face sheet dated 01/14/2014 revealed the facility admitted Resident #1 on 3/3/08, an [AGE] year old female with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE] revealed Resident #1 was diagnosed with [REDACTED]. Review of monthly physician orders [REDACTED]. Review of the resident's standing orders, dated 04/09/2013, revealed orders for staff to follow if Resident #1 experienced low FSBG. First, staff needed to hold all insulin. Second, staff needed to administer orange juice if Resident #1 could swallow or immediately administer [MEDICATION NAME] (medication to increase blood sugar levels) if Resident #1 could not swallow. Third, staff needed to recheck the FSBG in 15 minutes. Forth, staff needed to administer [MEDICATION NAME] if the FSBG remained below 60 mg/dL. Fifth, staff needed to recheck the FSBG in 15 minutes. Sixth, staff needed to administer intravenous [MEDICATION NAME] (sugar) if the FSBG remained below 60 mg/dL. Seventh, staff then needed to recheck the FSBG in 15 minutes and contact the physician for further instruction if the FSBG level remained below 60 mg/dL. Review of a care plan, dated 02/25/2013, revealed staff at times understood Resident #1's speech, and that she understood simple, direct communication. Her "Diabetes" care plan initiated 08/07/2012 revealed Resident #1 required ongoing staff assessments for [DIAGNOSES REDACTED], with all signs or symptoms recorded in the medical record and reported to the physician. Review of nursing notes dated 01/01/2014 at 5:52 AM, revealed staff obtained a FSBG level of "53" , treated Resident #4 with orange juice, then 30 minutes later rechecked her FSBG, and found it was "60." Despite the unusually low initial FSBG, staff failed to document any additional assessment before, during, or after her treatment. A comprehensive review of the medical record failed to provide any documented evidence to suggest nursing staff had followed the standing orders to treat the low FSBG of 53 mg/DL. Review of nursing notes dated 01/05/2014 at 6:32 AM, revealed Resident #1 "exhibited S&S (signs and symptoms) of [DIAGNOSES REDACTED]" with a FSBG level of "47." Staff treated Resident #1 with an intramuscular injection of [MEDICATION NAME] (a medication used to increase blood sugars), but failed to document what hypoglycemic signs and symptoms occurred or if these symptoms resolved after the treatment. A comprehensive review of the medical record failed to provide any documented evidence to suggest nursing staff had followed the standing orders to treat the low FSBG of 47 mg/dL. Review of nursing notes dated 01/05/2014 at 10:49 PM revealed staff obtained a FSBG level of "41" , treated Resident #1 with orange juice, but failed to document her assessment before the treatment. A comprehensive review of the medical record failed to provide any documented evidence to suggest nursing staff had followed the standing orders to treat the low FSBG of 41 mg/DL. Review of nursing notes dated 1/05/2014 at 11:16 PM revealed staff obtained a FSBG level of "43" at 10:00 PM, treated Resident #1 with [MEDICATION NAME], then rechecked her FSBG at 11:00 PM, and found it was "119." Despite the unusually low FSBG, staff failed to document Resident #1's assessment before, during, or after the treatment. A comprehensive review of the medical record failed to provide any documented evidence to suggest nursing staff had followed the standing orders to treat the low FSBG of 43 mg/dL. Review of nursing notes dated 01/06/2014 at 4:03 AM revealed Resident #1 was lethargic with a FSBG level of "46" , staff treated her with [MEDICATION NAME], but failed to document Resident #1's assessment after her treatment. A comprehensive review of the medical record failed to provide any documented evidence to suggest nursing staff had followed the standing orders to treat the low FSBG of 46 mg/dL. Review of nursing notes dated 01/10/2014 at 1:58 PM revealed family called staff to the bedside because "something was not right with her mother." The notes revealed Resident #1 had a right side facial droop and elevated blood pressure. A comprehensive review of the medical record failed to provide any documented evidence to suggest staff obtained a FSBG on Resident #1. During an interview on 02/14/2014 at 12:45 AM, Licensed Practical Nurse (LPN) #1 verified she was the primary nurse assigned to care for Resident #1, during the day shift on 01/10/2014. LPN #1 said, she knew the resident was an insulin dependent diabetic, because she administered her insulin the same morning. LPN #1 remembers the resident's daughter stepped from the bedroom into the hallway and asked for help because something was wrong with her mother at approximately 12:50 PM. LPN #1 immediately responded to the bedside with Registered Nurse (RN) #1. She found Resident #1 lying in bed, with a right side facial droop. When questioned, LPN #1 could not say if Resident #1 made any sounds or responded to any external stimuli, but said her eyes were open. LPN #1 could not hear a blood pressure, did not feel for a pulse, did not obtain a temperature, but knew Resident #1 was still breathing. LPN #1 said, RN #1 then checked the blood pressure and it was high. She left the bedroom and texted the physician from her private cell phone. LPN #1 said she did not attempt to get a FSBG level, because the resident's symptoms suggested stroke not low blood sugar. On 02/14/2014 at 12:45 PM review of the text messages documented in LPN #1's private phone dated 01/10/2014. The messages revealed nursing asked the physician to have Resident #1 transferred to the local hospital for an elevated blood pressure. Untimed, the physician responded in text, saying an isolated blood pressure elevation did not warrant a hospital transfer. During an interview on 02/14/2014 at 1:15 PM, RN #1 validated the above interview with the same recollection of events for 01/10/2014. RN #1 said the blood pressure she obtained was elevated and faint. Further, she did not feel for a pulse or obtain a temperature, but knew Resident #1 was breathing. She too noticed the right side facial droop and identified it as a new finding for Resident #1. Without any further assessment or monitoring, RN #1 said she left Resident #1 and returned to her office, while LPN #1 called the physician for a transfer order. Shortly thereafter, RN #1 returned to the hallway, because Resident #1's family got loud and upset when the physician declined a hospital transfer. She denied conducting any further assessments or monitoring, for the significant change seen in Resident #1. RN #1 said, she calmed the family, told LPN #1 to contact the physician again, and left for her office. When asked if she obtained a blood glucose level, RN #1 said, "No Ma'am, because I don't work with them every day it never crossed my mind that she was a diabetic." Continued review of the same group of text messages documented in LPN #1's private phone dated 01/10/2014 at 1:00 p.m., revealed LPN #1 contacted the doctor a second time, and notified him of the resident's facial droop. The physician then ordered a hospital transfer for Resident #1. During the same interview at 02/14/2014 at 12:45 PM, LPN #1 said, the second she received the physicians text that approved the resident's transfer, she called for an ambulance. Review of the "Pre-hospital Care Report", dated 1/10/2014, revealed the initial contact made by the facility occurred at 1:21 PM. Emergency medical personnel documented they arrived to the facility at 1:29 PM, where they found Resident #1 "awake but unresponsive" with a facial droop. EMS obtained a FSBG of 18 mg/dL and treated her with intravenous [MEDICATION NAME]. Review of the local hospital Emergency Department Records for Resident #1 dated 01/10/2014, revealed Resident #1's facial droop had resolved and though disoriented she could localize pain. Blood drawn at 2:20 PM, revealed Resident #1 had a blood glucose level of 184 mg/dL. During an interview on 02/01/2014 at 2:00 PM, Director of Nursing (DON) #1 reviewed the medical record for Resident #1. She said FSBG levels were a necessary part of insulin dependent diabetic assessments, but staff needed to record additional objective and subjective data. DON #1 said the facility required staff to assess each resident before treatment of [REDACTED]. DON #1 said the facility required staff to assess each resident after treatment of [REDACTED]. She was unable to explain why staff did not follow the standing orders established for Resident #1's low blood sugars. DON #1 then reviewed Resident #1's change in condition documented by nursing on 01/10/2014, and said a FSBG was "the first thing staff needed to do." She was unable to explain why staff did not complete a FSBG. Additionally, she felt the facial droop identified in the record indicated nursing needed to do a thorough neurological assessment to determine treatment needs. DON #1 was unable to find a thorough neurological assessment by nursing in the medical record.

CI MS #9655 Based on observation, record review and staff interview, the facility failed to ensure that measures put into place to prevent Resident #1 from receiving an injury were followed as evidenced by the resident being transferred with one person assist instead of a total lift resulting in a fall with a fracture and Resident #2 failed to have a clip alarm on to the Resident to alert staff to when she was going to stand and she experienced a fall resulting in a fractured hip. This was for two (2) of four (4) residents reviewed (Resident #1 and Resident #2). Findings Include: Resident #1 Review of Resident #1's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/09/11 revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 which was defined as Cognitively Intact. Resident #1's transfer was coded as extensive assistance with two (2) persons to physically assist. Observation of Resident #1 was conducted on 10/11/11 at 04:35 p.m. revealed the resident to be in a wheelchair. She was just returning from dialysis and two (2) Certified Nursing Assistants (CNA's) took her to her bedroom and transferred her to her bed with the aide of a total body lift with a sling made for amputees. Review of the Physician order [REDACTED]. A handwritten order was reviewed that read "6/13/11 Total body lift for safe transfers due to decrease mobility; Floor mat to right side of bed R/T (relate to) falls". Review of a facility document titled "Resident Assessment for Lift/Transfers/Assistance" was dated 07/07/11. The information on that document indicated that Resident #1 was dependent on staff for 50% or more assistance. She could not bear weigh, and did not have the upper extremity strength to support her weight during transfer. Resident #1 was noted to be cooperative and able to follow simple commands. Her weight was 151 pounds and her height was 65 inches (5 foot 5 inches). In the section "Care Plan" it was noted that a total body lift with the aide of 3 staff was to be used for transfers from bed to chair, chair to toilet and chair to chair. Review of the Activities of Daily Living (ADL) form for July 11 for Resident #1 revealed "Assistive/Protective Devices" to include a total body lift. Documentation on the ADL Assistance and Support document for Resident #1 for July 2011 revealed on July 30, 2011 a "2" was noted in the column for transfer on the evening shift. The "2" was defined as Limited assistance-resident is highly involved in activity; staff provide guided maneuvering of limbs or other non-weight -bearing assistance". Review of a document provided by the facility revealed an incident occurring on 07/30/11 at 10:10 p.m. for Resident #1. The "Description of Incident and Treatment Administered" was "Called to room by CNA's observed resident lying supine in bed, 0 (no)opened areas or bleeding but c/o (complaints of) severe pain of (R) {right} stump (BKA) {below the knee amputation}, CNA's stated resident was being transferred to be, the bed moved & resident landed on (R) stump on floormat. Resident sent to (name of hospital) for evaluation." Review of a "Physician Clinical Record" for Resident #1 revealed that on 07/30/11 she was seen by the physician at the hospital at 2253 (10:53 p.m.) for "Pt (patient) is a bil (bilateral) amputee who has ESRD (End Stage Renal Disease) and was being transferred from wheelchair to bed when she fill and hurt her right hip". Right Hip xray revealed "Displaced intertrochanteric fracture of the right hip." "Fracture of the proximal right femoral shaft". Review of a "Operation Record" for Resident #1 with a date of 08/01/11 revealed: "Preoperative Diagnosis: [REDACTED]. *1. Right trochangeric femur fracture. *2. History of right below-the-knee amputation. *3. History of left above-the-knee amputation. Operation: Trochanteric femoral nailing of the right intertrochangeric femur fracture." Review of a facility document titled "Report of Investigation" for Resident #1 revealed: "Date of Occurrence 7/30/11 Time of occurrence 1010 pm" "Type of occurrence requiring investigation: fall c hip fx (fracture)" "Detailed description of incident: CNA attempting to transfer resident from wheelchair to be independently, the bed moved, causing resident to slid down to floor Stumps Landing on mat beside bed." Review of another facility document titled "Report of Investigation" for Resident #1 revealed: "Details of Investigation: CNA statements reviewed which showed that (CNA #1) was transferring resident without a lift & 1 (one) person assist. from the wheelchair to the bed. CNA had resident grab Trapeze bar and grabbed residents arm & pants to transfer her. The bed moved and the resident slid down to floor off of bed landing on mat beside bed on her stumps. Resident was sent to ER (emergency room ) at (name of hospital) and transferred to (name of hospital) c fracture hip. (Bed was in locked position). Outcome of investigation CNA suspended-pending termination. Resident was transferred from (name of hospital) to (name of hospital) & underwent hip surgery". A statement written and signed by CNA #1 on 07/30/11 revealed: "I,(name), was assisting (Resident #1) with going to bed and while doing this she grabbed hold of her trapeze bar and I grabbed her arm and pants and as she stood up the bed started to move and she slid off the the bed while still holding the trapeze bar and I was still holding her arm and pants. The nurse was notified." A Nurses Note written on 07/30/11 at 10:25 p.m. revealed "Resident out to (name of hospital) for evaluation of (R) stump, resident being put in bed by CNA, while transferring resident bed moved resident was still holding trapezed bar + (and) leg was slightly twisted while C.N.A. was holding resident, resident states "it hurts, but I don't want to go to the hospital." "1025 p cont...Resident cont (continued) to complain of leg pain, MD (Medical Doctor) notified order to sent resident to ER for evaluation RP (Responsible Party) notified." A statement written and signed by CNA #2 revealed: "I, (CNA #2), was in (name of residents) checking to see if they was wet (making rounds) when I heard someone screaming. I know and intered (entered) (Resident #1) room and it was (Resident #1) on the floormat (CNA #1) was standing in there with her. I asked what happened and she told me (Resident #1) slid out the bed because it wasn't locked and she told me to go get the nurse. I went and got the nurse and we helped her in bed." Review of a facility policy "Modified Lifting Policy" with no date of implementation revealed: "Failure to utilize a mechanical resident lift when the use of this equipment is indicated in resident's assessments could result in disciplinary action up to and including termination of employment." Interviews with Certified Nursing Assistant (CNA) #1 and #2 were unable to be conducted as the numbers provided did not work or the person did not return messages left. Interview with LPN #1 was conducted on 10/11/11 at 05:15 p.m. and she stated that she was at the nurses desk when a CNA reported to her that Resident #1's leg was hurting. CNA stated that they were putting her in the bed and she slipped -said stump landed on mattress. When LPN #1 went into the bedroom of Resident #1 the resident was on the bed and stated to the nurse that "I hit floor". The nurse assessed the site and the resident stated "Oh, Oh, it hurts". LPN #1 stated that Resident #1 was alert and know what she is talking about. LPN #1 stated that Resident #1 was to be transferred with a total body lift because she could not bear weight even with a prosthesis. Interview with Resident #2 on 10/12/11 at 01:15 p.m. revealed that CNA #1 was transferring her without the assistance of any other staff or the aide of the total lift. She stated that it was common for staff to transfer her without the aide of the lift. She stated that she would stand on her prosthetic leg and pivot to turn toward the bed. She said she fell on the floor and CNA #1 and CNA #2 put her on the bed. Since she had the surgery on her hip she has been unable to wear the prosthesis. Resident #2 Review of Resident #2's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's MDS with an ARD of 09/27/11 revealed the BIMS score to be 7 which indicated that she was severely impaired cognitively. The bed mobility and transfer was coded as extensive assistance with two persons physical assist. Observation of Resident #2 was not conducted as she had transferred to another facility when she was discharged from the hospital. Review of Resident #2's "Assessment Risk for Falls" dated 09/20/11 revealed a score of "8" which indicated the resident was at high risk for falls. Review of the Therapy Screening Forms revealed that Resident #2 had experienced falls on 09/23/11 and 09/26/11. Review of an Incident Report dated 10/04/11 at 07:00 a.m. revealed, "Resident was in the dining room awaiting breakfast to be severed (served) and decided she was going to go help another resident and fell to the floor. I went in the dining room resident was lying on her left side on the right side of table. Resident complained of hip and leg pain when asked was she hurting anywhere. No open area noted. Emergency services was called to transport resident to hospital for evaluation and X-Ray". The incident report or investigation did not reveal any information about a clip alarm. Review of the computerized Physician order [REDACTED]. Review of a document titled "APS" dated October 2011 for Resident #2 revealed "May use body alarm while in bed and wheelchair to alert staff of unassisted transfer Start Date: 9/24/11". There was no documentation on the 07:00 a.m. to 03:00 p.m. shift that the alarm was on the resident. Review of a statement written and signed by CNA #6 on 10/04/11 revealed: "I, (name) CNA entered (name of facility) @ (at) 5:30 AM & Resident (#2) was already dressed & up in Dining Room having coffee. I went on North Hall to help get up Residents & (Resident #2) came down to her room & stated she was going to lay down. I told Res it was almost time for Breakfast. Res went back to dining. I proceded (proceeded) to push other Res to dining room. I had to redirect (Resident #2) a couple of times to stay at her table & keep w/c (wheelchair) locked. I returned to keep helping other Res in dining room & a male Res c poor sight needed help to get to his table I had my back to (Resident #2) at this time & suddenly I hear a commotion behind me & when I turned around (Resident #2) was on the Floor & I called for A Nurse. I asked (Resident #2) what Happened & she stated she was trying to help tablemate up to the table." Interview with CNA #6 on 10/12/11 at 12:40 p.m. confirmed that she wrote the document referenced above and confirmed the content. She stated that it was brought to her attention by LPN #4 that the alarm was not on Resident #2 as it should have been and she told the nurse that whoever got Resident #2 up did not place the alarm on her. She stated that the way she knew Resident #2 fell was when she heard her fall on floor. Interview with LPN #4 on 10/12/11 at 01:05 p.m. confirmed that Resident #2 did not have the alarm in place when she experienced the fall in the Dining Room on 10/04/11. She confirmed that she did not document that information on the incident report nor report that information to the DON or Administrator for investigation.

Based on record review, staff interview and policy review, the facility failed to ensure that a thorough investigation was conducted for Resident #2 who experienced a fall and the alarm that was ordered by the physician to alert staff when the resident was getting up was not in place when the resident fell . This was for one (1) of four (4) residents reviewed for falls (Resident #2). Findings Include: Review of Resident #2's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/27/11 revealed the Brief Interview for Mental Status (BIMS) score to be 7 (seven) which indicated that she was severely impaired cognitively. The bed mobility and transfer was coded as extensive assistance with two persons physical assist. Observation of Resident #2 was not conducted as she had transferred to another facility when she was discharged from the hospital. Review of Resident #2's "Assessment Risk for Falls", dated 09/20/11, revealed a score of "8" (eight) which indicated the resident was at high risk for falls. Review of the Therapy Screening Forms revealed that Resident #2 had experienced falls on 09/23/11 and 09/26/11 and 10/04/11. Review of an Incident Report dated 10/04/11 at 07:00 a.m. revealed, "Resident was in the dining room awaiting breakfast to be severed (served) and decided she was going to go help another resident and fell to the floor. I went in the dining room resident was lying on her left side on the right side of table. Resident complained of hip and leg pain when asked was she hurting anywhere. No open area noted. Emergency services was called to transport resident to hospital for evaluation and X-Ray". The incident report or investigation did not reveal any information about a clip alarm. Review of the computerized Physician order [REDACTED]. Review of a document titled "APS", dated October 2011, for Resident #2 revealed "May use body alarm while in bed and wheelchair to alert staff of unassisted transfer Start Date: 9/24/11". There was no documentation on the 07:00 a.m. to 03:00 p.m. shift that the alarm was on the resident. Review of a statement written and signed by CNA #6 on 10/04/11 revealed: "I, (name) CNA entered (name of facility) @ (at) 5:30 AM & Resident (#2) was already dressed & up in Dining Room having coffee. I went on North Hall to help get up Residents & (Resident #2) came down to her room & stated she was going to lay down. I told Res it was almost time for Breakfast. Res went back to dining. I proceded (proceeded) to push other Res to dining room. I had to redirect (Resident #2) a couple of times to stay at her table & keep w/c (wheelchair) locked. I returned to keep helping other Res in dining room & a male Res c (with) poor sight needed help to get to his table I had my back to (Resident #2) at this time & suddenly I hear a commotion behind me & when I turned around (Resident #2) was on the Floor & I called for A Nurse. I asked (Resident #2) what Happened & she stated she was trying to help tablemate up to the table." Interview with CNA #6 on 10/12/11 at 12:40 p.m. confirmed that she wrote the document referenced above and confirmed the content. She stated that it was brought to her attention by LPN #4 that the alarm was not on Resident #2 as it should have been and she told the nurse that whoever got Resident #2 up did not place the alarm on her. She stated that the way she knew Resident #2 fell was when she heard her fall on floor. Interview with LPN #4 on 10/12/11 at 01:05 p.m. confirmed that Resident #2 did not have the alarm in place when she experienced the fall in the Dining Room on 10/04/11. She confirmed that she did not document that information on the incident report nor report that information to the DON or Administrator for investigation.