Every finding on record at Memorial Woodland Village Nursing Center

Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies, specifically, the facility was cited for failing to properly store, label, and date food items and discard expired food on an annual recertification survey on 2/29/24 and was cited again for the same deficiencies during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of seven (7) deficiencies cited. F812. Findings Include: Record review of the facility's policy, Quality Assurance and Performance Improvement, dated 2/1/2025, revealed, .It is the policy of this facility to .maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life .Policy Explanation and Compliance Guidelines .2. The QAA Committee shall .c. Develop and implement appropriate plans of action to correct identified quality deficiencies . Record review of the Provider History Profile revealed the facility received a citation for F812-Food Procurement, Store/Prepare/Serve Sanitary on the survey conducted on 2/29/24. Record review of the CMS-2567 (a record that identifies the federal regulation in violation and describes the findings of noncompliance and the facility's plan of correction), with a survey date of 2/29/2024, revealed the facility received a citation for F812, .Based on observation, staff interview, record review, and facility policy review, the facility failed to store food .in accordance with professional standards for food service safety related to food items not dated with a use-by-date, no identifying label, expired foods, improperly stored and exposed food for one (1) of three (3) kitchen observations . During the current recertification survey, the facility failed to follow safe food storage and handling practices on one (1) of four (4) survey days. Specifically, the facility failed to properly store, label, and date frozen food items that were opened. discard expired bakery rolls and refrigerate lemon juice in accordance with manufacturer instructions On 6/26/25 at 2:31 PM, during an interview with the Administrator, she confirmed that during the facility's last recertification survey, they were cited under F812 for failing to date and label food items, specifically applesauce, orange juice, and apple juice. She acknowledged that the same concern was identified again during the current survey. She explained that, following the previous citation, the facility's Quality Assurance and Performance Improvement (QAPI) Committee implemented a corrective plan, which included weekly audits conducted by the dietitian or kitchen manager for four (4) weeks, followed by monthly audits for three (3) months, beginning on 3/4/24. She confirmed that the QAPI Committee meets monthly, although the facility policy only requires quarterly meetings, and those meetings include the full interdisciplinary team and medical staff, including the Medical Director. The Administrator stated that additional in-service training could be provided to reinforce expectations, and that the Quality Assurance(QA) nurse could conduct follow-up with dietary staff. She also noted that the dietary team currently in place is new and many were not employed during the time of the last survey, emphasizing the need for education on proper procedures and regulatory requirements.

Based on observation, interview, and facility policy review, the facility failed to follow safe food storage and handling practices on one (1) of four (4) survey days. Specifically, the facility failed to properly store, label, and date frozen food items that were opened, discard expired bakery rolls and refrigerate lemon juice in accordance with manufacturer instructions. Findings included: A record review of the facility's policy titled, Food and Supply Storage dated 01/2025, revealed, .All food .used in food preparation shall be stored in such a manner as to prevent contamination .Procedures .Foods past the use by, sell by, best-by or enjoy by date should be discarded. Cover, label and date unused portions and open packages .Frozen Storage .Label both the bind and the lid. Use food grade plastic bags for food storage .Wrap food tightly to prevent cross contamination . On 6/23/25 at 8:23 AM, during an observation and interview with the Dietary Manager, there was one (1) tray of [NAME] Artesano Bakery Sausage Rolls in the dry goods storage room with an expiration date of 6/20/25. The Dietary Manager stated he was unaware when the expired rolls had last been served. In the freezer, there was a package of breaded okra that was open, not repackaged, and not labeled. A bag of frozen biscuits was open without proper repackaging or dating. A bag of frozen chicken tenders was stored in a torn clear plastic bag that had been rolled down and was neither repackaged, labeled, nor dated. The Dietary Manager acknowledged that dietary aides routinely open large food packages, use a portion of the contents, and return the rest to storage without labeling or dating. There was a one-gallon container of opened ReaLemon juice stored on a shelf, despite manufacturer instructions requiring refrigeration after opening. The Dietary Manager confirmed the juice was not stored according to manufacturer guidelines. On 6/26/25 at 1:14 PM, during an interview with the Administrator, she stated that her expectation is for kitchen staff to ensure residents receive food that is properly prepared and tastes good. She acknowledged that the Dietary department was newly staffed, including the Dietary Manager, who was still learning the position and job responsibilities.

Based on observation, interview, and policy review, the facility failed to acknowledge and honor the documented food preferences of one (1) of twenty-three (23) sampled residents, Resident #88. Findings included: A review of the facility's policy titled Resident Meal Service, revised 1/2025, revealed, .Residents will be offered menu choices for all meals, beverages, and snacks, and are based on their .food preferences . A record review of the Clinical record revealed the facility admitted Resident #88 on 7/5/23 with diagnoses that included Hemiplegia and Hemiparesis. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/22/25 revealed Resident #88 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated his cognition was intact. A record review of the meal ticket, dated 6/23/25, revealed Resident #88 had Food Dislikes listing of multiple vegetables including broccoli, carrots, and cauliflower. A record review of the facility's MenuWorks Weekly Menu revealed the meal for Monday (06/23/2025) included California Vegetables. On 6/23/25 at 11:58 AM, during an observation and interview in the main dining hall, Resident #88 was removing vegetables from his plate. The meal on his tray included a California blend of vegetables consisting of broccoli, cauliflower, and carrots. Resident #88 stated he disliked vegetables and explained that this issue occurred frequently, despite his documented food preferences excluding such items. On 6/24/25 at 12:05 PM, during an interview with the Dietary Manager, he stated that kitchen staff do not currently review or acknowledge the food preferences listed on the residents' meal tickets. He explained that he had been in his role for less than ninety (90) days and had not yet had adequate time to address staff training or resolve deficiencies related to honoring resident meal preferences. He confirmed that dietary staff do not consistently review or implement resident preferences during meal service. On 6/26/25 at 1:14 PM, during an interview with the Administrator, she stated her expectation was for kitchen staff to ensure meals are prepared properly and meet residents' expectations. She acknowledged that the dietary department was newly staffed and that the Dietary Manager was still learning his role and responsibilities.

Based on observation, staff interview, record review, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) assessment related to a resident having a restraint, when no restraint had been ordered or used, for one (1) of twenty-three (23) residents reviewed. Resident #99. Findings included: A review of the facility's policy titled Conducting an Accurate Resident Assessment, dated 2/10/25, revealed, . The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment . A record review of the admission Record revealed the facility admitted Resident #99 on 6/14/24 with diagnoses including Unspecified Dementia. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/21/25 revealed Resident #99 had a limb restraint. A record review of the medical record revealed there was no documentation indicating Resident #99 had a limb restraint. On 6/23/25 at 7:34 AM, during an observation and interview, Resident #99 was lying in bed on her left side. Certified Nurse Aide (CNA) #1 explained that Resident #99 did not have any restraints. On 6/24/25 at 12:20 PM, during an interview, Licensed Practical Nurse (LPN) #1 explained the facility does not use restraints, and Resident #99 has not had any restraints since being admitted . On 6/24/25 at 2:30 PM, during an interview, the Director of Nursing (DON) reported the facility is a restraint-free building. During a review of Resident #99's Annual MDS with an ARD of 5/21/25, Section P0100 indicated the use of a limb restraint less than daily. The DON explained this was coded in error and confirmed that Resident #99 does not have a restraint. She stated that all assessments are expected to be coded accurately to reflect the resident's status. On 6/24/25 at 3:10 PM, during an interview, LPN #2 explained that she had coded the restraint in error on the MDS and confirmed that Resident #99 did not and had never had a restraint. On 6/26/25 at 12:10 PM, during an interview, the Administrator explained that she expected all residents' MDS assessments to be coded accurately to reflect their current assessments.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure a resident's right to privacy and confidentiality by posting personal health information on the resident's wall for one (1) of twenty-three (23) sampled residents, Resident #82. Findings included: A review of the facility's policy titled, Promoting/Maintaining Resident Dignity, dated 2/10/25, revealed, .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality . Compliance Guidelines .11 .No signage shall be posted in the room with personal information . On 6/23/25 at 8:48 AM, during an observation, signage was observed posted on the wall above the bed for Resident #82 which indicated 205 A- Nectar thick liquids with no straws. On 6/24/25 at 11:45 AM, during an observation and interview while Resident #82 was assisted with lunch, Certified Nurse Aide (CNA) #1 explained that Resident #82 was on nectar thickened liquids and was assisted with each meal. CNA #1 confirmed the signage on the wall above the bed, which read Nectar thick liquids no straws. She stated this information was already included in the resident's plan of care and meal ticket and expressed uncertainty as to why it was also posted on the wall. On 6/25/25 at 10:45 AM, during an observation and interview with the Director of Nursing (DON), she confirmed that signage in resident rooms disclosing personal care or health information was not permitted and constituted a violation of resident dignity. She verified the presence of the sign referencing nectar thick liquids and no straws in Resident #82's room. The DON stated she did not know who had posted the sign or how long it had been there but affirmed that she would have it removed and conduct a facility-wide audit to ensure compliance. On 6/26/25 at 12:21 PM, during an interview with the Administrator, she acknowledged being informed of the signage and affirmed that resident health information should not be posted in resident rooms. She stated that her expectation was for all staff to honor residents' dignity and privacy and to avoid posting any health-related care information on the walls. A record review of the admission Record revealed the facility admitted Resident #82 on 7/6/23 with diagnoses including Nontraumatic Intracranial Hemorrhage. A record review of the Order Listing Report with active orders revealed Resident #82 had a Physician's Dietary Order, dated 4/10/25, for Nectar/mildly thick consistency and no straws.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain an effective pest control program related to ants for one (1) of twenty-three (23) sampled residents, Resident #49. Findings included: A review of the facility's policy titled .Pest Control Program, dated 2/1/25, revealed: .It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Definition: 'Effective pest control program' is defined as measures to eradicate and contain common household pests (e.g .ants .) . A record review of the Transfer/Discharge Report revealed the admitted Resident #49 on 8/5/21 and he had diagnoses including Acute Respiratory Failure with Hypoxia. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/25/25, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. On 6/24/25 at 10:44 AM, during an interview, Resident #49 stated that his room had ants and he had been bitten on his knees while lying in bed earlier that morning. He explained that this was not the first occurrence, stating it also happened on the prior Saturday (6/21/25). On 6/24/25 at 11:45 AM, during an interview with the Administrator, she explained that the open cookies above the resident's bed and the proximity of his bed to the window likely contributed to the presence of ants. She confirmed that pest control services were provided monthly and that records showed visits dating back to January 2025, with the last visit in May. She added that the resident declined an offer to move to another room. On 6/24/25 at 12:30 PM, an observation of Resident #49 revealed two older-appearing insect bites with individual pustules, one on each mid-thigh, and approximately five (5) newer red pustules located on the back of both knees. On 6/24/25 at 12:41 PM, during an interview with the Director of Nursing (DON), she confirmed that visible bites were present on both legs. The DON explained that an unopened container of cookies found on the resident's above-bed shelf likely attracted the ants. She stated an investigation was conducted on Saturday (6/21/25) following the initial report, but no ants or bites were observed during the body audit. She confirmed that ants were later seen by Certified Nurse Aide (CNA) #3, who attempted to remove them from the resident's legs, but the resident declined, requesting the DON view them. The DON verified that pest control last visited the facility on 5/9/25 and was scheduled to return that day (6/24/25). On 6/24/25 at 3:37 PM, during an interview with the Ombudsman, he stated that residents in the past year had complained to him about ants getting into their rooms at the facility. On 6/26/25 at 11:46 AM, during a follow-up interview with the DON, she confirmed that Resident #49 had five (5) ant bites on the backs of his knees and two (2) older bites on the mid-thighs. She explained that the initial complaint was reported on 6/21/25 and a body audit conducted at that time did not reveal any bites or ants. However, the room was cleaned and treated. The DON stated the resident reported new ant bites again on 6/24/25. She acknowledged the risk of anaphylaxis from insect bites and emphasized the importance of staff reporting pest activity promptly. She reiterated that a pest control vendor conducts monthly visits and is expected to survey for infestations during each visit. Her expectation was that residents remain free from insect bites while residing in the facility. On 6/26/25 at 2:20 PM, during an interview with the Maintenance Director, he stated that a pest control vendor provides monthly services and responds to any pest-related concerns as needed. He explained that staff typically report any sightings and he remains vigilant during his daily rounds to monitor for pests.

Based on observation, interview, facility policy review, and record review, the facility failed to follow appropriate infection control practices when a Certified Nurse Aide (CNA) placed soiled linens on the floor of a resident's room after incontinent care for one (1) of twenty-three (23) sampled residents, Resident #97. Findings included: A review of the facility's policy titled Infection Prevention and Control Program, dated 2/1/25, revealed, . This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections .Policy Explanation and Compliance Guidelines .12. A. Linens and direct care staff shall handle, store, process, and transport linens to prevent spread of infection . e. Soiled linen shall be collected at the bedside and placed in a linen bag . When the task is complete, the bag shall be closed securely and placed in the soiled utility room . A record review of Resident #97's admission Record revealed the facility admitted the resident on 7/31/24 with diagnoses including Cerebral Infarction. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/17/25 revealed Resident #97 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact. On 6/23/25 at 12:15 PM, during an observation and interview in Resident #97's room, CNA #2 was returning to complete perineal care. Soiled linens were observed resting directly on the floor without a barrier or a bag. When asked whether the soiled linens should be in direct contact with the floor, CNA #2 responded, No, and stated that infection could be spread and cross-contamination could occur. CNA #2 then placed the soiled linens in a soiled utility bag. On 6/26/25 at 10:31 AM, during an interview with the facility's Infection Preventionist (IP) Nurse, she stated that proper infection control guidelines require placing soiled linens directly into a linen bag to prevent contact with the floor. Allowing linens to touch the floor increases the risk of cross-contamination and infection for staff and residents. On 6/26/25 at 11:39 AM, during an interview with the Director of Nursing (DON), she stated that CNA #2 should have placed the soiled linens in a bag immediately and avoided letting them touch the floor to prevent contamination and the spread of infection throughout the building. She confirmed it was her expectation for staff to follow infection prevention guidelines when providing care.

Based on interviews, record review, and review of resident council monthly meeting minutes, the facility failed to resolve grievances regarding food complaints for five (5) of eight (8) months reviewed. Findings include: Review of the Resident Council minutes revealed the residents complained about the food during their meetings in October 2023, November 2023, December 2023, January 2024, and February 2024. A record review of a written letter, dated 2/5/24, from the Resident Council President revealed the resident council had concerns regarding the food. During an interview on 02/26/24 at 10:32 AM, with the Ombudsmen stated the residents invited him to their last resident council meeting. The Ombudsmen stated the residents complained about the food being cold and not tasting good. The Dietary Manager (DM) attended that meeting. During an interview on 2/29/24 at 1:00 PM, with the Activities Director (AD), she confirmed that she recorded the minutes at the Resident Council meetings and the residents complained every month for the last five (5) months about the food. The AD explained the residents complained about the taste and the temperature of the food and she had reported their complaints to the DM and the Administrator. During an interview on 2/29/24 at 1:30 PM, with the DM she confirmed the residents have been complaining about the food being cold and not palatable for several months. She explained the previous Administrator was going to buy new food warmers to help with the temperature of the food and she would discuss this issue with the current Administrator. During an interview on 2/29/24 at 02:00 PM, with the Administrator, she confirmed the residents had complained about the food being cold and not tasting good. She stated she would be talking with the resident to get these issues corrected.

Based on interviews, record review, and the facility policy review the facility failed to offer residents in the facility a bedtime snack for (3) of 23 sampled residents. (Resident #94, Resident #95, and Resident #107). Findings Include: A review of the facility's policy, Offering/Serving Bedtime Snacks, revised 4/20/23, revealed, .It is the practice of this facility to offer and serve residents with a nourishing snack in accordance with their needs, preferences and requests at bedtime on a daily basis .Policy Explanation and Compliance Guidelines .1. The nursing staff offers bedtime snacks to all residents . Resident #94 On 02/27/24 at 01:30 PM, in an interview with Resident #94, she explained she has not noticed the staff offering snacks to residents in the facility, or taking bedtime snacks to residents who are unable to leave their room. She said that if she asked for a snack, the staff would provide it. A record review of the Face Sheet revealed the facility admitted Resident #94 on 12/21/22 and she had current diagnoses including Type 2 Diabetes Mellitus. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/01/24 revealed Resident #94 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Resident #95 On 02/27/24 at 01:30 PM, an interview with Resident #95, he stated that he had never been offered a snack after dinner and did not know that bedtime snacks were available. A record review of the Face Sheet revealed the facility admitted Resident #95 on 11/10/22 and he had current diagnoses including Hypertension. A record review of the Quarterly MDS with an ARD of 12/27/23 revealed Resident #95 had a BIMS score of 14, which indicated he was cognitively intact. Resident #107 On 02/26/24 at 11:39 AM, an interview with Resident #107 revealed the activities staff offered snacks to the residents after breakfast and lunch, but there was no snack offered at bedtime. The resident reported mainly staying in her room and seldom ventures down the hall. The resident stated she has not been offered an after-dinner snack in the time she has been at the facility. A record review of the Face Sheet revealed the facility admitted Resident #107 on 01/31/24 with current diagnoses including Osteoarthritis. A record review of the Admission MDS with an ARD of 2/07/24 revealed Resident #107 had a BIMS score of 14, which indicated he was cognitively intact. On 02/27/24 at 03:13 PM, an interview with the Assistant Director of Nursing (ADON) revealed snacks are brought from the kitchen at 10 AM and 2 PM and the Activities staff offered them to the residents. The ADON confirmed there was no bedtime snacks offered, but if a resident wanted a snack, they could ask a nurse. On 02/29/24 at 12:07 PM, in an interview with the Administrator, she confirmed that although snacks were available upon request, all residents were not offered a bedtime snack. She stated that going forward, the nursing staff would offer all residents a bedtime snack.

Based on observation, interview, record review, and facility policy review, the facility failed to implement care plan approaches related to an indwelling catheter care for one (1) of 23 sampled residents. Resident #70 Findings include: A record review of the facility's policy Care Plans, Comprehensive Person-Centered, revised December 2022 revealed . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The Interdisciplinary Team .implement a comprehensive, person-centered care plan for each resident . 7. The comprehensive, person-centered care plan will: . b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Record review of the Care Plan with a problem onset date of 9/15/2025 revealed Problem/Need .high risk for UTI (Urinary Tract Infection) r/t (related to) presence of indwelling foley (type of indwelling catheter) .Approaches .Wipe front to back when providing pericare .Secure catheter tubing using leg strap . During an observation and interview on 2/27/24 at 11:00 AM, Certified Nurse Aide (CNA) #3 and CNA #4 provided catheter care for Resident #70. There was no leg strap securing the catheter tubing to reduce the risk of tension or pulling on the catheter to prevent trauma. Both CNAs reported the resident does not wear a leg strap because the resident would pull it off. CNA #3 used a disposable wipe and wiped the perineal area from the from the back to the front. CNA #4 reminded CNA #3 that she should wipe from the front to the back. After discarding the wipe and repositioning the resident, CNA #3 used a disposable wipe to clean the catheter by wiping the tubing several times, using the same wipe, and not changing the position of the wipe. After completing the care, CNA #3 reported she was unsure how many times she wiped the catheter with the disposable wipe, but thought it was at least five (5) to six (6) times and explained she was nervous. During an interview with the Director of Nursing (DON) on 02/27/24 at 12:00 PM, she explained all residents with a catheter should have a leg strap to secure the catheter. She stated that CNAs should inform the nurse if a resident does not have a leg strap. She said she expected all CNAs to perform catheter care properly. The DON also stated that she expected the staff to follow the resident's care plan. On 02/29/24 at 4:40 PM, during an interview with Licensed Practical Nurse (LPN)#3/Care Plan Nurse she explained she expected the staff to review and follow resident's care plans because they are individualized and inform the staff how to care for the resident. Record review of the Face Sheet revealed the facility admitted Resident #70 on 7/27/23 with current diagnoses including Neuromuscular Dysfunction of Bladder. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/12/24 revealed Resident #70 required a Staff Assessment for Mental Status which indicated her cognition was severely impaired.

Based on interviews, record review, and facility policy review, the facility failed to protect residents from misappropriation of property for one (1) of 23 sampled residents. Resident #64 Findings include: Review of the facility's policy, Abuse, Neglect and Exploitation, dated and initialed [DATE], revealed, Policy: It is the policy of this facility to provide protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent .misappropriation of resident property .Definitions: .Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent . Record review of the Facility Investigation, dated [DATE], revealed, that on [DATE], Resident #64 reported fraudulent changes on his bank statement to the Social Worker and Director of Nurses (DON). Resident #64 still had the card present in his wallet. Social services contacted the bank and placed a hold on the bank card. The local police were also contacted, and a report was made. An investigation was initiated for Resident #64. The resident was asked to provide the facility with any further documents received from the bank to the DON. The week of [DATE], Resident #64 received another bank statement. Upon review of the bank statement with Resident #64, there was a charge noted on the bank statement for CPR (Cardiopulmonary Resuscitation) certification on [DATE]. The charge was placed through CPR National Foundation. An e-mail was sent to the CPR National Foundation to identify the CPR certification for [DATE], using Resident #64's card number. A response was received on February 6, 2024, at 2:08 PM identifying the individual that had used the bank card number with the last four numbers of the bank card belonging to Resident #64. The local police were contacted, and another report was made including the identity of the person's information. The suspect was identified as (proper name) of a Certified Nurse aide (CNA). The CNA was an employee of (proper name) contracting company. The CNA worked as needed scheduling at the facility through (proper name) contracting company. The CNA has not worked at the facility since [DATE]. The facility identified interventions in response to the incident, which, in addition to notification of the local police department, in-services were initiated on abuse, neglect, and misappropriation of funds, the resident's bank replaced the money back into the resident's account, the State Agency, as well as the Attorney General were contacted, the Social Worker conducted interviews with other residents that reside in the same area of the facility, and the contracting agency was notified. The conclusion of the investigation resulted in substantiation of misappropriation of resident funds. On [DATE] at 12:15 PM, an interview with Resident #64 revealed he discovered fraudulent charges on the January statement of his bank account. He stated that he reported the charges on his bank statement to the Social Worker who in turn reported the charges to the DON and the Administrator. The resident added that the charges went back as far as [DATE] all the way through February of 2024. Review of the bank documents depicting the fraudulent charges were reviewed and the charges were listed as the following: $82.05 on [DATE] (pizza restaurant), $61.59 on [DATE] (grocery store), $42.05 on [DATE] (chicken restaurant), $35.09 on [DATE] (department store), $35.56 on [DATE] (grocery store), $29.07 on [DATE] (chicken restaurant), $28.32 on [DATE] (pizza restaurant), $41.47 on [DATE] (fast food restaurant), $14.07 on [DATE] (fast food restaurant), $14.95 on [DATE] (national CPR certification), $11.73 on [DATE] (fast food restaurant), $8.71 on [DATE] (fast food restaurant), $17.10 on [DATE] (pizza restaurant), $24.32 on [DATE] (pizza restaurant), $4.69 on [DATE] (fast food restaurant), $9.28 on [DATE] (fast food restaurant), $12.23 on [DATE] (fast food restaurant), $13.57 on [DATE] (fast food restaurant), $17.87 on [DATE] (food delivery service), $62.96 on [DATE] (food delivery service), $171.20 on [DATE] (sporting good store), $2.56 on [DATE] (fast food restaurant), $44.49 on [DATE] (wireless telephone service), and $29.41 on/,d+[DATE] (fast food restaurant). On [DATE] at 12:00 PM, during an interview with the DON, she confirmed that Resident #64 had made the Social Worker aware of the fraudulent charges on his bank statement and revealed that he still had his bank card in his wallet. The DON revealed that it was at that time that the local police department was notified, and the facility began an investigation. The DON stated that she had asked the resident to bring any future bank documents that he received to her for review. The week of [DATE], when Resident #64 received another bank statement, there was a charge made for CPR certification and that charge provided the information needed to identify the individual responsible for the charges. The suspect was identified as (proper name), CNA, as an as needed CNA contracted to work through (proper name) contracting company. The DON revealed that the contracting company was notified, and the employee had not worked at the facility since [DATE]. Record review of the Face Sheet for Resident #64 revealed the facility admitted the resident to the facility on [DATE], with diagnoses that included Essential Hypertension and Type 2 Diabetes Mellitus. Record review of the Annual Minimum Data Set (MDS), for Resident #64, with an Assessment Reference Date (ARD) [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12. which indicated the resident had moderate cognitive impairment.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide catheter care in a manner to prevent complications for one (1) of one of seven (7) residents with urinary catheters. Resident #70 Findings include: A record review of the facility's policy Catheter Care, dated 10/2022 revealed, . It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use . Policy Explanation: . Female .10. Wipe from front to back with a clean cloth . 11. Use a new part of the cloth or different cloth for each side. 12. With a new moistened cloth .wipe the catheter . At 11:00 AM on 02/27/24, during an observation and interview, Certified Nurse Aide (CNA) #3 and CNA #4 provided catheter care for Resident #70. There was not a leg strap securing the catheter tubing to reduce the risk of tension or pulling on the catheter to prevent trauma. Both CNAs reported the resident does not wear a leg strap because the resident would pull it off. CNA #3 used a disposable wipe and wiped the perineal area from the from the back to the front. CNA #4 reminded CNA #3 that she should wipe from the front to the back. After discarding the wipe and repositioning the resident, CNA #3 used a disposable wipe to clean the catheter by wiping the tubing several times, using the same wipe, and not changing the position of the wipe. After completing the care, CNA #3 reported she was unsure how many times she wiped the catheter with the disposable wipe, but thought it was at least five (5) to six (6) times and explained she was nervous. On 02/27/24 at 12:00 PM, during an interview with the Director of Nursing (DON), she explained all residents with a catheter should have a leg strap to secure the catheter. She stated that CNAs should inform the nurse if a resident does not have a leg strap. She said she expected all CNAs to perform catheter care properly and explained the facility completed competency check offs for CNAs yearly. Record review of the Face Sheet revealed the facility admitted Resident #70 on 7/27/23 with current diagnoses including Neuromuscular Dysfunction of Bladder. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/12/24 revealed Resident #70 required a Staff Assessment for Mental Status which indicated her cognition was severely impaired. Section H revealed Resident #70 had an indwelling catheter.

Level II 47873 Based on interview, and record review, the facility failed to provide a pest free living environment for one (1) of 23 sampled residents. Resident #262 Findings include: A record review of the facility investigation dated 11/13/23, revealed Resident #262 was admitted by the facility on 9/22/23, as a skilled resident, with diagnoses of Acute Embolism and Thrombus of the Right Popliteal Vein. The investigation stated that on November 11, 2023, at approximately 9:00 AM, the resident reported to a day shift nurse that she thought she had some insect bites. The day shift nurse visually noted several red raised areas on skin upon. However, the nurse inspected the resident's bed and found no insects in the resident's bed or on her body at the time the red raised areas were observed. The investigation noted that the resident's husband was at the bedside when the day nurse observed the red raised areas on the resident's skin, and he requested the resident be sent to the hospital. The facility honored his request, and the resident was sent a local hospital for evaluation. Upon further investigation by the facility, the resident had an incident on the previous shift, on November 11th at approximately 12:14 AM. At that time, insects were observed on the residence bed. The resident was given a bath and clothing was changed, her room was inspected and cleaned. All the bedding in the resident's room was removed and replaced with clean fresh bedding. A body audit was completed, and no insect bites were observed at that time and there were no complaints of pain and itching. An interview on 2/28/24 at 11:45 AM, with the Resident Representative (RR) of Resident #262 revealed that ants had been found in his wife's room during the night shift on 11/11/23. He commented that the resident had not wanted to be moved, so staff came in and sprayed and cleaned her room and made sure that ants were no longer there. The RR stated the following day or night, ants came in more this time than the first time and got in the bed with his wife and bit her around the groin area. He requested that his wife be taken to a hospital for the ant bites and to follow up on other issues. He confirmed his wife was moved the second time until the room was completely cleaned, and outside extermination had been completed. The RR commented that if more attention had been paid to his wife after the first incident, the second incident would not have happened. An interview on 02/28/24 at 1:01 PM, was conducted with the Maintenance Lead Tech (MLT). The MLT revealed that when was made aware of the incident, he did an initial walk through of the room and all the rooms on that side of the hall. The MLT stated that it had been raining and that had possibly led to the ants coming in from the outside of the building. The MLT revealed that all the patient's belongings were taken out of the room, the room was cleaned per their protocol and pest control was called in to further exterminate. He commented that he was told that the ants were seen on that Saturday, but the resident had refused to move. He stated that after the second incident, the resident was sent to the hospital and all belongings were removed from the room until further evaluation could be done. The MLT confirmed that the facility has an ongoing contract with a local pest control company. A record review of the facility's pest control contract revealed that the facility has an ongoing contract with a local pest control company. The contract was signed on 4/13/20. There were two recent visits made by the pest control company, as the company filled out a report of their inspection and activities related to the incident. There was a routine pest control visit made on 11/10/23, prior to the incident and a second visit made of 11/13/23, when the facility requested the company to come inspect the facility for insects and perform additional spraying. A record review of the progress note from the emergency room visit of Resident #262, dated 11/11/23, revealed, .Patient has a benign exam insect bites were confirmed on exam there is no acute emergent intervention required . there is no acute cellulitis of the skin. I find no criteria for admission to the hospital . A review of the physical examination section of the document revealed, .Well nourished, in no apparent distress . An interview on 2/29/24 at 10:07 AM, with the facility Administrator and Director of Nurses revealed that they were told about the incident by nursing staff. They confirmed that the incident as depicted in the investigation was an accurate account of the incident involving Resident #262. The Administrator revealed that since the resident refused to move after the first incident, due diligence had been done by the staff to make sure that there were no more pests in the room. However, after the second incident, they strongly encouraged the resident to take another room until pest control could come and complete a review of the environment. The DON confirmed that part of nursing assessment includes assessing the environment, and staff should look at the whole picture when checking on residents. An interview on 2/29/24 at 3:01 PM, with the facility Social Worker (SW), revealed, the resident was admitted [DATE]. The Social Worker stated that the incident of Resident #262 involving ants was reported to her on that following Monday. She confirmed she did a follow up with the husband and the resident. However, she revealed that the resident has since been discharged from the facility to a nursing home located closer her family. A review of the facility's Face Sheet revealed the facility admitted the resident on 9/22/23, with diagnoses that included Acute Embolism and Thrombosis of Right Popliteal Vein. The discharge date noted on the form was 1/22/24. A review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/4/24, revealed Resident #262 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to store food and engage in sanitary practice in accordance with professional standards for food service safety related to food items not dated with a use-by-date, no identifying label, expired foods, improperly stored and exposed food for one (1) of three (3) kitchen observations. Findings include: A review of the facility's policy, Food Safety Requirements, revised [DATE], revealed, .Foods will also be stored, prepared, distributed and served in accordance with professional standards for service safety .Policy Explanation and Compliance Guidelines Policy .1. Food safety practices shall be followed .b. Storage of food in a manner that helps prevent .contamination of food .3. Facility shall inspect all food .C. Refrigerated storage .iv. Labeling, dating and monitoring refrigerated food .so it is used by its use-by date . On [DATE] at 10:10 AM, an observation with the Dietary Manager (DM) revealed the following: 1. Refrigerator #1 contained 24 (4)-ounce (oz) containers of apple juice with no use by date, one (1) 4 oz container of cranberry flavored juice cocktail with no use by date, one (1) opened 46 oz jar of apple sauce opened on [DATE] and was good though [DATE], one (1) opened 46 oz jar of apple sauce with no use by date, one (1) tray containing six (6) 4 oz containers of orange juice with no use by date, and eight (8) - 4 oz containers of apple juice with no use by date. 2. Refrigerator #2 contained two (2) unopened bags of coleslaw with a use by date of [DATE]. One (1) unopened gallon of milk with the best by date of [DATE]. One (1) opened gallon of milk with the best by date of [DATE], one (1) opened quart carton of heavy cream with no use by date, one (1) opened five (5) pound block of processed cheese with no use by date. 3. Freezer #2 contained one (1) opened and exposed plastic bag of hash browns with no identifying label or manufacturer date and 1 (one) opened bag of diced chicken with no identifying label and no manufacturers date. 4. An observation of the pantry revealed the sugar bin lid was not secured and left a large gap, leaving the sugar exposed. On [DATE] at 8:09 AM, in an interview with the DM, she acknowledged the outdated, improperly stored, and exposed foods. The DM reported it is her responsibility to label and check expiration dates for food items. She explained the kitchen staff receive monthly in-service training on food safety. On [DATE] at 12:07 PM, in an interview with the Administrator, she confirmed she had been made aware of the issues in the dietary department related to outdated, improperly stored, and exposed foods in the kitchen.

Based on interviews, record review and facility policy review the facility failed to provide showers for residents who require assistance for three (3) of (23) sampled residents. (Residents #74, #78 and #97) Findings Include: Review of the facility's policy, Activities of Daily Living (ADL's), revised 11/28/2023, revealed .The facility will, based on the residence comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate .Care and services will be provided for the following activities of daily living .1. Bathing, dressing, grooming . Review of the facility policy, Resident Showers, revised 11/29/23, revealed, .It is the practice of this facility to assist residents with bathing to maintain proper hygiene .Policy Explanation and Compliance Guidelines .1. Residents will be provided showers are per request or as per facility schedule protocols . Resident #74 On 2/28/29 at 04:50 PM, in an interview with Resident #74, she stated that she does not receive a shower consistently. The resident explained that she received a shower on Tuesday, Thursday, and Saturday and she did not receive a shower the previous day, which was a Tuesday. The resident said that she hoped she would get a shower tomorrow because the staff give showers whenever they want to and not when it is scheduled. A record review of the facility's, Activities of Daily Living (ADL) Assistance and Support documentation revealed Resident #74 received four (4) showers for the month of February. A record review of the Face Sheet revealed the facility admitted Resident #74 on 2/22/20 and she had current diagnoses Muscle Weakness. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/26/23 revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated her cognition was moderately impaired. Resident #78 During an interview on 02/28/24 at 4:46 PM, with a Resident #78's family member, she explained that every time she visited her mother, she was dirty, and her hair was greasy. She stated that her family member was not getting bathed, and she had previously met with the Director of Nursing (DON) and other staff regarding this matter. During an interview on 02/28/24 at 04:50 PM, with Resident #78, she explained that she was incontinent and needed to have showers, but she had to have help. During an interview on 02/28/24 at 05:00 PM, with Licensed Practical Nurse (LPN) #2, she explained she was the cart nurse for the hall. She stated that she has not been told by a nurse aide that the resident refused her shower. During an interview on 2/28/24 at 05:10 PM, with Certified Nurse Aide (CNA) #5, she stated that Resident #78 often refused to take a shower. She acknowledged that the resident's family visited and wanted to know why the resident was dirty and she explained that the resident refused to take showers. CNA #5 confirmed Resident #5 had not received a shower at 4:30 PM because the resident had refused, but she did not notify the nurse or the DON that the resident had refused. A record review of the ADL Assistance and Support documentation for February 2024 revealed Resident #78 was dependent upon staff for bathing and received five (5) baths for the month of February. A record review of the Face Sheet revealed the facility admitted Resident # 78 on 7/31/23 and she had current diagnoses including Hypertension. A record review of the MDS with an ARD of 12/26/23 revealed Resident #78 had a BIMS score of 11, which indicated her cognition was moderately impaired. Resident #97 In a phone interview on 2/26/24 at 2:00 PM, with the social worker at the local hospital, she stated she received report from the emergency room medical doctor and nurses that Resident #97 was dirty, unkempt, and had an odor when he arrived from the facility. She confirmed the resident was currently admitted to the hospital. During an interview on 2/26/24 at 5:00 PM, with Resident #97's family member, she confirmed Resident #97 was sent to the hospital dirty and unkempt. The wife said she told the hospital staff that he was always dirty and had odors. A record review of the ADL Assistance and Support document for February 2024 revealed Resident #97 was dependent upon staff for bathing and received one (1) bath on 2/14/24 for the month of February. A record review of the Face Sheet revealed the facility admitted Resident #97 on 8/16/22 and he had current diagnoses including Alzheimer's Disease. A record review of the MDS with an ARD of 12/19/23 revealed Resident #97 had a BIMS score of 8, which indicated his cognition was severely impaired. During an interview 02/29/24 at 09:31 AM with the DON, she confirmed there was no documentation on the shower sheets to show Resident #78 had received showers three (3) times per week and confirmed she had recently met with the resident's family. The DON said she believed the CNAs were giving showers but were not documenting it on the computer. The DON explained that if a resident refused a shower, the CNAs are trained to document the refusal and notify the nurse, and the cart nurse should notify the charge nurse so the charge nurse can further encourage the resident. If a resident continues to refuse a bath, then the Assistant Director of Nurses (ADON) and DON should be notified. The DON explained the shower schedule is set up for residents who are on the A bed received showers on Monday, Wednesday, and Friday and the residents on the B bed received showers on Tuesday, Thursday, and Saturday. The DON said the charge nurse was responsible for monitoring the CNAs to ensure the showers and baths were given. The DON also said she was not aware that Resident #74 was not getting a shower. During an interview on 02/29/24 at 10:00 AM, with the Administrator, she revealed she was not aware residents were not getting their baths or showers. The Administrator said she was going to make changes to ensure the resident's needs and preferences were being met.

Based on interviews, record review, and facility policy review, the facility failed to protect a resident from misappropriation of property for one (1) of five (5) sampled residents. Resident #5 Findings include: Review of the facility's policy, Abuse, Neglect and Exploitation with a review/revision date 5/1/23, revealed Policy: It is the policy of this facility to provide protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent .misappropriation of resident property .Definitions: .Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent . Record review of the Facility Investigation, dated 4/18/23, revealed, On April 13th, 2023, (Proper Name of Resident #5) reported to ADON (Assistant Director of Nursing) that her bank card was missing and she had noted some unauthorized charges on her account. The (Proper Name of Local police department) was contacted and a report was made .Upon Investigation: on April 6th, 2023 between 8:00am and 8:55am, (Proper Name of Resident #5) had requested that a staff member use her bank card to go get her and her roommate some donuts. (Proper Name of Resident #5) stated that the staff member returned her bank card, the donuts and her receipt. Later that evening the following unauthorized charges were made .April 6th @ (at) 1523 (3:23 PM) (Proper Name of Local Gas Station) April 6th @ 1742 (5:42 PM) (Proper Name of Local Daquari establishment), April 6th @ 2106 (9:06 PM) (Proper Name of Local Gas Station). The unauthorized charges continued over the next few days, these charges are as follows: April 7th @ 0532 (5:32 AM) (Proper Name of Local Gas Station) and April 11th @12:08 (PM) (Proper Name of Local Gas Station). (Proper Name of Resident #5) did not realize the bank card was missing until April 13th, 2023. At that time she requested her niece .go by the bank and get a print out of her recent transactions due to the changes on her statement .Conclusion: Substantiated: Misappropriation of funds . On 7/12/23 at 12:15 PM, an interview with Resident #5 revealed she discovered that her debit card was missing after her niece had contacted her on 4/13/23 and asked about questionable charges to the resident's checking account. Resident #5 stated she reported to the Assistant Director of Nursing (ADON) that the card was missing and there were questionable charges on her account. She said she obtained a copy of the ATM/Debit Card Details from her bank and identified four transactions which she had not made or authorized. She stated that she did not see anyone take the debit card from her room and she was told by the facility administration that Certified Nurse Aide (CNA) #1 had taken the debit card. She said that since the transactions were reported to her bank as fraudulent, her bank had reimbursed her account for the total amount. She stated that she did recall giving her card to CNA #1 on 4/06/23 to go get us some donuts and she recalled the CNA returned her card the same day, along with the donuts. She stated that she could not recall if CNA #1 observed her take her card out of her wallet or replace it upon return. On 7/12/23 at 12:35 PM, during an interview with the ADON, she said she had been notified by Resident #5 on 4/13/23 at approximately 4:40 PM that the resident's debit card was missing and that there had been unauthorized charges/purchases made using her debit card. The ADON stated that she had immediately reported the allegation to the Director of Nursing (DON) and the Administrator. She stated that she had participated in the investigation which had been initiated immediately. She stated that Resident #5 had told her that the last time she saw her debit card was when she put the card back into her wallet after she had given it to CNA #1 to purchase some donuts for her and her roommate. On 7/12/23 at 8:42 PM, during a telephone interview with CNA #1, he stated that on 4/06/23, Resident #5 had provided her debit card and requested donuts from the store. He went to the store on his break, used the card to purchase donuts, delivered them, and returned the card to Resident #5. He stated that he was interviewed by the ADON a week or two later regarding the whereabouts of the debit card and he was notified on 4/14/23 that he was suspended pending investigation of the allegation and should not return to the facility. He stated that on the afternoon of 4/17/23 he was notified by the DON that his employment at the facility was terminated. CNA #1 stated he had not taken or used the debit card. CNA #1 confirmed that the facility provided an in-service training regarding misappropriation of resident funds, abuse, and neglect on 4/13/23. On 7/12/23 at 12:00 PM, an interview with the DON revealed that she had been made aware of the allegation of misappropriation by the ADON at approximately 4:45 PM on 4/13/23 and an investigation was initiated immediately. She confirmed that all staff that had entered the room of Resident #5 on the last day the resident reported seeing her debit card were interviewed. She said she had also interviewed Resident #5. She stated the results of the investigation included the suspension of CNA #1 pending conclusion of the investigation. She said she had spoken with the police department investigator following his investigation and was told that charges were being processed against CNA #1 for credit card fraud based on the conclusion of the police investigation. On 7/13/23 at 9:19 AM, during a telephone interview with the investigator of the local sheriff's office, he confirmed that he had been assigned to investigate what he described as credit card fraud against a resident at the nursing home. He stated that after review of the unauthorized transactions conducted with Resident #5's debit card, he had visited one of the establishments involved and viewed security camera footage recorded at the time of the transaction. He stated the footage clearly showed CNA #1 conducting the transaction. He stated he had also interviewed the bartender and obtained a statement in which the bartender confirmed the identity of CNA #1. The investigator confirmed that the total amount of unauthorized purchases made on 4/06/23 using Resident #5's debit card totaled thirty-five dollars and fifty-nine cents ($35.59). The investigator said he had filed a felony warrant request with the county justice court clerk against CNA #1 on 4/18/23 and a felony arrest warrant had been issued. Record review of the Face Sheet revealed the facility admitted Resident #5 on 1/14/22 with diagnoses including of Chronic Obstructive Pulmonary disease and Osteoarthritis. Record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/19/23 revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact. The SA validated through record review of the In-Service Sign-In sheet dated 4/13/23 and staff interviews that the facility provided in-service training related to Misappropriation of Residents Funds, Abuse and Neglect on 4/13/23. The SA validated through record review of the Quality Assurance and Assessment QAPI) Sign-In Sheet dated 4/18/23 that the QAPI committee met on 4/18/23 and discussion included Abuse, Neglect and Misappropriation of Funds with review of current practices and new practices designed to prevent recurrence of misappropriation; In-Service training for employees; and incident investigation. The QAPI Sign-In Sheet confirmed attendance by the Administrator, DON, Medical Director and other attendees including department supervisors. The SA validated through record review of the personnel file for CNA #1 revealed his employment at the facility was officially terminated on 4/18/23. The SA validated that the facility had taken all necessary measures to be at past noncompliance by 4/18/23 with the deficient practice that occurred on 4/6/23.

Based on record review, facility policy review, and staff interviews, the facility failed to act upon a Consultant Pharmacy (CP) recommendation for one (1) resident of seven (7) residents reviewed for unnecessary medications. Resident #22 A record review of the facility's policy, Medication Regime Reviews with a revised date of April 2007 revealed, .7. The Consultant Pharmacist will document his/her findings and recommendations . A record review of the Note to Attending Physician/Prescriber revealed .Please consider if GDR (Gradual Dose Reduction) is appropriate for: [MEDICATION(S)] 10 mg (milligrams) po (by mouth) daily .RECOMMENDATION: If a gradual dose reduction is appropriate, please consider reducing dose to [MEDICATION(S)] 5 mg po daily .Physician/Prescriber Response .Agree. The recommendation was signed by the Nurse Practitioner (NP) and dated 10/13/21. A record review of the medical record for Resident #22 revealed there was no physician order to reduce the [MEDICATION(S)] from 10 mg to 5 mg as was recommended by the CP and agreed upon by the NP. A record review of the electronic-Medication Administration Records (e-MAR's) from October 2021 through December 2021 revealed Resident #22 continued to receive [MEDICATION(S)] 10 mg with an order date of 4/27/21, instead of the [MEDICATION(S)] 5 mg that was recommended on 10/13/21 by the CP and agreed upon by the NP. On 01/26/22 at 4:30 PM, during an interview with the Director of Nursing (DON), she confirmed a CP recommendation was written for Resident #22 on 10/13/21 to decrease [MEDICATION(S)] from 10 mg to 5 mg daily and that the NP did agree with the recommendation. The DON stated that staff missed carrying out the recommendation and no dose reduction was completed. On 01/26/22 at 4:45 PM, during a phone interview with the facility's Medical Director, he confirmed the CP recommendation was not acted upon and gave the facility a new order on 01/26/22 to decrease the [MEDICATION(S)] to 5 mg PO daily. A record review of Resident #22's Face Sheet revealed the the resident was originally admitted on [DATE], and was readmitted by the facility on 09/22/2019 with diagnoses including [CONDITION(S)], Anxiety Disorder, and Other Recurrent Depressive Disorders.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) for a resident taking an antipsychotic medication for one (1) of 20 residents sampled for MDS accuracy. Resident #74. A record review of the signed statement by the Nursing Home Administrator revealed the facility used the Resident Assessment Instrument (RAI) for coding the MDS. A record review of the Face Sheet revealed the facility admitted Resident #74 on 06/16/21, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #74's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/05/22 revealed N0410A was coded as zero (0) which indicated Resident #74 did not receive an antipsychotic medication during the seven (7) day look-back period. A review of the question for N0450A, Resident received antipsychotic medications was coded as No - Antipsychotics were not received. A record review of Resident #74's electronic-Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/28/22 at 11:30 AM, during an interview with the facility's MDS Coordinator, LIcensed Practical Nurse (LPN) #1, she confirmed the MDS submitted on 01/05/22 for Resident #74 was entered incorrectly and was inaccurate. She explained the facility uses the RAI manual as guidance for accurately coding the MDS. On 01/28/22 at 11:40 AM, during an interview with the Director of Nursing (DON) , she confirmed the facility uses the RAI manual for guidance in coding the MDS. She stated she expects the MDS to be coded accurately. On 01/28/22 at 11:45 AM, during an interview with MDS LPN #2, she confirmed the MDS submited by her on 01/05/22 for Resident #74 was a documentation error. After she reviewed Resident #74's e-MAR, she verified he had received [MEDICATION(S)], which is an antipsychotic medication, during the seven (7) day look-back period of the MDS.

Based on record review, staff interview, and facility policy review, the facility failed to provide a written notification to the Resident Representative (RR), and to notify the office of Mississippi Long Term Care Ombudsman of a resident's transfer to an acute care facility for three (3) of seven (7) residents reviewed for discharge or transfer to the hospital. Resident #100, Resident #125, and Resident #131. Findings include: Review of the facility's Transfer or Discharge Notice policy, dated (MONTH) (YEAR), indicated it is the policy of this facility that the facility shall provide a resident and the RR with a written notice of an impending transfer and discharge. The facility policy noted that the facility will send a copy of all acute care transfers based on resident urgent medical needs to the State Long Term Care Area Ombudsman office as soon as practicable, such as in a list of residents on a monthly basis. Resident #100 Review of Resident #100's Physician's Telephone Orders, dated [DATE] and [DATE], revealed an order to send Resident #100 out to the hospital. Review of the document titled, Departmental Notes, dated [DATE], revealed, at 7:37 AM, a late entry was entered to indicate, on [DATE], Resident #100 was sent out to the emergency room (ER) for an evaluation of abnormal vital signs, to include a low oxygen saturation, an increased heart rate, and an elevated temperature. The Departmental Notes indicated, on [DATE], there was a late entry, noted that Resident #100 arrived back from the hospital on [DATE] at approximately 18:45 (6:45 PM). The Departmental Notes also indicated, on [DATE] at 7:55 PM, that Resident #100 was sent to the ER at 1:45 PM related to an altered level of consciousness. The Departmental Notes also indicated that Resident #100 returned to the facility on [DATE]. During an interview, on [DATE] at 1:40 PM, with the Social Services Director (SSD), it was revealed that a written notice of transfer to an acute care hospital was not sent to Resident #100's RR for the hospital transfers on [DATE] and [DATE]. The SSD stated Resident #100 was listed on the (MONTH) 2019 transfer log, sent to the State Ombudsman Office, for the [DATE] hospital transfer, but was not listed on the (MONTH) 2019 transfer log for the [DATE] hospital transfer. The SSD stated she has only been at the facility for approximately four (4) weeks, and she has been unable to locate any notice of transfer letters sent out prior to her employment at the facility. During an interview, on [DATE] at 1:58 PM, the Director of Nursing (DON), it was revealed she was unaware the written notice of transfers had not been sent out to the RR(s) by the previous SSD. The DON stated that she was unaware the log that is sent to the Stated Ombudsman every month, had not been complete. Resident #125 During an interview, on [DATE] at 12:15 PM, Resident #125's daughter revealed the facility does not notify her when they send her mother to the hospital. The daughter said the last time Resident #125 went to the hospital the facility did not notify her. Resident #125's daughter also said the facility told her a week later. Review of the Minimum Data Set ((MDS) dated [DATE], revealed Resident #125 was a discharge assessment-return anticipated. Review the nurses notes, dated [DATE], revealed the nurse attempted to call the family to report the resident was sent to the hospital. The family did not answer the phone. On [DATE] the Responsible Representative (RR) called and said she was unaware of the resident going to the hospital. The facility noted the RR failed to notify the facility of the change in her number. The new number was given to the facility at that time. During an interview, on [DATE] at 2:40 PM, the Social Services Director (SSD) revealed that a written notice of transfer to an acute hospital was not sent to Resident #125's family for the hospital transfer on [DATE]. The social worker stated a notice to the State Ombudsman Office was sent of the hospital transfers at the end of the month. The social worker stated she has only been at the facility for four (4) weeks. The social worker also stated she has been unable to locate any notice of transfer letters sent out prior to her employment at the facility. Resident #131 Review of Resident #131's medical record revealed the resident was sent to the hospital, on [DATE], because she was observed unresponsive, no respirations. The facility was unable to obtain an apical or radial pulse. The facility initiated CPR (Cardiopulmonary Resuscitation). Record of the Minimum Data Set ((MDS) dated [DATE], revealed Resident #131 was a discharged assessment-return not anticipated. During an interview, on [DATE] at 2:07 PM, Registered Nurse (RN) #2 revealed the resident was sent to the hospital and was taken via (by) American Medical Response (AMR). Cardiopulmonary Resuscitation (CPR) was continued by the Emergency Medical Technician (EMT) on the way to the hospital. During an interview, on [DATE] at 2:40 PM, the SSD revealed a written notice of transfer to an acute hospital was not sent to Resident #131's family for the hospital transfer on [DATE]. The SSD stated a notice to the State Ombudsman Office was sent of the hospital transfers at the end of the month. The SSD also stated she has only been at the facility for four (4) weeks and is unable to locate any notice of transfer letters sent out prior to her employment at the facility.

Based on record review, staff interview and facility policy review, the facility failed to accurately code the Comprehensive Minimum Data Set (MDS) Assessment for two (2) of (29) MDS Assessments reviewed. Resident #23 and Resident #50. Findings include: A review of the facility policy titled, Resident Assessment Instrument, dated (MONTH) (YEAR), revealed, 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. 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. Resident #23 Review of Resident #23 MDS Assessment, dated 1/31/19, revealed Section H of the MDS was coded inaccurately for bowel continence. The MDS was coded as Resident #23 is always continent while previous records indicated Resident #23 is incontinent of bowel. Review of the care plan revealed Resident #23 is incontinent of bowel. An interview, on 4/09/19 at 11:05 AM, with Licensed Practical Nurse (LPN) #2 regarding the MDS Assessment, dated 1/31/19, for Resident #23 revealed, It's just an error. The MDS assessment should have been coded as always incontinent instead of always continent. An interview, on 4/10/19 at 10:15 AM, with the Director of Nursing (DON) revealed, Resident #23 should have been coded on the MDS for bowel incontinence, but after reviewing the MDS it was coded for always continent. Resident #50 Review of Resident #50's MDS Assessment, dated 2/15/19, revealed the MDS was not coded accurately indicating Resident #50 was receiving [MEDICAL TREATMENT]. Review of the care plan revealed Resident #50 was to attend [MEDICAL TREATMENT]. Review of the Physicians Orders, for Resident #50, revealed Resident #50 was to go out for [MEDICAL TREATMENT] on Tuesday/Thursday/Saturday. An interview, on 4/09/19 at 11:05 AM, with Registered Nurse (RN) #1/MDS Director, regarding Resident #50 MDS Assessment revealed, I just over looked it. The resident's MDS assessment should have been coded for [MEDICAL TREATMENT] and it wasn't. An interview, on 4/10/19 at 10:15 AM, with the Director of Nursing (DON) revealed, [MEDICAL TREATMENT] should have been coded on the resident's MDS and after viewing the MDS is was not coded for [MEDICAL TREATMENT].

Based on observation, record review, interview, and policy/procedure review, the facility failed to ensure qualified staff were designated on the care plan that were knowledgeable and/or competent in how to care for a resident with a [MEDICAL CONDITION], as evidenced by each resident's comprehensive care plan for the [MEDICAL CONDITION] failed to properly identify which licensed professional would perform each task of [MEDICAL CONDITION] care. The facility also failed to have the available qualified staff to properly deep suction and perform other emergency duties per care plan as evidenced by failure to ensure 24 hour, seven (7) days a week coverage by Qualified Professionals; Registered Nurses (RN) and/or Respiratory Therapist (RT). This affected six (6) of six (6) residents on census with a [MEDICAL CONDITION], Four (4) in-house residents, Residents #5, #6, #8 and #10, and Residents #7 and #9, who were in the hospital. The failure to have qualified personnel designated on the care plan and available for deep suctioning and other emergency respiratory services for residents with a [MEDICAL CONDITION], placed Residents #5, #6, #8, and #10, and any other residents admitted to the facility with a [MEDICAL CONDITION], at risk for serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ), which began on 2/16/18, when the facility failed to ensure residents with a tracheotomy were care planned for the appropriate discipline and had readily available and qualified staff to perform all aspects [MEDICAL CONDITION] 24 hours per day. The State Agency (SA) notified the Administrator on 05/04/18, of the Immediate Jeopardy (IJ). An acceptable Allegation of Compliance (AoC) was received on 5/10/18, in which the facility alleged the Immediate Jeopardy was removed on 05/05/18. The SA determined the IJ to be removed on 5/11/18, prior to exit. The scope and severity for the IJ at 42 CFR 483.21 (b) (3) (ii) Comprehensive Care Plans services provided by qualified persons, was lowered to a [NAME] while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the Facility's policy/procedure for Care Plan-Comprehensive, last revised (MONTH) (YEAR), revealed a Policy Statement An individualized comprehensive person-centered plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The Policy Interpretation and Implementation states Each resident's comprehensive care plan is designed to: [NAME] Identify the professional services that are responsible for each element of care. M. Reflect currently recognized standards of practice for problem areas and conditions. Resident #5 Review of the facility's face sheet revealed the facility admitted Resident #5 on 04/10/18. Resident #5's [DIAGNOSES REDACTED]. Resident #5 had a [MEDICAL CONDITION]. Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date of 04/17/18, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, indicating she had no cognitive impairments. Record review of Resident #5's: Gas exchange impairment risk, related to the presence of a [MEDICAL CONDITION] with requirement of suctioning care plan, with a problem onset of 4/10/18, revealed the Approaches section of the care plan revealed to suction [MEDICAL CONDITION] for increased secretions, a N in the role for this task. The care plan does not specify Registered Nurse (RN) or Licensed Practical Nurse (LPN) and does not specify in the approaches if the suction task is a deep right main stem suction or surface suction. Resident #6 Review of the facility's face sheet for Resident #6 revealed he had been admitted to the facility on [DATE]. Resident #6's [DIAGNOSES REDACTED]. Resident #6 had a [MEDICAL CONDITION]. Review of the residents most recent MDS with an ARD of 04/25/18, revealed staff assessed Resident #6 with a moderately impaired cognitive status. Review of Resident #6's Baseline Care Plan, dated 4/18/18, for Special Treatment/procedures revealed to Suction: as ordered for the [MEDICAL CONDITION] section of the care plan. There is no reference to which Qualified Professional is to perform this task. Review of the (MONTH) (YEAR), Medical Doctor Orders revealed tracheal suctioning with #14 French suction catheter as needed for unmanageable secretions. The order does not specify which Qualified Professional is to perform the task of tracheal suctioning. Resident #7 Review of the facility's face sheet revealed the facility admitted Resident #7 on 12/19/16, with a re-admitted [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the residents most recent MDS with an ARD of 02/26/18, revealed the resident had a BIMS score of 11, indicating mildly impaired cognitive status. Review of Resident #7's care plan for, Gas Exchange Impaired, high risk related to [MEDICAL CONDITION] with unmanageable secretions, with a problem onset of 12/19/16, revealed an approach of Tracheal suctioning as ordered with a N as the role for this task. The care plan does not specify RN or LPN to perform the task. Review of the (MONTH) (YEAR), Medical Doctor orders revealed tracheal suctioning with #14 French catheter for unmanageable secretions as needed and does not specify RN or LPN to perform the tracheal suctioning. Resident #8 Review of Resident #8's face sheet revealed the facility admitted the resident on 01/05/17. His [DIAGNOSES REDACTED]. Resident #8 had a [MEDICAL CONDITION]. Review of the residents most recent MDS, with an ARD of 04/10/18, revealed the resident had a BIMS score of 15, indicating Resident #8 had no cognitive impairment. Record review of Resident #8's Aspiration, High Risk for care plan, with a problem onset of 1/5/17, revealed an approach Tracheal suctioning #14 French suction or cath with no role assigned to perform this task. Resident #9 Review of Resident #9's face sheet revealed the facility admitted the resident on 04/05/18. Resident #9's [DIAGNOSES REDACTED]. Resident #9 had a Tracheotomy. Review of the residents most recent MDS, with an ARD of 04/17/18, revealed the Resident #8 had a BIMS score of 15, indicating no cognitive impairment. Record review of Resident #9's Baseline Care Plan, dated 4/5/18, revealed in the special treatments/procedures to [MEDICAL CONDITION] needed. There is no role assigned to perform this task. Resident #10 Review of Resident #10's face sheet revealed the facility admitted the resident on 05/16/16. The resident's [DIAGNOSES REDACTED]. Resident #10 had a Tracheotomy. Review of Resident #10's most recent MDS, with an ARD of 05/02/17, revealed the resident had a BIMS score of 3, indicating severe cognitive impairment. Record review of Resident #10's Aspiration, High Risk, with a problem onset of 5/16/16, revealed an approach for tracheal suctioning as ordered with NNA as the role to perform this task. It does not specify RN or LPN to perform the tracheal suctioning. An interview with Licensed Practical Nurse (LPN) #4, on 5/10/18 at 11:45 AM, revealed The care plan role part should be staff specific. It should have been specific to which nurse, Registered Nurse (RN) or Licensed Practical Nurse (LPN), can perform that activity. LPN #4 stated that two (2) weeks ago she began going through care plans in this building to correct everything making sure everything is resident specific. She stated that her plan now on [MEDICAL CONDITION] residents, is to indicate a Deep suctioning as needed intervention and designate the role for the RN or Respiratory Therapist (RT). She stated that the LPN function in the care plan interventions will be, (MONTH) perform endotracheal/trach suctioning and may suction secretions from the [MEDICAL CONDITION]. LPN #4 stated, If deep suctioning is required, it must be performed by the RN or RT. An interview with Registered Nurse (RN) #2 at 11:55 AM, on 5/10/18, revealed she had been working on changing the care plans to be more specific. She stated, Yes, they should be resident specific. RN #2 stated that the N on the care plan only meant nursing, not specific to RN or LPN. She stated they are now being more specific and putting RN or LPN for some of the interventions, especially with the [MEDICAL CONDITION] residents, which started on 5/4/18. RN #2 stated, A RN deep suctions, a LPN can't. Interview with the Director of Nursing (DON), on 05/03/18 at 3:00 PM, revealed the facility had several residents with tracheostomies. When asked about Registered Nurse (RN) coverage, she stated the facility was covered by an RN at least eight (8) hours each day, not always 24 hours per day. The DON confirmed the Respiratory Therapist was not always on site to [MEDICAL CONDITION]. Review of the nursing schedules for RNs from (MONTH) 17, (YEAR) through (MONTH) 4, (YEAR), revealed only RN coverage for the day shift and occasionally through 8:00 PM, however, no consistent RN coverage was documented from 6:00 PM-11:00 PM and no coverage from 11:00 PM through 6:00 AM. The facility submitted and acceptable Allegation of Compliance (AoC) on 5/10/18, for the Immediate Jeopardy (IJ) Review of the facility's AoC revealed the facility took the following corrective actions to remove the IJ, prior to exit: At approximately 1:00 PM on (MONTH) 4, (YEAR), the facility was notified by the surveyor that an Immediate Jeopardy was being called. The facility respectfully submits this allegation of compliance (A[NAME]). 1. On (MONTH) 04, (YEAR), Mississippi State Department of Health conducted an on-site visit to the facility and informed the facility of qualified staff requirements in order to provide [MEDICAL CONDITION] care and services. [MEDICAL CONDITION] resident's included Resident #5, #6, #7, #8, #9 and #10 of the sample currently residing at the facility. The State Agency informed the facility they did not have coverage of qualified staff on all shifts, specifically the 6 p.m. to 6 a.m. shift to provide emergency [MEDICAL CONDITION] care and services to residents with tracheostomies. The facility has six (6) residents with tracheostomies on census with two (2) residents currently in the hospital. The facility has not provided Registered Nurse or Respiratory Therapist coverage for the 6:00 p.m. to 6:00 a.m. shift consistently in the past for residents with tracheostomies. 2. At 6:30 PM on (MONTH) 04, (YEAR), the facility implemented a twenty-four (24) hour Registered Nurse coverage schedule, and has continued to provide this coverage. An audit of physician orders, care plans, [MEDICAL CONDITION] kits, set-ups and equipment for Residents #5, #6, #7, #8, #9 and #10 was completed with no care concerns or harm noted on (MONTH) 04, (YEAR) at 6:00 PM. The audit was completed by the Director of Nursing (DON), the Quality Assurance (QA) Nurse and the Minimum Data Set (MDS)/Care Plan (CP) Nurses. 3. On (MONTH) 04, (YEAR), at 5:00 PM, a Quality Assurance (QA) Meeting was conducted with the Medical Director, the Director of Nursing, the Administrator, the Quality Assurance Nurse, and the Chief Nursing Officer. The QA Committee agreed the facility would provide twenty-four (24) hour Registered Nurse or Respiratory Therapy coverage for the facility when [MEDICAL CONDITION] residents were on census. Review was completed of the revised policy and procedure, tag F695, and the Nurse Practice Act with Scope of Practice for Registered Nurses, including the ability to perform deep right main stem suctioning and Licensed Practical Nurses may only perform [MEDICAL CONDITION] care, Naso-pharyngeal suctioning and suction secretions from the [MEDICAL CONDITION]. Also reviewed were emergency bed side kits readily available, care plans, facility assessment, and the revised schedule. An update was made to the policy and procedure for [MEDICAL CONDITION] care to define what an LPN's scope of practice is, what an RN's scope of practice is and twenty-four (24) Registered Nurse or Respiratory Therapy coverage when a [MEDICAL CONDITION] resident is on census. The policy and procedure was revised and approved on (MONTH) 04, (YEAR), during the Quality Assurance meeting at 5:00 PM. 4. In-servicing, provided by the Quality Assurance Nurse, began at 5:30 PM on (MONTH) 04, (YEAR). All Registered Nurses and Licensed Practical Nurses working on (MONTH) 04, (YEAR), were in-serviced on the requirement of twenty-four (24) hour Registered Nurse or Respiratory Therapy coverage when [MEDICAL CONDITION] residents are on census. There were 2 RN's and 5 LPN's on duty when inservicing began. There are seven (7) RN's and 24 LPN's currently employed with all but three (3) completing the in-service training and competency successful return demonstration check-off. These employees have not worked and will not work until training and competency return demonstration is completed. All Registered Nurses, Licensed Practical Nurses and new hires scheduled to work will not be allowed to work until in-serviced on [MEDICAL CONDITION] care and services, F695, MS Nurse Practice Act with RN and LPN scope of practice for [MEDICAL CONDITION] care and services, changes made to [MEDICAL CONDITION] resident care plans, and the revised policy and procedure. There are two (2) LPN's and one (1) RN who work as needed (PRN) who have not completed the in-service training and competency return demonstration. The Director of Nursing or Quality Assurance Nurse will review the schedule daily to assure twenty-four (24) hour coverage of a Registered Nurse or Respiratory Therapist when [MEDICAL CONDITION] residents are on census. The in-servicing and observation of the return demonstration was conducted by the Quality Assurance Nurse at 5:30 PM on (MONTH) 04, (YEAR). The facility is alleging that all activities to remove the Immediate Jeopardy were completed as of (MONTH) 04, (YEAR), and the Immediate Jeopardy was removed as of (MONTH) 05, (YEAR). Validation of the Allegation of Compliance 1. The State Agency (SA) validated through record review, observation and interviews that the facility has six (6) residents with tracheostomies on census with two (2) residents currently in the hospital and that the facility had not provided Registered Nurse or Respiratory Therapist coverage for the 6:00 PM to 6:00 AM shift consistently in the past for residents with tracheostomies. 2. The SA validated through interviews and record review that at 6:30 PM on (MONTH) 04, (YEAR), the facility implemented a twenty-four (24) hour Registered Nurse coverage schedule, and has continued to provide this coverage and that an audit of physician orders, care plans, [MEDICAL CONDITION] kits, set-ups and equipment for Residents #5, #6, #7, #8, #9 and #10 was completed with no care concerns or harm noted on (MONTH) 04, (YEAR) at 6:00 PM, and that an audit was completed by the Director of Nursing, the Quality Assurance Nurse and the MDS/CP Nurses. 3. The SA validated through record review and interviews that on (MONTH) 04, (YEAR), at 5:00 PM, a QA Meeting was conducted with the Medical Director, the Director of Nursing, the Administrator, the QA Nurse and the Chief Nursing Officer and the QA Committee recommended and implemented 24 hour Registered Nurse or Respiratory Therapy coverage for the facility when [MEDICAL CONDITION] residents were on census. The SA verified that a review was completed of the revised policy and procedure, F695, the Nurse Practice Act with Scope of Practice for Registered Nurses, which includes the ability to perform deep right main stem suctioning and Licensed Practical Nurses may only perform [MEDICAL CONDITION] care, Naso-pharyngeal suctioning and suctioning secretions from the [MEDICAL CONDITION]. Also reviewed was the emergency bed side kits readily available, care plans, Facility Assessment and the revised schedule. The SA validated through record review and interview than an update was made to the policy and procedure for [MEDICAL CONDITION] care to define what an LPN's scope of practice is, what an RN's scope of practice is and 24 hour Registered Nurse or Respiratory Therapy coverage when a [MEDICAL CONDITION] resident is on census. The SA validated that the policy and procedure was approved and that the policy and procedure was revised during the QA meeting. 4. The SA validated through record review and interviews that the in-servicing provided by the QA Nurse began at 5:30 PM on (MONTH) 04, (YEAR), and all Registered Nurses and Licensed Practical Nurses working on (MONTH) 04, (YEAR), were in-serviced on the requirement of 24 hour Registered Nurse or Respiratory Therapy coverage when [MEDICAL CONDITION] residents are on census. The SA verified that there were two (2) RN's and five (5) LPN's on duty when inservicing began, also there are currently seven (7) RN's and 24 LPN's employed with all but three (3) completing the in-service training and competency return demonstration check-offs. The SA validated through record review and interview that these employees have not worked and the facility has plans to in-service prior to return to work. The SA validated that all Registered Nurses, Licensed Practical Nurses and new hires scheduled to work will not be allowed to work until in-serviced on [MEDICAL CONDITION] care and services, F695, MS Nurse Practice Act with RN and LPN scope of practice for [MEDICAL CONDITION] care and services, changes made to [MEDICAL CONDITION] resident care plans, and the revised policy and procedure. The SA validated through record review and interviews that there are two (2) LPN's and one (1) RN who work PRN who have not completed the in-service training and competency return demonstration. The SA validated by review of the schedule and interview, that the Director of Nursing or Quality Assurance Nurse review the schedule daily to assure 24 hour coverage of a Registered Nurse or Respiratory Therapist when [MEDICAL CONDITION] residents are on census. The SA validated through record review and interviews that the in-servicing and observation of the return demonstration was conducted by the Quality Assurance Nurse at 5:30 PM on (MONTH) 04, (YEAR). The SA interviewed six (6) Licensed Practical Nurses, three (3) Registered Nurses, one (1) MDS Registered Nurse and two (2) MDS Licensed Practical Nurses. The SA also validated that the facility reviewed and updated their Facility Assessment to include 24 hour coverage of RNs and necessary supplies to ensure proper care of the resident(s) with [MEDICAL CONDITION].

Based on observation, record review, interview, and policy/procedure review, the facility failed to ensure qualified staff were designated on the care plan that were knowledgeable and/or competent in how to care for a resident with a [MEDICAL CONDITION], as evidenced by each resident's comprehensive care plan for the [MEDICAL CONDITION] failed to properly identify which licensed professional would perform each task of [MEDICAL CONDITION] care. The facility also failed to have the available qualified staff to properly deep suction and perform other emergency duties per care plan as evidenced by failure to ensure 24 hour, seven (7) days a week coverage by Qualified Professionals; Registered Nurses (RN) and/or Respiratory Therapist (RT). This affected six (6) of six (6) residents on census with a [MEDICAL CONDITION], Four (4) in-house residents, Residents #5, #6, #8 and #10, and Residents #7 and #9, who were in the hospital. The failure to have qualified personnel designated on the care plan and available for deep suctioning and other emergency respiratory services for residents with a [MEDICAL CONDITION], placed Residents #5, #6, #8, and #10, and any other residents admitted to the facility with a [MEDICAL CONDITION], at risk for serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ), which began on 2/16/18, when the facility failed to ensure residents with a tracheotomy were care planned for the appropriate discipline and had readily available and qualified staff to perform all aspects [MEDICAL CONDITION] 24 hours per day. The State Agency (SA) notified the Administrator on 05/04/18, of the Immediate Jeopardy (IJ). An acceptable Allegation of Compliance (AoC) was received on 5/10/18, in which the facility alleged the Immediate Jeopardy was removed on 05/05/18. The SA determined the IJ to be removed on 5/11/18, prior to exit. The scope and severity for the IJ at 42 CFR 483.21 (b) (3) (ii) Comprehensive Care Plans services provided by qualified persons, was lowered to a E while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the Facility's policy/procedure for Care Plan-Comprehensive, last revised (MONTH) (YEAR), revealed a Policy Statement An individualized comprehensive person-centered plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The Policy Interpretation and Implementation states Each resident's comprehensive care plan is designed to: J. Identify the professional services that are responsible for each element of care. M. Reflect currently recognized standards of practice for problem areas and conditions. Resident #5 Review of the facility's face sheet revealed the facility admitted Resident #5 on 04/10/18. Resident #5's [DIAGNOSES REDACTED]. Resident #5 had a [MEDICAL CONDITION]. Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date of 04/17/18, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, indicating she had no cognitive impairments. Record review of Resident #5's: Gas exchange impairment risk, related to the presence of a [MEDICAL CONDITION] with requirement of suctioning care plan, with a problem onset of 4/10/18, revealed the Approaches section of the care plan revealed to suction [MEDICAL CONDITION] for increased secretions, a N in the role for this task. The care plan does not specify Registered Nurse (RN) or Licensed Practical Nurse (LPN) and does not specify in the approaches if the suction task is a deep right main stem suction or surface suction. Resident #6 Review of the facility's face sheet for Resident #6 revealed he had been admitted to the facility on [DATE]. Resident #6's [DIAGNOSES REDACTED]. Resident #6 had a [MEDICAL CONDITION]. Review of the residents most recent MDS with an ARD of 04/25/18, revealed staff assessed Resident #6 with a moderately impaired cognitive status. Review of Resident #6's Baseline Care Plan, dated 4/18/18, for Special Treatment/procedures revealed to Suction: as ordered for the [MEDICAL CONDITION] section of the care plan. There is no reference to which Qualified Professional is to perform this task. Review of the (MONTH) (YEAR), Medical Doctor Orders revealed tracheal suctioning with #14 French suction catheter as needed for unmanageable secretions. The order does not specify which Qualified Professional is to perform the task of tracheal suctioning. Resident #7 Review of the facility's face sheet revealed the facility admitted Resident #7 on 12/19/16, with a re-admitted [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the residents most recent MDS with an ARD of 02/26/18, revealed the resident had a BIMS score of 11, indicating mildly impaired cognitive status. Review of Resident #7's care plan for, Gas Exchange Impaired, high risk related to [MEDICAL CONDITION] with unmanageable secretions, with a problem onset of 12/19/16, revealed an approach of Tracheal suctioning as ordered with a N as the role for this task. The care plan does not specify RN or LPN to perform the task. Review of the (MONTH) (YEAR), Medical Doctor orders revealed tracheal suctioning with #14 French catheter for unmanageable secretions as needed and does not specify RN or LPN to perform the tracheal suctioning. Resident #8 Review of Resident #8's face sheet revealed the facility admitted the resident on 01/05/17. His [DIAGNOSES REDACTED]. Resident #8 had a [MEDICAL CONDITION]. Review of the residents most recent MDS, with an ARD of 04/10/18, revealed the resident had a BIMS score of 15, indicating Resident #8 had no cognitive impairment. Record review of Resident #8's Aspiration, High Risk for care plan, with a problem onset of 1/5/17, revealed an approach Tracheal suctioning #14 French suction or cath with no role assigned to perform this task. Resident #9 Review of Resident #9's face sheet revealed the facility admitted the resident on 04/05/18. Resident #9's [DIAGNOSES REDACTED]. Resident #9 had a Tracheotomy. Review of the residents most recent MDS, with an ARD of 04/17/18, revealed the Resident #8 had a BIMS score of 15, indicating no cognitive impairment. Record review of Resident #9's Baseline Care Plan, dated 4/5/18, revealed in the special treatments/procedures to [MEDICAL CONDITION] needed. There is no role assigned to perform this task. Resident #10 Review of Resident #10's face sheet revealed the facility admitted the resident on 05/16/16. The resident's [DIAGNOSES REDACTED]. Resident #10 had a Tracheotomy. Review of Resident #10's most recent MDS, with an ARD of 05/02/17, revealed the resident had a BIMS score of 3, indicating severe cognitive impairment. Record review of Resident #10's Aspiration, High Risk, with a problem onset of 5/16/16, revealed an approach for tracheal suctioning as ordered with NNA as the role to perform this task. It does not specify RN or LPN to perform the tracheal suctioning. An interview with Licensed Practical Nurse (LPN) #4, on 5/10/18 at 11:45 AM, revealed The care plan role part should be staff specific. It should have been specific to which nurse, Registered Nurse (RN) or Licensed Practical Nurse (LPN), can perform that activity. LPN #4 stated that two (2) weeks ago she began going through care plans in this building to correct everything making sure everything is resident specific. She stated that her plan now on [MEDICAL CONDITION] residents, is to indicate a Deep suctioning as needed intervention and designate the role for the RN or Respiratory Therapist (RT). She stated that the LPN function in the care plan interventions will be, (MONTH) perform endotracheal/trach suctioning and may suction secretions from the [MEDICAL CONDITION]. LPN #4 stated, If deep suctioning is required, it must be performed by the RN or RT. An interview with Registered Nurse (RN) #2 at 11:55 AM, on 5/10/18, revealed she had been working on changing the care plans to be more specific. She stated, Yes, they should be resident specific. RN #2 stated that the N on the care plan only meant nursing, not specific to RN or LPN. She stated they are now being more specific and putting RN or LPN for some of the interventions, especially with the [MEDICAL CONDITION] residents, which started on 5/4/18. RN #2 stated, A RN deep suctions, a LPN can't. Interview with the Director of Nursing (DON), on 05/03/18 at 3:00 PM, revealed the facility had several residents with tracheostomies. When asked about Registered Nurse (RN) coverage, she stated the facility was covered by an RN at least eight (8) hours each day, not always 24 hours per day. The DON confirmed the Respiratory Therapist was not always on site to [MEDICAL CONDITION]. Review of the nursing schedules for RNs from (MONTH) 17, (YEAR) through (MONTH) 4, (YEAR), revealed only RN coverage for the day shift and occasionally through 8:00 PM, however, no consistent RN coverage was documented from 6:00 PM-11:00 PM and no coverage from 11:00 PM through 6:00 AM. The facility submitted and acceptable Allegation of Compliance (AoC) on 5/10/18, for the Immediate Jeopardy (IJ) Review of the facility's AoC revealed the facility took the following corrective actions to remove the IJ, prior to exit: At approximately 1:00 PM on (MONTH) 4, (YEAR), the facility was notified by the surveyor that an Immediate Jeopardy was being called. The facility respectfully submits this allegation of compliance (A[NAME]). 1. On (MONTH) 04, (YEAR), Mississippi State Department of Health conducted an on-site visit to the facility and informed the facility of qualified staff requirements in order to provide [MEDICAL CONDITION] care and services. [MEDICAL CONDITION] resident's included Resident #5, #6, #7, #8, #9 and #10 of the sample currently residing at the facility. The State Agency informed the facility they did not have coverage of qualified staff on all shifts, specifically the 6 p.m. to 6 a.m. shift to provide emergency [MEDICAL CONDITION] care and services to residents with tracheostomies. The facility has six (6) residents with tracheostomies on census with two (2) residents currently in the hospital. The facility has not provided Registered Nurse or Respiratory Therapist coverage for the 6:00 p.m. to 6:00 a.m. shift consistently in the past for residents with tracheostomies. 2. At 6:30 PM on (MONTH) 04, (YEAR), the facility implemented a twenty-four (24) hour Registered Nurse coverage schedule, and has continued to provide this coverage. An audit of physician orders, care plans, [MEDICAL CONDITION] kits, set-ups and equipment for Residents #5, #6, #7, #8, #9 and #10 was completed with no care concerns or harm noted on (MONTH) 04, (YEAR) at 6:00 PM. The audit was completed by the Director of Nursing (DON), the Quality Assurance (QA) Nurse and the Minimum Data Set (MDS)/Care Plan (CP) Nurses. 3. On (MONTH) 04, (YEAR), at 5:00 PM, a Quality Assurance (QA) Meeting was conducted with the Medical Director, the Director of Nursing, the Administrator, the Quality Assurance Nurse, and the Chief Nursing Officer. The QA Committee agreed the facility would provide twenty-four (24) hour Registered Nurse or Respiratory Therapy coverage for the facility when [MEDICAL CONDITION] residents were on census. Review was completed of the revised policy and procedure, tag F695, and the Nurse Practice Act with Scope of Practice for Registered Nurses, including the ability to perform deep right main stem suctioning and Licensed Practical Nurses may only perform [MEDICAL CONDITION] care, Naso-pharyngeal suctioning and suction secretions from the [MEDICAL CONDITION]. Also reviewed were emergency bed side kits readily available, care plans, facility assessment, and the revised schedule. An update was made to the policy and procedure for [MEDICAL CONDITION] care to define what an LPN's scope of practice is, what an RN's scope of practice is and twenty-four (24) Registered Nurse or Respiratory Therapy coverage when a [MEDICAL CONDITION] resident is on census. The policy and procedure was revised and approved on (MONTH) 04, (YEAR), during the Quality Assurance meeting at 5:00 PM. 4. In-servicing, provided by the Quality Assurance Nurse, began at 5:30 PM on (MONTH) 04, (YEAR). All Registered Nurses and Licensed Practical Nurses working on (MONTH) 04, (YEAR), were in-serviced on the requirement of twenty-four (24) hour Registered Nurse or Respiratory Therapy coverage when [MEDICAL CONDITION] residents are on census. There were 2 RN's and 5 LPN's on duty when inservicing began. There are seven (7) RN's and 24 LPN's currently employed with all but three (3) completing the in-service training and competency successful return demonstration check-off. These employees have not worked and will not work until training and competency return demonstration is completed. All Registered Nurses, Licensed Practical Nurses and new hires scheduled to work will not be allowed to work until in-serviced on [MEDICAL CONDITION] care and services, F695, MS Nurse Practice Act with RN and LPN scope of practice for [MEDICAL CONDITION] care and services, changes made to [MEDICAL CONDITION] resident care plans, and the revised policy and procedure. There are two (2) LPN's and one (1) RN who work as needed (PRN) who have not completed the in-service training and competency return demonstration. The Director of Nursing or Quality Assurance Nurse will review the schedule daily to assure twenty-four (24) hour coverage of a Registered Nurse or Respiratory Therapist when [MEDICAL CONDITION] residents are on census. The in-servicing and observation of the return demonstration was conducted by the Quality Assurance Nurse at 5:30 PM on (MONTH) 04, (YEAR). The facility is alleging that all activities to remove the Immediate Jeopardy were completed as of (MONTH) 04, (YEAR), and the Immediate Jeopardy was removed as of (MONTH) 05, (YEAR). Validation of the Allegation of Compliance 1. The State Agency (SA) validated through record review, observation and interviews that the facility has six (6) residents with tracheostomies on census with two (2) residents currently in the hospital and that the facility had not provided Registered Nurse or Respiratory Therapist coverage for the 6:00 PM to 6:00 AM shift consistently in the past for residents with tracheostomies. 2. The SA validated through interviews and record review that at 6:30 PM on (MONTH) 04, (YEAR), the facility implemented a twenty-four (24) hour Registered Nurse coverage schedule, and has continued to provide this coverage and that an audit of physician orders, care plans, [MEDICAL CONDITION] kits, set-ups and equipment for Residents #5, #6, #7, #8, #9 and #10 was completed with no care concerns or harm noted on (MONTH) 04, (YEAR) at 6:00 PM, and that an audit was completed by the Director of Nursing, the Quality Assurance Nurse and the MDS/CP Nurses. 3. The SA validated through record review and interviews that on (MONTH) 04, (YEAR), at 5:00 PM, a QA Meeting was conducted with the Medical Director, the Director of Nursing, the Administrator, the QA Nurse and the Chief Nursing Officer and the QA Committee recommended and implemented 24 hour Registered Nurse or Respiratory Therapy coverage for the facility when [MEDICAL CONDITION] residents were on census. The SA verified that a review was completed of the revised policy and procedure, F695, the Nurse Practice Act with Scope of Practice for Registered Nurses, which includes the ability to perform deep right main stem suctioning and Licensed Practical Nurses may only perform [MEDICAL CONDITION] care, Naso-pharyngeal suctioning and suctioning secretions from the [MEDICAL CONDITION]. Also reviewed was the emergency bed side kits readily available, care plans, Facility Assessment and the revised schedule. The SA validated through record review and interview than an update was made to the policy and procedure for [MEDICAL CONDITION] care to define what an LPN's scope of practice is, what an RN's scope of practice is and 24 hour Registered Nurse or Respiratory Therapy coverage when a [MEDICAL CONDITION] resident is on census. The SA validated that the policy and procedure was approved and that the policy and procedure was revised during the QA meeting. 4. The SA validated through record review and interviews that the in-servicing provided by the QA Nurse began at 5:30 PM on (MONTH) 04, (YEAR), and all Registered Nurses and Licensed Practical Nurses working on (MONTH) 04, (YEAR), were in-serviced on the requirement of 24 hour Registered Nurse or Respiratory Therapy coverage when [MEDICAL CONDITION] residents are on census. The SA verified that there were two (2) RN's and five (5) LPN's on duty when inservicing began, also there are currently seven (7) RN's and 24 LPN's employed with all but three (3) completing the in-service training and competency return demonstration check-offs. The SA validated through record review and interview that these employees have not worked and the facility has plans to in-service prior to return to work. The SA validated that all Registered Nurses, Licensed Practical Nurses and new hires scheduled to work will not be allowed to work until in-serviced on [MEDICAL CONDITION] care and services, F695, MS Nurse Practice Act with RN and LPN scope of practice for [MEDICAL CONDITION] care and services, changes made to [MEDICAL CONDITION] resident care plans, and the revised policy and procedure. The SA validated through record review and interviews that there are two (2) LPN's and one (1) RN who work PRN who have not completed the in-service training and competency return demonstration. The SA validated by review of the schedule and interview, that the Director of Nursing or Quality Assurance Nurse review the schedule daily to assure 24 hour coverage of a Registered Nurse or Respiratory Therapist when [MEDICAL CONDITION] residents are on census. The SA validated through record review and interviews that the in-servicing and observation of the return demonstration was conducted by the Quality Assurance Nurse at 5:30 PM on (MONTH) 04, (YEAR). The SA interviewed six (6) Licensed Practical Nurses, three (3) Registered Nurses, one (1) MDS Registered Nurse and two (2) MDS Licensed Practical Nurses. The SA also validated that the facility reviewed and updated their Facility Assessment to include 24 hour coverage of RNs and necessary supplies to ensure proper care of the resident(s) with [MEDICAL CONDITION].

Based on interview and record review the facility failed to provide qualified sufficient nursing staff, with appropriate competencies and skills, to provide respiratory services on a 24 hour basis for resident's with [MEDICAL CONDITION] for four (4) of six (6) residents with [MEDICAL CONDITION] on census. Residents #5, #6, #8, and #10 were in the facility and Residents #7 and #9 were in the hospital at the time of survey. The facility's failure to provide qualified competent nursing staff to provide deep [MEDICAL CONDITION] suctioning if necessary, and other emergency care for resident's with [MEDICAL CONDITION], caused a situation that was likely to cause serious injury, harm, impairment or death to resident's with [MEDICAL CONDITION]. This situation was determined to be an Immediate Jeopardy (IJ) on 05/04/18. The facility's Administrator was notified of the Immediate Jeopardy (IJ) on 05/04/18. An acceptable credible Allegation of Compliance (A[NAME]) was received on 05/10/18, in which the facility alleged the Immediate Jeopardy was removed on 05/05/18. The State Survey Agency (SA) validated the Allegation of Compliance on 05/11/18, prior to exit. Therefore, the Scope and Severity for Immediate Jeopardy at 42 CFR 483.35(a) (1)-(2) was lowered to an [NAME] while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility document, Staffing, revised (MONTH) (YEAR), revealed a policy statement: To assure that sufficient qualified nursing staff are available on a daily basis to meet the residents' needs for nursing care in a manner and in an environment which promote each resident's physical, mental and psychosocial well-being, thus enhancing the quality of life. Policy interpretation and implementation revealed: The facility maintains sufficient nursing staff to provide and monitor nursing and related services to meet the needs of our residents. Review of the Mississippi State 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, 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, under the direction of the RN, Advanced Practice Registered Nurse (APRN), Licensed Physician or Licensed Dentist. Review of the State Board of Nursing (BON) web site revealed frequently asked questions (FAQ's). The BON 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 to suction secretions from [MEDICAL CONDITION]. However, it is not within the scope of practice of the LPN to perform deep right main stem suctioning. If deep right main stem suctioning is required for the patient a Registered Nurse (RN) must perform the procedure. Review of the facility's nursing schedule and Staffing Grid on 05/03/18 at 3:00 PM, revealed no Registered Nurse coverage on the third shift from 04/19/18 - 05/02/18, including no coverage on the 6:00 PM-6:00 AM shift. Review of the facility's working schedules from 02/17/18 through 05/04/18, revealed 62 of 77 days had no RN coverage for the 6:00 AM-6:00 PM shift. An interview on 5/16/18 at 4:30 PM, with the Nurse Investigator at the MS State BON revealed, Yes, a RN is required in a Long Term Care facility 24 hours a day, seven (7) days per week for consultation. The RN has to be on premises and not just available by phone. The Nurse Investigator confirmed this included care provided to [MEDICAL CONDITION]. Interview with the Director of Nurses (DON), while reviewing the staffing grid on 05/03/18 at 3:00 PM, revealed she was pleased to be adding Respiratory Therapist (RT) coverage for seven (7) days a week for eight (8) hours a day, instead of just five (5) days of eight (8) hour coverage. The DON stated they had several residents with trachs in the building. The DON confirmed Registered Nurse (RN) coverage was provided at least eight (8) hours each day, but not 24 hours per day. In a further interview, on 5/4/18 at 12:15 PM, the DON confirmed LPNs could not deep suction as [MEDICAL CONDITION], it was not in their scope of practice. The DON confirmed the facility did not have RN's on all shifts, only on day shifts. The DON stated it would take approximately five (5) minutes for Emergency Medical Services (EMS) to get to the facility and an additional five (5) to 10 minutes for the patient to reach the local emergency room if EMS were called. The DON stated the Respiratory Therapist was out of town and couldn't be reached by phone and was not expected back until Tuesday. Interview with LPN #3 on 05/04/18 at 11:30 AM, revealed there were always RNs in the building on day shift and RT was not always in the building. LPN #3 stated that LPN's can't deep [MEDICAL CONDITION], if needed. Resident #5 Review of the facility's Physician order [REDACTED]. Observation of Resident #5 on 05/04/18 at 10:45 AM revealed the resident had a [MEDICAL CONDITION] held in place [MEDICAL CONDITION] and a Passy-Muir in place which allowed the resident to speak. No [MEDICAL CONDITION] was seen at the bedside. Interview with Resident #5 and her father on 05/04/18 at 1:30 PM, revealed the resident'[MEDICAL CONDITION] come out recently and the Respiratory Therapist had replaced it. All surfaces, drawers, and closets were checked and no [MEDICAL CONDITION] found and no [MEDICAL CONDITION] was found at the bedside. The father and resident both stated that they had never seen a [MEDICAL CONDITION] the room. Review of the facility's face sheet for Resident #5 revealed she had been admitted to the facility on [DATE]. Resident #5's [DIAGNOSES REDACTED]. Resident #5 was admitted with [MEDICAL CONDITION]. Resident #6 Review of the facility's Physician order [REDACTED]. Observation of Resident #6 on 05/04/18 at 10:30 AM, revealed the resident had [MEDICAL CONDITION] in place with Velcro ties and received humidified oxygen [MEDICAL CONDITION]. There was no an [MEDICAL CONDITION] at the bedside. Review of the facility's face sheet for Resident #6 revealed he had been admitted to the facility on [DATE]. Resident #6's [DIAGNOSES REDACTED]. Resident #6 had a [MEDICAL CONDITION] on admit. Resident #7 Review of the facility's Physician order [REDACTED]. Review of Nurse Notes for Resident #7, dated 04/27/18 at 5:26 PM, revealed resident sent to hospital related to nausea/vomiting/diarrhea. The note documented the Resident's secretions as yellow, thick and very large. Interview with LPN #2 on 05/04/18 at 11:20 AM, revealed Resident # 7 had [MEDICAL CONDITION] had been sent to the hospital for aspiration pneumonia. She stated she had suctioned [MEDICAL CONDITION], but if he needed deep suctioning she would get an RN or RT. LPN #2 stated that RN's or RT's were not always in the facility at all times. She was unable to find a replacement tube at the bedside. She stated that if a [MEDICAL CONDITION] needed and not in the room, they would get one from the RT's office in the Rehab building. Review of the facility's face sheet revealed the facility admitted Resident #7 on 12/19/16 with a re-admit on 1/11/18. The resident's [DIAGNOSES REDACTED]. Resident #8 Review of the facility's Physician order [REDACTED]. Observation of Resident #8 at 10:40 AM on 05/04/18, revealed the resident had [MEDICAL CONDITION] held in place [MEDICAL CONDITION] and received humidified oxygen [MEDICAL CONDITION]. There was no an [MEDICAL CONDITION] at the bedside. Review of Resident #8's face sheet revealed the facility admitted the resident on 01/05/17. His [DIAGNOSES REDACTED]. Resident #8 was admitted with a [MEDICAL CONDITION]. Resident #9 Review of Resident #9's Physicians orders for (MONTH) (YEAR), revealed to suction [MEDICAL CONDITION] needed and keep Replacement [MEDICAL CONDITION] at bedside, Shiley size #4 (keep in [MEDICAL CONDITION] bag). Observation of Resident #9's room on 05/04/18 at 11:00 AM, revealed there was no [MEDICAL CONDITION] at the bedside. Interview with LPN #4 on 05/04/17 at 11:40 AM, revealed that she sent Resident #9 out to theER on Tuesday for elevated temperature and that he was still in the hospital. LPN #4 stated that LPN's do not deep suction trachs, that RT's and RN's do deep suctioning when needed. LPN #4 stated that replacement trachs should be kept at the bedside, but she was unable to locate a [MEDICAL CONDITION] Resident #9's room. Review of Resident #9's face sheet revealed the facility admitted the resident on 04/05/18, with a Tracheotomy tube. Resident #9's [DIAGNOSES REDACTED]. Resident #10 Review of Resident #10's Physician order [REDACTED].#14 French catheter as needed for unmanageable secretions. Observation of Resident #10 on 05/04/18 at 10:45 AM, revealed [MEDICAL CONDITION] in place and humidified oxygen given [MEDICAL CONDITION]. The resident's breath sounds were audible and sounded wet and rattling. There was no [MEDICAL CONDITION] at the bedside. Interview with LPN #1 on 05/04/18 at 11:10 AM, revealed she had already suctioned Resident #10 that morning. LPN #1 stated that LPN's cannot deep suction trachs. She stated, We call Respiratory Therapists (RT's) for that. She stated that she would get the RN to suction a resident if RT was not here. LPN #1 stated that Resident #10 often had wet rattling sounding respirations and copious secretions and needed suctioning. LPN #1 stated they kept [MEDICAL CONDITION] at the bedside, however she was unable to find a replacement tube in Resident #10's room. Review of Resident #10's face sheet revealed the facility admitted the resident on 05/16/16 with a [MEDICAL CONDITION]. The resident's [DIAGNOSES REDACTED]. Interview with LPN #6 on 5/8/18 at 7:45 PM, revealed there had not been an RN on the 7:00 PM-7:00 AM shift in the past and RT was not in the building at night. She stated now there is RN coverage at night. She stated there had been occasions when residents have pulled at [MEDICAL CONDITION] and actually pulled them out and we've had to send them out to the hospital which is about 15-20 minutes away, but thankfully they did okay. The facility submitted and acceptable Allegation of Compliance (AoC) on 5/10/18, for the Immediate Jeopardy (IJ) Review of the facility's AoC revealed the facility took the following corrective actions to remove the IJ, prior to exit: At approximately 1:00 PM on (MONTH) 4, (YEAR), the facility was notified by the surveyor that an Immediate Jeopardy was being called. The facility respectfully submits this allegation of compliance (A[NAME]). 1. On (MONTH) 04, (YEAR), Mississippi State Department of Health conducted an on-site visit to the facility and informed the facility of qualified staff requirements in order to provide [MEDICAL CONDITION] care and services. [MEDICAL CONDITION] resident's included Resident #5, #6, #7, #8, #9 and #10 of the sample currently residing at the facility. The State Agency informed the facility they did not have coverage of qualified staff on all shifts, specifically the 6 p.m. to 6 a.m. shift to provide emergency [MEDICAL CONDITION] care and services to residents with tracheostomies. The facility has six (6) residents with tracheostomies on census with two (2) residents currently in the hospital. The facility has not provided Registered Nurse or Respiratory Therapist coverage for the 6:00 p.m. to 6:00 a.m. shift consistently in the past for residents with tracheostomies. 2. At 6:30 PM on (MONTH) 04, (YEAR), the facility implemented a twenty-four (24) hour Registered Nurse coverage schedule, and has continued to provide this coverage. An audit of physician orders, care plans, [MEDICAL CONDITION] kits, set-ups and equipment for Residents #5, #6, #7, #8, #9 and #10 was completed with no care concerns or harm noted on (MONTH) 04, (YEAR) at 6:00 PM. The audit was completed by the Director of Nursing (DON), the Quality Assurance (QA) Nurse and the Minimum Data Set (MDS)/Care Plan (CP) Nurses. 3. On (MONTH) 04, (YEAR), at 5:00 PM, a Quality Assurance (QA) Meeting was conducted with the Medical Director, the Director of Nursing, the Administrator, the Quality Assurance Nurse, and the Chief Nursing Officer. The QA Committee agreed the facility would provide twenty-four (24) hour Registered Nurse or Respiratory Therapy coverage for the facility when [MEDICAL CONDITION] residents were on census. Review was completed of the revised policy and procedure, tag F695, and the Nurse Practice Act with Scope of Practice for Registered Nurses, including the ability to perform deep right main stem suctioning and Licensed Practical Nurses may only perform [MEDICAL CONDITION] care, Naso-pharyngeal suctioning and suction secretions from the [MEDICAL CONDITION]. Also reviewed were emergency bed side kits readily available, care plans, facility assessment, and the revised schedule. An update was made to the policy and procedure for [MEDICAL CONDITION] care to define what an LPN's scope of practice is, what an RN's scope of practice is and twenty-four (24) Registered Nurse or Respiratory Therapy coverage when a [MEDICAL CONDITION] resident is on census. The policy and procedure was revised and approved on (MONTH) 04, (YEAR), during the Quality Assurance meeting at 5:00 PM. 4. In-servicing, provided by the Quality Assurance Nurse, began at 5:30 PM on (MONTH) 04, (YEAR). All Registered Nurses and Licensed Practical Nurses working on (MONTH) 04, (YEAR), were in-serviced on the requirement of twenty-four (24) hour Registered Nurse or Respiratory Therapy coverage when [MEDICAL CONDITION] residents are on census. There were 2 RN's and 5 LPN's on duty when inservicing began. There are seven (7) RN's and 24 LPN's currently employed with all but three (3) completing the in-service training and competency successful return demonstration check-off. These employees have not worked and will not work until training and competency return demonstration is completed. All Registered Nurses, Licensed Practical Nurses and new hires scheduled to work will not be allowed to work until in-serviced on [MEDICAL CONDITION] care and services, F695, MS Nurse Practice Act with RN and LPN scope of practice for [MEDICAL CONDITION] care and services, changes made to [MEDICAL CONDITION] resident care plans, and the revised policy and procedure. There are two (2) LPN's and one (1) RN who work as needed (PRN) who have not completed the in-service training and competency return demonstration. The Director of Nursing or Quality Assurance Nurse will review the schedule daily to assure twenty-four (24) hour coverage of a Registered Nurse or Respiratory Therapist when [MEDICAL CONDITION] residents are on census. The in-servicing and observation of the return demonstration was conducted by the Quality Assurance Nurse at 5:30 PM on (MONTH) 04, (YEAR). The facility is alleging that all activities to remove the Immediate Jeopardy were completed as of (MONTH) 04, (YEAR), and the Immediate Jeopardy was removed as of (MONTH) 05, (YEAR). Validation of the Allegation of Compliance 1. The State Agency (SA) validated through record review, observation and interviews that the facility has six (6) residents with tracheostomies on census with two (2) residents currently in the hospital and that the facility had not provided Registered Nurse or Respiratory Therapist coverage for the 6:00 PM to 6:00 AM shift consistently in the past for residents with tracheostomies. 2. The SA validated through interviews and record review that at 6:30 PM on (MONTH) 04, (YEAR), the facility implemented a twenty-four (24) hour Registered Nurse coverage schedule, and has continued to provide this coverage and that an audit of physician orders, care plans, [MEDICAL CONDITION] kits, set-ups and equipment for Residents #5, #6, #7, #8, #9 and #10 was completed with no care concerns or harm noted on (MONTH) 04, (YEAR) at 6:00 PM, and that an audit was completed by the Director of Nursing, the Quality Assurance Nurse and the MDS/CP Nurses. 3. The SA validated through record review and interviews that on (MONTH) 04, (YEAR), at 5:00 PM, a QA Meeting was conducted with the Medical Director, the Director of Nursing, the Administrator, the QA Nurse and the Chief Nursing Officer and the QA Committee recommended and implemented 24 hour Registered Nurse or Respiratory Therapy coverage for the facility when [MEDICAL CONDITION] residents were on census. The SA verified that a review was completed of the revised policy and procedure, F695, the Nurse Practice Act with Scope of Practice for Registered Nurses, which includes the ability to perform deep right main stem suctioning and Licensed Practical Nurses may only perform [MEDICAL CONDITION] care, Naso-pharyngeal suctioning and suctioning secretions from the [MEDICAL CONDITION]. Also reviewed was the emergency bed side kits readily available, care plans, Facility Assessment and the revised schedule. The SA validated through record review and interview than an update was made to the policy and procedure for [MEDICAL CONDITION] care to define what an LPN's scope of practice is, what an RN's scope of practice is and 24 hour Registered Nurse or Respiratory Therapy coverage when a [MEDICAL CONDITION] resident is on census. The SA validated that the policy and procedure was approved and that the policy and procedure was revised during the QA meeting. 4. The SA validated through record review and interviews that the in-servicing provided by the QA Nurse began at 5:30 PM on (MONTH) 04, (YEAR), and all Registered Nurses and Licensed Practical Nurses working on (MONTH) 04, (YEAR), were in-serviced on the requirement of 24 hour Registered Nurse or Respiratory Therapy coverage when [MEDICAL CONDITION] residents are on census. The SA verified that there were two (2) RN's and five (5) LPN's on duty when inservicing began, also there are currently seven (7) RN's and 24 LPN's employed with all but three (3) completing the in-service training and competency return demonstration check-offs. The SA validated through record review and interview that these employees have not worked and the facility has plans to in-service prior to return to work. The SA validated that all Registered Nurses, Licensed Practical Nurses and new hires scheduled to work will not be allowed to work until in-serviced on [MEDICAL CONDITION] care and services, F695, MS Nurse Practice Act with RN and LPN scope of practice for [MEDICAL CONDITION] care and services, changes made to [MEDICAL CONDITION] resident care plans, and the revised policy and procedure. The SA validated through record review and interviews that there are two (2) LPN's and one (1) RN who work PRN who have not completed the in-service training and competency return demonstration. The SA validated by review of the schedule and interview, that the Director of Nursing or Quality Assurance Nurse review the schedule daily to assure 24 hour coverage of a Registered Nurse or Respiratory Therapist when [MEDICAL CONDITION] residents are on census. The SA validated through record review and interviews that the in-servicing and observation of the return demonstration was conducted by the Quality Assurance Nurse at 5:30 PM on (MONTH) 04, (YEAR). The SA interviewed six (6) Licensed Practical Nurses, three (3) Registered Nurses, one (1) MDS Registered Nurse and two (2) MDS Licensed Practical Nurses. The SA also validated that the facility reviewed and updated their Facility Assessment to include 24 hour coverage of RNs and necessary supplies to ensure proper care of the resident(s) with [MEDICAL CONDITION].

Based on interview and record review the facility failed to provide qualified sufficient nursing staff, with appropriate competencies and skills, to provide respiratory services on a 24 hour basis for resident's with [MEDICAL CONDITION] for four (4) of six (6) residents with [MEDICAL CONDITION] on census. Residents #5, #6, #8, and #10 were in the facility and Residents #7 and #9 were in the hospital at the time of survey. The facility's failure to provide qualified competent nursing staff to provide deep [MEDICAL CONDITION] suctioning if necessary, and other emergency care for resident's with [MEDICAL CONDITION], caused a situation that was likely to cause serious injury, harm, impairment or death to resident's with [MEDICAL CONDITION]. This situation was determined to be an Immediate Jeopardy (IJ) on 05/04/18. The facility's Administrator was notified of the Immediate Jeopardy (IJ) on 05/04/18. An acceptable credible Allegation of Compliance (A[NAME]) was received on 05/10/18, in which the facility alleged the Immediate Jeopardy was removed on 05/05/18. The State Survey Agency (SA) validated the Allegation of Compliance on 05/11/18, prior to exit. Therefore, the Scope and Severity for Immediate Jeopardy at 42 CFR 483.35(a) (1)-(2) was lowered to an E while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility document, Staffing, revised (MONTH) (YEAR), revealed a policy statement: To assure that sufficient qualified nursing staff are available on a daily basis to meet the residents' needs for nursing care in a manner and in an environment which promote each resident's physical, mental and psychosocial well-being, thus enhancing the quality of life. Policy interpretation and implementation revealed: The facility maintains sufficient nursing staff to provide and monitor nursing and related services to meet the needs of our residents. Review of the Mississippi State 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, 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, under the direction of the RN, Advanced Practice Registered Nurse (APRN), Licensed Physician or Licensed Dentist. Review of the State Board of Nursing (BON) web site revealed frequently asked questions (FAQ's). The BON 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 to suction secretions from [MEDICAL CONDITION]. However, it is not within the scope of practice of the LPN to perform deep right main stem suctioning. If deep right main stem suctioning is required for the patient a Registered Nurse (RN) must perform the procedure. Review of the facility's nursing schedule and Staffing Grid on 05/03/18 at 3:00 PM, revealed no Registered Nurse coverage on the third shift from 04/19/18 - 05/02/18, including no coverage on the 6:00 PM-6:00 AM shift. Review of the facility's working schedules from 02/17/18 through 05/04/18, revealed 62 of 77 days had no RN coverage for the 6:00 AM-6:00 PM shift. An interview on 5/16/18 at 4:30 PM, with the Nurse Investigator at the MS State BON revealed, Yes, a RN is required in a Long Term Care facility 24 hours a day, seven (7) days per week for consultation. The RN has to be on premises and not just available by phone. The Nurse Investigator confirmed this included care provided to [MEDICAL CONDITION]. Interview with the Director of Nurses (DON), while reviewing the staffing grid on 05/03/18 at 3:00 PM, revealed she was pleased to be adding Respiratory Therapist (RT) coverage for seven (7) days a week for eight (8) hours a day, instead of just five (5) days of eight (8) hour coverage. The DON stated they had several residents with trachs in the building. The DON confirmed Registered Nurse (RN) coverage was provided at least eight (8) hours each day, but not 24 hours per day. In a further interview, on 5/4/18 at 12:15 PM, the DON confirmed LPNs could not deep suction as [MEDICAL CONDITION], it was not in their scope of practice. The DON confirmed the facility did not have RN's on all shifts, only on day shifts. The DON stated it would take approximately five (5) minutes for Emergency Medical Services (EMS) to get to the facility and an additional five (5) to 10 minutes for the patient to reach the local emergency room if EMS were called. The DON stated the Respiratory Therapist was out of town and couldn't be reached by phone and was not expected back until Tuesday. Interview with LPN #3 on 05/04/18 at 11:30 AM, revealed there were always RNs in the building on day shift and RT was not always in the building. LPN #3 stated that LPN's can't deep [MEDICAL CONDITION], if needed. Resident #5 Review of the facility's Physician order [REDACTED]. Observation of Resident #5 on 05/04/18 at 10:45 AM revealed the resident had a [MEDICAL CONDITION] held in place [MEDICAL CONDITION] and a Passy-Muir in place which allowed the resident to speak. No [MEDICAL CONDITION] was seen at the bedside. Interview with Resident #5 and her father on 05/04/18 at 1:30 PM, revealed the resident'[MEDICAL CONDITION] come out recently and the Respiratory Therapist had replaced it. All surfaces, drawers, and closets were checked and no [MEDICAL CONDITION] found and no [MEDICAL CONDITION] was found at the bedside. The father and resident both stated that they had never seen a [MEDICAL CONDITION] the room. Review of the facility's face sheet for Resident #5 revealed she had been admitted to the facility on [DATE]. Resident #5's [DIAGNOSES REDACTED]. Resident #5 was admitted with [MEDICAL CONDITION]. Resident #6 Review of the facility's Physician order [REDACTED]. Observation of Resident #6 on 05/04/18 at 10:30 AM, revealed the resident had [MEDICAL CONDITION] in place with Velcro ties and received humidified oxygen [MEDICAL CONDITION]. There was no an [MEDICAL CONDITION] at the bedside. Review of the facility's face sheet for Resident #6 revealed he had been admitted to the facility on [DATE]. Resident #6's [DIAGNOSES REDACTED]. Resident #6 had a [MEDICAL CONDITION] on admit. Resident #7 Review of the facility's Physician order [REDACTED]. Review of Nurse Notes for Resident #7, dated 04/27/18 at 5:26 PM, revealed resident sent to hospital related to nausea/vomiting/diarrhea. The note documented the Resident's secretions as yellow, thick and very large. Interview with LPN #2 on 05/04/18 at 11:20 AM, revealed Resident # 7 had [MEDICAL CONDITION] had been sent to the hospital for aspiration pneumonia. She stated she had suctioned [MEDICAL CONDITION], but if he needed deep suctioning she would get an RN or RT. LPN #2 stated that RN's or RT's were not always in the facility at all times. She was unable to find a replacement tube at the bedside. She stated that if a [MEDICAL CONDITION] needed and not in the room, they would get one from the RT's office in the Rehab building. Review of the facility's face sheet revealed the facility admitted Resident #7 on 12/19/16 with a re-admit on 1/11/18. The resident's [DIAGNOSES REDACTED]. Resident #8 Review of the facility's Physician order [REDACTED]. Observation of Resident #8 at 10:40 AM on 05/04/18, revealed the resident had [MEDICAL CONDITION] held in place [MEDICAL CONDITION] and received humidified oxygen [MEDICAL CONDITION]. There was no an [MEDICAL CONDITION] at the bedside. Review of Resident #8's face sheet revealed the facility admitted the resident on 01/05/17. His [DIAGNOSES REDACTED]. Resident #8 was admitted with a [MEDICAL CONDITION]. Resident #9 Review of Resident #9's Physicians orders for (MONTH) (YEAR), revealed to suction [MEDICAL CONDITION] needed and keep Replacement [MEDICAL CONDITION] at bedside, Shiley size #4 (keep in [MEDICAL CONDITION] bag). Observation of Resident #9's room on 05/04/18 at 11:00 AM, revealed there was no [MEDICAL CONDITION] at the bedside. Interview with LPN #4 on 05/04/17 at 11:40 AM, revealed that she sent Resident #9 out to theER on Tuesday for elevated temperature and that he was still in the hospital. LPN #4 stated that LPN's do not deep suction trachs, that RT's and RN's do deep suctioning when needed. LPN #4 stated that replacement trachs should be kept at the bedside, but she was unable to locate a [MEDICAL CONDITION] Resident #9's room. Review of Resident #9's face sheet revealed the facility admitted the resident on 04/05/18, with a Tracheotomy tube. Resident #9's [DIAGNOSES REDACTED]. Resident #10 Review of Resident #10's Physician order [REDACTED].#14 French catheter as needed for unmanageable secretions. Observation of Resident #10 on 05/04/18 at 10:45 AM, revealed [MEDICAL CONDITION] in place and humidified oxygen given [MEDICAL CONDITION]. The resident's breath sounds were audible and sounded wet and rattling. There was no [MEDICAL CONDITION] at the bedside. Interview with LPN #1 on 05/04/18 at 11:10 AM, revealed she had already suctioned Resident #10 that morning. LPN #1 stated that LPN's cannot deep suction trachs. She stated, We call Respiratory Therapists (RT's) for that. She stated that she would get the RN to suction a resident if RT was not here. LPN #1 stated that Resident #10 often had wet rattling sounding respirations and copious secretions and needed suctioning. LPN #1 stated they kept [MEDICAL CONDITION] at the bedside, however she was unable to find a replacement tube in Resident #10's room. Review of Resident #10's face sheet revealed the facility admitted the resident on 05/16/16 with a [MEDICAL CONDITION]. The resident's [DIAGNOSES REDACTED]. Interview with LPN #6 on 5/8/18 at 7:45 PM, revealed there had not been an RN on the 7:00 PM-7:00 AM shift in the past and RT was not in the building at night. She stated now there is RN coverage at night. She stated there had been occasions when residents have pulled at [MEDICAL CONDITION] and actually pulled them out and we've had to send them out to the hospital which is about 15-20 minutes away, but thankfully they did okay. The facility submitted and acceptable Allegation of Compliance (AoC) on 5/10/18, for the Immediate Jeopardy (IJ) Review of the facility's AoC revealed the facility took the following corrective actions to remove the IJ, prior to exit: At approximately 1:00 PM on (MONTH) 4, (YEAR), the facility was notified by the surveyor that an Immediate Jeopardy was being called. The facility respectfully submits this allegation of compliance (A[NAME]). 1. On (MONTH) 04, (YEAR), Mississippi State Department of Health conducted an on-site visit to the facility and informed the facility of qualified staff requirements in order to provide [MEDICAL CONDITION] care and services. [MEDICAL CONDITION] resident's included Resident #5, #6, #7, #8, #9 and #10 of the sample currently residing at the facility. The State Agency informed the facility they did not have coverage of qualified staff on all shifts, specifically the 6 p.m. to 6 a.m. shift to provide emergency [MEDICAL CONDITION] care and services to residents with tracheostomies. The facility has six (6) residents with tracheostomies on census with two (2) residents currently in the hospital. The facility has not provided Registered Nurse or Respiratory Therapist coverage for the 6:00 p.m. to 6:00 a.m. shift consistently in the past for residents with tracheostomies. 2. At 6:30 PM on (MONTH) 04, (YEAR), the facility implemented a twenty-four (24) hour Registered Nurse coverage schedule, and has continued to provide this coverage. An audit of physician orders, care plans, [MEDICAL CONDITION] kits, set-ups and equipment for Residents #5, #6, #7, #8, #9 and #10 was completed with no care concerns or harm noted on (MONTH) 04, (YEAR) at 6:00 PM. The audit was completed by the Director of Nursing (DON), the Quality Assurance (QA) Nurse and the Minimum Data Set (MDS)/Care Plan (CP) Nurses. 3. On (MONTH) 04, (YEAR), at 5:00 PM, a Quality Assurance (QA) Meeting was conducted with the Medical Director, the Director of Nursing, the Administrator, the Quality Assurance Nurse, and the Chief Nursing Officer. The QA Committee agreed the facility would provide twenty-four (24) hour Registered Nurse or Respiratory Therapy coverage for the facility when [MEDICAL CONDITION] residents were on census. Review was completed of the revised policy and procedure, tag F695, and the Nurse Practice Act with Scope of Practice for Registered Nurses, including the ability to perform deep right main stem suctioning and Licensed Practical Nurses may only perform [MEDICAL CONDITION] care, Naso-pharyngeal suctioning and suction secretions from the [MEDICAL CONDITION]. Also reviewed were emergency bed side kits readily available, care plans, facility assessment, and the revised schedule. An update was made to the policy and procedure for [MEDICAL CONDITION] care to define what an LPN's scope of practice is, what an RN's scope of practice is and twenty-four (24) Registered Nurse or Respiratory Therapy coverage when a [MEDICAL CONDITION] resident is on census. The policy and procedure was revised and approved on (MONTH) 04, (YEAR), during the Quality Assurance meeting at 5:00 PM. 4. In-servicing, provided by the Quality Assurance Nurse, began at 5:30 PM on (MONTH) 04, (YEAR). All Registered Nurses and Licensed Practical Nurses working on (MONTH) 04, (YEAR), were in-serviced on the requirement of twenty-four (24) hour Registered Nurse or Respiratory Therapy coverage when [MEDICAL CONDITION] residents are on census. There were 2 RN's and 5 LPN's on duty when inservicing began. There are seven (7) RN's and 24 LPN's currently employed with all but three (3) completing the in-service training and competency successful return demonstration check-off. These employees have not worked and will not work until training and competency return demonstration is completed. All Registered Nurses, Licensed Practical Nurses and new hires scheduled to work will not be allowed to work until in-serviced on [MEDICAL CONDITION] care and services, F695, MS Nurse Practice Act with RN and LPN scope of practice for [MEDICAL CONDITION] care and services, changes made to [MEDICAL CONDITION] resident care plans, and the revised policy and procedure. There are two (2) LPN's and one (1) RN who work as needed (PRN) who have not completed the in-service training and competency return demonstration. The Director of Nursing or Quality Assurance Nurse will review the schedule daily to assure twenty-four (24) hour coverage of a Registered Nurse or Respiratory Therapist when [MEDICAL CONDITION] residents are on census. The in-servicing and observation of the return demonstration was conducted by the Quality Assurance Nurse at 5:30 PM on (MONTH) 04, (YEAR). The facility is alleging that all activities to remove the Immediate Jeopardy were completed as of (MONTH) 04, (YEAR), and the Immediate Jeopardy was removed as of (MONTH) 05, (YEAR). Validation of the Allegation of Compliance 1. The State Agency (SA) validated through record review, observation and interviews that the facility has six (6) residents with tracheostomies on census with two (2) residents currently in the hospital and that the facility had not provided Registered Nurse or Respiratory Therapist coverage for the 6:00 PM to 6:00 AM shift consistently in the past for residents with tracheostomies. 2. The SA validated through interviews and record review that at 6:30 PM on (MONTH) 04, (YEAR), the facility implemented a twenty-four (24) hour Registered Nurse coverage schedule, and has continued to provide this coverage and that an audit of physician orders, care plans, [MEDICAL CONDITION] kits, set-ups and equipment for Residents #5, #6, #7, #8, #9 and #10 was completed with no care concerns or harm noted on (MONTH) 04, (YEAR) at 6:00 PM, and that an audit was completed by the Director of Nursing, the Quality Assurance Nurse and the MDS/CP Nurses. 3. The SA validated through record review and interviews that on (MONTH) 04, (YEAR), at 5:00 PM, a QA Meeting was conducted with the Medical Director, the Director of Nursing, the Administrator, the QA Nurse and the Chief Nursing Officer and the QA Committee recommended and implemented 24 hour Registered Nurse or Respiratory Therapy coverage for the facility when [MEDICAL CONDITION] residents were on census. The SA verified that a review was completed of the revised policy and procedure, F695, the Nurse Practice Act with Scope of Practice for Registered Nurses, which includes the ability to perform deep right main stem suctioning and Licensed Practical Nurses may only perform [MEDICAL CONDITION] care, Naso-pharyngeal suctioning and suctioning secretions from the [MEDICAL CONDITION]. Also reviewed was the emergency bed side kits readily available, care plans, Facility Assessment and the revised schedule. The SA validated through record review and interview than an update was made to the policy and procedure for [MEDICAL CONDITION] care to define what an LPN's scope of practice is, what an RN's scope of practice is and 24 hour Registered Nurse or Respiratory Therapy coverage when a [MEDICAL CONDITION] resident is on census. The SA validated that the policy and procedure was approved and that the policy and procedure was revised during the QA meeting. 4. The SA validated through record review and interviews that the in-servicing provided by the QA Nurse began at 5:30 PM on (MONTH) 04, (YEAR), and all Registered Nurses and Licensed Practical Nurses working on (MONTH) 04, (YEAR), were in-serviced on the requirement of 24 hour Registered Nurse or Respiratory Therapy coverage when [MEDICAL CONDITION] residents are on census. The SA verified that there were two (2) RN's and five (5) LPN's on duty when inservicing began, also there are currently seven (7) RN's and 24 LPN's employed with all but three (3) completing the in-service training and competency return demonstration check-offs. The SA validated through record review and interview that these employees have not worked and the facility has plans to in-service prior to return to work. The SA validated that all Registered Nurses, Licensed Practical Nurses and new hires scheduled to work will not be allowed to work until in-serviced on [MEDICAL CONDITION] care and services, F695, MS Nurse Practice Act with RN and LPN scope of practice for [MEDICAL CONDITION] care and services, changes made to [MEDICAL CONDITION] resident care plans, and the revised policy and procedure. The SA validated through record review and interviews that there are two (2) LPN's and one (1) RN who work PRN who have not completed the in-service training and competency return demonstration. The SA validated by review of the schedule and interview, that the Director of Nursing or Quality Assurance Nurse review the schedule daily to assure 24 hour coverage of a Registered Nurse or Respiratory Therapist when [MEDICAL CONDITION] residents are on census. The SA validated through record review and interviews that the in-servicing and observation of the return demonstration was conducted by the Quality Assurance Nurse at 5:30 PM on (MONTH) 04, (YEAR). The SA interviewed six (6) Licensed Practical Nurses, three (3) Registered Nurses, one (1) MDS Registered Nurse and two (2) MDS Licensed Practical Nurses. The SA also validated that the facility reviewed and updated their Facility Assessment to include 24 hour coverage of RNs and necessary supplies to ensure proper care of the resident(s) with [MEDICAL CONDITION].

Based on observation, record review, policy/procedure review, and staff interview, the facility failed to ensure qualified staff with staff competencies that are necessary to provide the level and types of care needed for six (6) of six (6) residents reviewed (Resident #5, Resident #6, Resident #8 Resident #10 were in-house and Residents #7 and #9 were in the hospital) that required [MEDICAL CONDITION] care, as evidenced by the facility failed to provide 24 hour Registered Nurse or Respiratory Therapy coverage in their facility assessment for residents that have tracheotomies. The facility's failure to provide/or update their facility assessment to include coverage of a Respiratory Therapist (RT) or Registered Nurses (RN's) to provide respiratory care, possible deep suctioning, and other emergency [MEDICAL CONDITION] care around the clock for resident's with [MEDICAL CONDITION] (trach) tubes caused a situation that was likely to cause serious injury, harm, impairment of death to resident's with [MEDICAL CONDITION]. This situation was determined to be an Immediate Jeopardy (IJ) on 5/4/18. The facility's Administrator and Director of Nurses (DON) were notified of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 05/04/18. An acceptable credible Allegation of Compliance (A[NAME]) was received on 05/10/18, in which the facility alleged the Immediate Jeopardy was removed on 05/05/18. The State Survey Agency (SA) validated the Allegation of Compliance on 05/11/18, prior to exit. Therefore, Scope and Severity for the Immediate Jeopardy and Substandard Quality of care at 42 CFR 483.70 (e)-(F838) was lowered to an [NAME] while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Policy/Procedure review of the Facility Assessment, (Revised (MONTH) (YEAR)), revealed: The facility will conduct and document a facility-wide assessment to determine what resources are necessary to care for its resident competently during both day-to-day operation and emergencies. It noted: The facility Assessment will include but not limited to ii The care required by the resident population considering the types of diseases, condition iii. The staff competencies that are necessary to provide the level and types of care needed for the resident population. Record review of the Facility Assessment, dated 11/22/17, revealed that it did not include at least one (1) Respiratory Therapist (RT) or one (1) Registered Nurse (RN) for 24 hour coverage due to residents with tracheostomies. The facility identified four (4)-six (6) residents for [MEDICAL CONDITION] care in their assessment. The facility identified one (1) RT 5 days per week. The facility identified that each RN and LPN complete a skills check off bi-annually to ensure each nurse remains competent in performing required nursing skills. Interview with the Administrator on 5/10/18 at 10:30 AM, revealed that when the facility did the emergency Quality Assurance (QA) meeting, on 5/4/18, the facility assessment was changed to include 24 hour RN or RT coverage when there [MEDICAL CONDITION] in the facility. The Administrator confirmed the RN/RT coverage had not been in the facility assessment until 5/4/18. Resident #5 Review of the facility's face sheet for Resident #5 revealed she had been admitted to the facility on [DATE] with a Trach. Resident #5's [DIAGNOSES REDACTED]. Resident #6 Review of the facility's face sheet and physician's orders [REDACTED]. Resident #6's [DIAGNOSES REDACTED]. Resident #7 Review of the facility's face sheet and physician's orders [REDACTED].#7 on 12/19/16. The resident's [DIAGNOSES REDACTED]. Resident #8 Review of Resident #8's face sheet and physician's orders [REDACTED]. His [DIAGNOSES REDACTED]. Resident #8 had a [MEDICAL CONDITION]. Resident #9 Review of Resident #9's face sheet and physician's orders [REDACTED]. Resident #9's [DIAGNOSES REDACTED]. Resident #9 had a [MEDICAL CONDITION]. Resident #10 Review of Resident #10's face sheet and physician's orders [REDACTED]. The resident's [DIAGNOSES REDACTED]. The facility submitted and acceptable Allegation of Compliance (AoC) on 5/10/18, for the Immediate Jeopardy (IJ) Review of the facility's AoC revealed the facility took the following corrective actions to remove the IJ, prior to exit: At approximately 1:00 PM on (MONTH) 4, (YEAR), the facility was notified by the surveyor that an Immediate Jeopardy was being called. The facility respectfully submits this allegation of compliance (A[NAME]). 1. On (MONTH) 04, (YEAR), Mississippi State Department of Health conducted an on-site visit to the facility and informed the facility of qualified staff requirements in order to provide [MEDICAL CONDITION] care and services. [MEDICAL CONDITION] resident's included Resident #5, #6, #7, #8, #9 and #10 of the sample currently residing at the facility. The State Agency informed the facility they did not have coverage of qualified staff on all shifts, specifically the 6 p.m. to 6 a.m. shift to provide emergency [MEDICAL CONDITION] care and services to residents with tracheostomies. The facility has six (6) residents with tracheostomies on census with two (2) residents currently in the hospital. The facility has not provided Registered Nurse or Respiratory Therapist coverage for the 6:00 p.m. to 6:00 a.m. shift consistently in the past for residents with tracheostomies. 2. At 6:30 PM on (MONTH) 04, (YEAR), the facility implemented a twenty-four (24) hour Registered Nurse coverage schedule, and has continued to provide this coverage. An audit of physician orders, care plans, [MEDICAL CONDITION] kits, set-ups and equipment for Residents #5, #6, #7, #8, #9 and #10 was completed with no care concerns or harm noted on (MONTH) 04, (YEAR) at 6:00 PM. The audit was completed by the Director of Nursing (DON), the Quality Assurance (QA) Nurse and the Minimum Data Set (MDS)/Care Plan (CP) Nurses. 3. On (MONTH) 04, (YEAR), at 5:00 PM, a Quality Assurance (QA) Meeting was conducted with the Medical Director, the Director of Nursing, the Administrator, the Quality Assurance Nurse, and the Chief Nursing Officer. The QA Committee agreed the facility would provide twenty-four (24) hour Registered Nurse or Respiratory Therapy coverage for the facility when [MEDICAL CONDITION] residents were on census. Review was completed of the revised policy and procedure, tag F695, and the Nurse Practice Act with Scope of Practice for Registered Nurses, including the ability to perform deep right main stem suctioning and Licensed Practical Nurses may only perform [MEDICAL CONDITION] care, Naso-pharyngeal suctioning and suction secretions from the [MEDICAL CONDITION]. Also reviewed were emergency bed side kits readily available, care plans, facility assessment, and the revised schedule. An update was made to the policy and procedure for [MEDICAL CONDITION] care to define what an LPN's scope of practice is, what an RN's scope of practice is and twenty-four (24) Registered Nurse or Respiratory Therapy coverage when a [MEDICAL CONDITION] resident is on census. The policy and procedure was revised and approved on (MONTH) 04, (YEAR), during the Quality Assurance meeting at 5:00 PM. 4. In-servicing, provided by the Quality Assurance Nurse, began at 5:30 PM on (MONTH) 04, (YEAR). All Registered Nurses and Licensed Practical Nurses working on (MONTH) 04, (YEAR), were in-serviced on the requirement of twenty-four (24) hour Registered Nurse or Respiratory Therapy coverage when [MEDICAL CONDITION] residents are on census. There were 2 RN's and 5 LPN's on duty when inservicing began. There are seven (7) RN's and 24 LPN's currently employed with all but three (3) completing the in-service training and competency successful return demonstration check-off. These employees have not worked and will not work until training and competency return demonstration is completed. All Registered Nurses, Licensed Practical Nurses and new hires scheduled to work will not be allowed to work until in-serviced on [MEDICAL CONDITION] care and services, F695, MS Nurse Practice Act with RN and LPN scope of practice for [MEDICAL CONDITION] care and services, changes made to [MEDICAL CONDITION] resident care plans, and the revised policy and procedure. There are two (2) LPN's and one (1) RN who work as needed (PRN) who have not completed the in-service training and competency return demonstration. The Director of Nursing or Quality Assurance Nurse will review the schedule daily to assure twenty-four (24) hour coverage of a Registered Nurse or Respiratory Therapist when [MEDICAL CONDITION] residents are on census. The in-servicing and observation of the return demonstration was conducted by the Quality Assurance Nurse at 5:30 PM on (MONTH) 04, (YEAR). The facility is alleging that all activities to remove the Immediate Jeopardy were completed as of (MONTH) 04, (YEAR), and the Immediate Jeopardy was removed as of (MONTH) 05, (YEAR). Validation of the Allegation of Compliance 1. The State Agency (SA) validated through record review, observation and interviews that the facility has six (6) residents with tracheostomies on census with two (2) residents currently in the hospital and that the facility had not provided Registered Nurse or Respiratory Therapist coverage for the 6:00 PM to 6:00 AM shift consistently in the past for residents with tracheostomies. 2. The SA validated through interviews and record review that at 6:30 PM on (MONTH) 04, (YEAR), the facility implemented a twenty-four (24) hour Registered Nurse coverage schedule, and has continued to provide this coverage and that an audit of physician orders, care plans, [MEDICAL CONDITION] kits, set-ups and equipment for Residents #5, #6, #7, #8, #9 and #10 was completed with no care concerns or harm noted on (MONTH) 04, (YEAR) at 6:00 PM, and that an audit was completed by the Director of Nursing, the Quality Assurance Nurse and the MDS/CP Nurses. 3. The SA validated through record review and interviews that on (MONTH) 04, (YEAR), at 5:00 PM, a QA Meeting was conducted with the Medical Director, the Director of Nursing, the Administrator, the QA Nurse and the Chief Nursing Officer and the QA Committee recommended and implemented 24 hour Registered Nurse or Respiratory Therapy coverage for the facility when [MEDICAL CONDITION] residents were on census. The SA verified that a review was completed of the revised policy and procedure, F695, the Nurse Practice Act with Scope of Practice for Registered Nurses, which includes the ability to perform deep right main stem suctioning and Licensed Practical Nurses may only perform [MEDICAL CONDITION] care, Naso-pharyngeal suctioning and suctioning secretions from the [MEDICAL CONDITION]. Also reviewed was the emergency bed side kits readily available, care plans, Facility Assessment and the revised schedule. The SA validated through record review and interview than an update was made to the policy and procedure for [MEDICAL CONDITION] care to define what an LPN's scope of practice is, what an RN's scope of practice is and 24 hour Registered Nurse or Respiratory Therapy coverage when a [MEDICAL CONDITION] resident is on census. The SA validated that the policy and procedure was approved and that the policy and procedure was revised during the QA meeting. 4. The SA validated through record review and interviews that the in-servicing provided by the QA Nurse began at 5:30 PM on (MONTH) 04, (YEAR), and all Registered Nurses and Licensed Practical Nurses working on (MONTH) 04, (YEAR), were in-serviced on the requirement of 24 hour Registered Nurse or Respiratory Therapy coverage when [MEDICAL CONDITION] residents are on census. The SA verified that there were two (2) RN's and five (5) LPN's on duty when inservicing began, also there are currently seven (7) RN's and 24 LPN's employed with all but three (3) completing the in-service training and competency return demonstration check-offs. The SA validated through record review and interview that these employees have not worked and the facility has plans to in-service prior to return to work. The SA validated that all Registered Nurses, Licensed Practical Nurses and new hires scheduled to work will not be allowed to work until in-serviced on [MEDICAL CONDITION] care and services, F695, MS Nurse Practice Act with RN and LPN scope of practice for [MEDICAL CONDITION] care and services, changes made to [MEDICAL CONDITION] resident care plans, and the revised policy and procedure. The SA validated through record review and interviews that there are two (2) LPN's and one (1) RN who work PRN who have not completed the in-service training and competency return demonstration. The SA validated by review of the schedule and interview, that the Director of Nursing or Quality Assurance Nurse review the schedule daily to assure 24 hour coverage of a Registered Nurse or Respiratory Therapist when [MEDICAL CONDITION] residents are on census. The SA validated through record review and interviews that the in-servicing and observation of the return demonstration was conducted by the Quality Assurance Nurse at 5:30 PM on (MONTH) 04, (YEAR). The SA interviewed six (6) Licensed Practical Nurses, three (3) Registered Nurses, one (1) MDS Registered Nurse and two (2) MDS Licensed Practical Nurses. The SA also validated that the facility reviewed and updated their Facility Assessment to include 24 hour coverage of RNs and necessary supplies to ensure proper care of the resident(s) with [MEDICAL CONDITION].

Based on observation, record review, policy/procedure review, and staff interview, the facility failed to ensure qualified staff with staff competencies that are necessary to provide the level and types of care needed for six (6) of six (6) residents reviewed (Resident #5, Resident #6, Resident #8 Resident #10 were in-house and Residents #7 and #9 were in the hospital) that required [MEDICAL CONDITION] care, as evidenced by the facility failed to provide 24 hour Registered Nurse or Respiratory Therapy coverage in their facility assessment for residents that have tracheotomies. The facility's failure to provide/or update their facility assessment to include coverage of a Respiratory Therapist (RT) or Registered Nurses (RN's) to provide respiratory care, possible deep suctioning, and other emergency [MEDICAL CONDITION] care around the clock for resident's with [MEDICAL CONDITION] (trach) tubes caused a situation that was likely to cause serious injury, harm, impairment of death to resident's with [MEDICAL CONDITION]. This situation was determined to be an Immediate Jeopardy (IJ) on 5/4/18. The facility's Administrator and Director of Nurses (DON) were notified of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 05/04/18. An acceptable credible Allegation of Compliance (A[NAME]) was received on 05/10/18, in which the facility alleged the Immediate Jeopardy was removed on 05/05/18. The State Survey Agency (SA) validated the Allegation of Compliance on 05/11/18, prior to exit. Therefore, Scope and Severity for the Immediate Jeopardy and Substandard Quality of care at 42 CFR 483.70 (e)-(F838) was lowered to an E while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Policy/Procedure review of the Facility Assessment, (Revised (MONTH) (YEAR)), revealed: The facility will conduct and document a facility-wide assessment to determine what resources are necessary to care for its resident competently during both day-to-day operation and emergencies. It noted: The facility Assessment will include but not limited to ii The care required by the resident population considering the types of diseases, condition iii. The staff competencies that are necessary to provide the level and types of care needed for the resident population. Record review of the Facility Assessment, dated 11/22/17, revealed that it did not include at least one (1) Respiratory Therapist (RT) or one (1) Registered Nurse (RN) for 24 hour coverage due to residents with tracheostomies. The facility identified four (4)-six (6) residents for [MEDICAL CONDITION] care in their assessment. The facility identified one (1) RT 5 days per week. The facility identified that each RN and LPN complete a skills check off bi-annually to ensure each nurse remains competent in performing required nursing skills. Interview with the Administrator on 5/10/18 at 10:30 AM, revealed that when the facility did the emergency Quality Assurance (QA) meeting, on 5/4/18, the facility assessment was changed to include 24 hour RN or RT coverage when there [MEDICAL CONDITION] in the facility. The Administrator confirmed the RN/RT coverage had not been in the facility assessment until 5/4/18. Resident #5 Review of the facility's face sheet for Resident #5 revealed she had been admitted to the facility on [DATE] with a Trach. Resident #5's [DIAGNOSES REDACTED]. Resident #6 Review of the facility's face sheet and physician's orders [REDACTED]. Resident #6's [DIAGNOSES REDACTED]. Resident #7 Review of the facility's face sheet and physician's orders [REDACTED].#7 on 12/19/16. The resident's [DIAGNOSES REDACTED]. Resident #8 Review of Resident #8's face sheet and physician's orders [REDACTED]. His [DIAGNOSES REDACTED]. Resident #8 had a [MEDICAL CONDITION]. Resident #9 Review of Resident #9's face sheet and physician's orders [REDACTED]. Resident #9's [DIAGNOSES REDACTED]. Resident #9 had a [MEDICAL CONDITION]. Resident #10 Review of Resident #10's face sheet and physician's orders [REDACTED]. The resident's [DIAGNOSES REDACTED]. The facility submitted and acceptable Allegation of Compliance (AoC) on 5/10/18, for the Immediate Jeopardy (IJ) Review of the facility's AoC revealed the facility took the following corrective actions to remove the IJ, prior to exit: At approximately 1:00 PM on (MONTH) 4, (YEAR), the facility was notified by the surveyor that an Immediate Jeopardy was being called. The facility respectfully submits this allegation of compliance (A[NAME]). 1. On (MONTH) 04, (YEAR), Mississippi State Department of Health conducted an on-site visit to the facility and informed the facility of qualified staff requirements in order to provide [MEDICAL CONDITION] care and services. [MEDICAL CONDITION] resident's included Resident #5, #6, #7, #8, #9 and #10 of the sample currently residing at the facility. The State Agency informed the facility they did not have coverage of qualified staff on all shifts, specifically the 6 p.m. to 6 a.m. shift to provide emergency [MEDICAL CONDITION] care and services to residents with tracheostomies. The facility has six (6) residents with tracheostomies on census with two (2) residents currently in the hospital. The facility has not provided Registered Nurse or Respiratory Therapist coverage for the 6:00 p.m. to 6:00 a.m. shift consistently in the past for residents with tracheostomies. 2. At 6:30 PM on (MONTH) 04, (YEAR), the facility implemented a twenty-four (24) hour Registered Nurse coverage schedule, and has continued to provide this coverage. An audit of physician orders, care plans, [MEDICAL CONDITION] kits, set-ups and equipment for Residents #5, #6, #7, #8, #9 and #10 was completed with no care concerns or harm noted on (MONTH) 04, (YEAR) at 6:00 PM. The audit was completed by the Director of Nursing (DON), the Quality Assurance (QA) Nurse and the Minimum Data Set (MDS)/Care Plan (CP) Nurses. 3. On (MONTH) 04, (YEAR), at 5:00 PM, a Quality Assurance (QA) Meeting was conducted with the Medical Director, the Director of Nursing, the Administrator, the Quality Assurance Nurse, and the Chief Nursing Officer. The QA Committee agreed the facility would provide twenty-four (24) hour Registered Nurse or Respiratory Therapy coverage for the facility when [MEDICAL CONDITION] residents were on census. Review was completed of the revised policy and procedure, tag F695, and the Nurse Practice Act with Scope of Practice for Registered Nurses, including the ability to perform deep right main stem suctioning and Licensed Practical Nurses may only perform [MEDICAL CONDITION] care, Naso-pharyngeal suctioning and suction secretions from the [MEDICAL CONDITION]. Also reviewed were emergency bed side kits readily available, care plans, facility assessment, and the revised schedule. An update was made to the policy and procedure for [MEDICAL CONDITION] care to define what an LPN's scope of practice is, what an RN's scope of practice is and twenty-four (24) Registered Nurse or Respiratory Therapy coverage when a [MEDICAL CONDITION] resident is on census. The policy and procedure was revised and approved on (MONTH) 04, (YEAR), during the Quality Assurance meeting at 5:00 PM. 4. In-servicing, provided by the Quality Assurance Nurse, began at 5:30 PM on (MONTH) 04, (YEAR). All Registered Nurses and Licensed Practical Nurses working on (MONTH) 04, (YEAR), were in-serviced on the requirement of twenty-four (24) hour Registered Nurse or Respiratory Therapy coverage when [MEDICAL CONDITION] residents are on census. There were 2 RN's and 5 LPN's on duty when inservicing began. There are seven (7) RN's and 24 LPN's currently employed with all but three (3) completing the in-service training and competency successful return demonstration check-off. These employees have not worked and will not work until training and competency return demonstration is completed. All Registered Nurses, Licensed Practical Nurses and new hires scheduled to work will not be allowed to work until in-serviced on [MEDICAL CONDITION] care and services, F695, MS Nurse Practice Act with RN and LPN scope of practice for [MEDICAL CONDITION] care and services, changes made to [MEDICAL CONDITION] resident care plans, and the revised policy and procedure. There are two (2) LPN's and one (1) RN who work as needed (PRN) who have not completed the in-service training and competency return demonstration. The Director of Nursing or Quality Assurance Nurse will review the schedule daily to assure twenty-four (24) hour coverage of a Registered Nurse or Respiratory Therapist when [MEDICAL CONDITION] residents are on census. The in-servicing and observation of the return demonstration was conducted by the Quality Assurance Nurse at 5:30 PM on (MONTH) 04, (YEAR). The facility is alleging that all activities to remove the Immediate Jeopardy were completed as of (MONTH) 04, (YEAR), and the Immediate Jeopardy was removed as of (MONTH) 05, (YEAR). Validation of the Allegation of Compliance 1. The State Agency (SA) validated through record review, observation and interviews that the facility has six (6) residents with tracheostomies on census with two (2) residents currently in the hospital and that the facility had not provided Registered Nurse or Respiratory Therapist coverage for the 6:00 PM to 6:00 AM shift consistently in the past for residents with tracheostomies. 2. The SA validated through interviews and record review that at 6:30 PM on (MONTH) 04, (YEAR), the facility implemented a twenty-four (24) hour Registered Nurse coverage schedule, and has continued to provide this coverage and that an audit of physician orders, care plans, [MEDICAL CONDITION] kits, set-ups and equipment for Residents #5, #6, #7, #8, #9 and #10 was completed with no care concerns or harm noted on (MONTH) 04, (YEAR) at 6:00 PM, and that an audit was completed by the Director of Nursing, the Quality Assurance Nurse and the MDS/CP Nurses. 3. The SA validated through record review and interviews that on (MONTH) 04, (YEAR), at 5:00 PM, a QA Meeting was conducted with the Medical Director, the Director of Nursing, the Administrator, the QA Nurse and the Chief Nursing Officer and the QA Committee recommended and implemented 24 hour Registered Nurse or Respiratory Therapy coverage for the facility when [MEDICAL CONDITION] residents were on census. The SA verified that a review was completed of the revised policy and procedure, F695, the Nurse Practice Act with Scope of Practice for Registered Nurses, which includes the ability to perform deep right main stem suctioning and Licensed Practical Nurses may only perform [MEDICAL CONDITION] care, Naso-pharyngeal suctioning and suctioning secretions from the [MEDICAL CONDITION]. Also reviewed was the emergency bed side kits readily available, care plans, Facility Assessment and the revised schedule. The SA validated through record review and interview than an update was made to the policy and procedure for [MEDICAL CONDITION] care to define what an LPN's scope of practice is, what an RN's scope of practice is and 24 hour Registered Nurse or Respiratory Therapy coverage when a [MEDICAL CONDITION] resident is on census. The SA validated that the policy and procedure was approved and that the policy and procedure was revised during the QA meeting. 4. The SA validated through record review and interviews that the in-servicing provided by the QA Nurse began at 5:30 PM on (MONTH) 04, (YEAR), and all Registered Nurses and Licensed Practical Nurses working on (MONTH) 04, (YEAR), were in-serviced on the requirement of 24 hour Registered Nurse or Respiratory Therapy coverage when [MEDICAL CONDITION] residents are on census. The SA verified that there were two (2) RN's and five (5) LPN's on duty when inservicing began, also there are currently seven (7) RN's and 24 LPN's employed with all but three (3) completing the in-service training and competency return demonstration check-offs. The SA validated through record review and interview that these employees have not worked and the facility has plans to in-service prior to return to work. The SA validated that all Registered Nurses, Licensed Practical Nurses and new hires scheduled to work will not be allowed to work until in-serviced on [MEDICAL CONDITION] care and services, F695, MS Nurse Practice Act with RN and LPN scope of practice for [MEDICAL CONDITION] care and services, changes made to [MEDICAL CONDITION] resident care plans, and the revised policy and procedure. The SA validated through record review and interviews that there are two (2) LPN's and one (1) RN who work PRN who have not completed the in-service training and competency return demonstration. The SA validated by review of the schedule and interview, that the Director of Nursing or Quality Assurance Nurse review the schedule daily to assure 24 hour coverage of a Registered Nurse or Respiratory Therapist when [MEDICAL CONDITION] residents are on census. The SA validated through record review and interviews that the in-servicing and observation of the return demonstration was conducted by the Quality Assurance Nurse at 5:30 PM on (MONTH) 04, (YEAR). The SA interviewed six (6) Licensed Practical Nurses, three (3) Registered Nurses, one (1) MDS Registered Nurse and two (2) MDS Licensed Practical Nurses. The SA also validated that the facility reviewed and updated their Facility Assessment to include 24 hour coverage of RNs and necessary supplies to ensure proper care of the resident(s) with [MEDICAL CONDITION].