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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, record review, and facility policy review, the facility failed to develop and implement a Comprehensive Care Plan related to Resident #214's tracheostomy (trach) care or the resident's self trach care and interventions to ensure Registered Nurse (RN) or Respiratory Therapist (RT) coverage 24 hours per day seven (7) days per week to provide deep tracheal suctioning or emergency tracheostomy care if needed, and to implement Resident #50's Care Plan related to Activities of Daily Living (ADL) for two (2) of 19 Comprehensive Care Plans reviewed. Resident #214 was admitted by the facility from the hospital, on 01/24/2020, with a tracheostomy she had been providing self trach care for at home. Resident #214 was admitted to the hospital on [DATE] due to alteration in mental status, and the assessment by the physician was Acute Metabolic Encephalopathy. Resident #214 had previously been hospitalized from [DATE] to 01/14/2020 for Pneumonia. Her husband reported since she was discharged from the hospital, on 01/14/2020, she was sleeping a lot and when she was awake, she was confused. Resident #214's Baseline Care Plan, dated 01/24/2020, revealed the facility did address trach care to be done daily, but the care plan did not address Resident #214 performing self trach care or the need for RN and/or RT coverage 24 hours per day seven (7) days per week to provide deep tracheal suctioning and possible emergency tracheostomy care. Resident #214 had a Physician's Order, dated 01/28/2020, to provide her own trach care and suction the trach as needed to remove excess secretions. The facility's failure to develop and implement a Comprehensive Care Plan to address Resident #214's trach care and self trach care, and providing coverage 24 hours per day seven (7) days per week for the RN and/or RT roles to provide deep tracheal suctioning and possible tracheostomy emergency care placed Resident #214 and other residents with tracheostomies at risk for serious injury, harm, impairment or death. On 02/17/2020 at 7:50 PM, the SA notified the facility's Administrator and Director of Nurses (DON) of the Immediate Jeopardy (IJ). The facility submitted an acceptable Immediate Jeopardy Removal Plan, on 02/19/2020, in which the facility alleged all corrective actions were completed on 02/19/2020, and the IJ was removed on 02/19/2020. The SA validated the facility's Immediate Jeopardy Removal Plan, on 02/20/2020, and determined the IJ was removed on 2/19/2020, prior to the SA's exit. Findings include: A review of the facility's policy titled Care Plans, Comprehensive Person-Centered, with a revision date of December 2016, revealed 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain the resident's highest practicable physical, mental, and psychological well-being; g. Incorporate identified problem areas; l. Identify the professional services that are responsible for each element of care; o. Reflect currently recognized standards of practice for problem areas and conditions. 10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS/Minimum Data Set). 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. Review of the facility's policy titled, Resident Assessment Instrument, revised September 2010, revealed a comprehensive assessment of a resident's needs shall be made within fourteen (14) days of the resident's admission. The Policy Interpretation and Implementation revealed: 3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. 4. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. 6. Within seven (7) days of the completion of the resident assessment, a comprehensive care plan will be developed. Review of the facility's policy titled, Suctioning the Lower Airway (Endotracheal (ET) or Tracheostomy Tube), with a revised date of October 2010, revealed the training was addressed for in-servicing on the policy and demonstrated competency in the procedure is required on hire, and at least annually for Registered Nurses. Resident #214 Review of Resident #214's Care Plans revealed a Baseline Care Plan, dated 01/24/2020, where the facility identified a Skin Care Need and Special Treatments/Procedures for Trach (Tracheostomy) care and oxygen (O2) at five liters per minute (5L/M) via the trach tube. The Baseline Care Plan also identified tracheostomy care to be done daily. The Baseline Care Plan did not address Resident #214's self trach care and the need for RN and/or RT roles to provide deep tracheal suctioning and possible tracheostomy emergency care. The facility did not develop a Comprehensive Care Plan regarding these concerns until the SA identified them on 02/17/2020. Resident #214 also had a Physician's Order, dated 01/28/2020, to provide her own trach care and suction the trach as needed to remove excess secretions. Review of Resident #214's Comprehensive Care Plan revealed the facility developed the following Problem/Needs, dated 02/17/2020: (1) The Potential for Complications related to (r/t) Tracheostomy. The Interventions included: Deep suctioning as needed (PRN) for thick copious amounts of secretions resident is unable to expel. If resident becomes decannulated, cannula to be replaced using sterile technique. Respiratory Therapist to assess the resident each visit to facility and will be available for consultation PRN. Assess for signs and symptoms (s/s) of respiratory distress to include, but not limited to labored breathing, rapid breathing, cyanosis, low blood pressure, restlessness, dyspnea, decreased O2 (oxygen), rattling breath sounds PRN (as needed), and notify the MD (Medical Doctor) of any negative findings. The Roles for these interventions was assigned to the RN/RT. (2) At Risk for Aspiration r/t Tracheostomy. The Interventions included: Assess for s/s of respiratory distress. Assess for s/s of aspiration to include but not limited to fever, cough, shortness of breath (SOB), fatigue PRN and notify the MD of any negative findings. The Roles were assigned to the RN/RT. (3) Resident Prefers To Perform Own Trach Care. The Interventions included: Allow resident to perform own trach care. Honor resident's right to perform own trach care. RN staffing 24 hours per day seven (7) days per week in case of emergency trach care. Encourage resident to notify Licensed Practical Nurse (LPN) or RN prior to performing trach care. An interview, on 02/19/2020 at 3:55 PM, revealed Licensed Practical Nurse (LPN) #5/Care Plan Nurse, stated she was responsible for the care plans. LPN #5 stated the facility uses the admission assessment to develop the care plan, and the MDS Nurse was responsible to check the care plan and make sure it is done and accurate. LPN #5 stated the facility has a new computer charting system that started in October 2019, and the system caused her to get behind on the care plans. LPN #5 stated the nurses are supposed to let her know of any changes in the residents so she can update the care plans. Review of Resident #214's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/30/2020, revealed the Special Treatments/Programs section was checked for oxygen (O2) use and tracheostomy care. Suctioning was not checked. Resident #214's Basic Interview for Mental Status (BIMS) score was 11, which indicated moderate cognitive impairment. The MDS also revealed Resident #214 did not have any vision, hearing or speech deficits, and was able to make herself understood to others, and she was able to understand others. On 02/17/2020 at 3:55 PM, an observation revealed Resident #214 was lying in bed, awake, alert, and oriented times four (X 4), which indicated the resident was aware of her place, time, date, and situation. Resident #214 had a tracheostomy intact. No distress was noted. An interview, on 02/17/2020 at 4:09 PM, revealed Resident #214 stated the facility told her she would have to take care of her tracheostomy. Review of Resident #214's Medical Record revealed there were no assessments regarding the resident's ability to perform self trach care until the Departmental Notes-Respiratory Therapy, dated 02/18/2020 at 9:07 PM, late entry for 6:30 PM, for Resident Trach Care Self Performance, revealed Resident #214 is performing adequate trach care for herself to a seven (7) year established trach. The RT explains due to the resident's report of being sick at her stomach and not wanting to move the trach around very much right now, they agreed for her to demonstrate and describe how she provided her trach care. The RT also documented she had asked the resident if she wanted the RT to get the nurse, but the resident reported the nurse had already given her something for the nausea. The RT documented Resident #214's demonstration showed the resident was comfortable and competent to provide her own trach care, and the RT's opinion was that Resident #214 was very competent in doing her own trach care. An interview, on 02/19/2020 at 5:20 PM, revealed the Director of Nurses (DON) stated she should have observed Resident #214 perform her trach care to ensure she was doing it correctly. On 02/17/20 at 4:00 PM, an interview with Director of Nursing (DON) and Administer revealed they do not have a Register Nurse 24 hours a day seven (7) days a week at the facility. They stated Resident #214 takes care of her trach herself, and the resident has had it for seven years. The Administrator and DON both agreed Resident #214 knows how to take care of it herself and she prefers to take care it herself. On 02/18/2020 at 1:55 PM, an interview with Licensed Practical Nurse (LPN) #4, revealed to the best of her knowledge the LPN and RN does the trach care. The LPN does the suctioning and deep suctioning is done by the RN. On 02/18/2020 at 3:00 PM, an interview with the DON and Administer revealed the DON stated she just did not think about the 24 hour RN/RT care. The DON said it would take the ambulance five (5) minutes to get here and two (2) minutes to get to the hospital. It would be seven (7) minutes total time, and that could cause brain damage to the resident. On 02/18/2020 at 3:26 PM, an interview with LPN #3 revealed she has been employed at the facility for nine (9) years, and this is the first trach resident since she has been here. LPN #3 stated Resident #214 does her own trach care. Review of Resident #214's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/20/2020, revealed the resident required extensive assistance with one person physical assist for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. Resident #50 A review of Resident #50's Comprehensive Care Plan revealed the facility failed to provide Resident #50's nail care. The Care Plan revealed the Problem/Need, dated 06/14/2017, the resident requires assistance with Activities of Daily Living (ADL) related to (r/t) impaired mobility and requires one person extensive assistance with personal hygiene. The Care Plan addressed the Problem/Need, dated 01/09/2020, Psoriasis to the left lower leg and the Approaches included keep nails clean and trimmed. Staff responsible was listed as Nursing/CNA. An observation and interview, on 02/17/2020 at 12:15 PM, revealed Resident #50's Family Member #1 was clipping the resident's toenails. Family Member #1 stated she was trimming the resident's nails because the facility staff would never do it. Family Member #1 said she had already trimmed the resident's fingernails. Family Member #1 stated the facility told her someone comes once a year to take care of the toenails. The resident stated she didn't ask for staff to do it because she didn't want to bother anyone. An interview, on 02/17/2020 at 12:30 PM, with Certified Nurse Assistant (CNA) #1 revealed she stated hospice does the resident's nails, and that the CNAs were supposed to check the resident's nails during their bath time. CNA #1 said she had been on A Hall off and on the past couple of weeks but had not notified the nurse or her partner Resident #50's nails needed to be trimmed. CNA #1 said when she sees long nails she tells her partner. CNA #1 said she had noticed the long nails, but she did not like to cut the nails because she cuts to low, to short, all the way down. CNA #1 said when she sees long nails she tells her partner. On 02/17/2020 at 12:35 PM, an observation and interview with the Assistant Director of Nurses (ADON) revealed the ADON measured Resident #50's left great toenail and right great toenails at 0.5 centimeters (cm). The ADON also observed the smaller toenails were curling around the end of the toes on the right foot. The ADON stated the CNAs tell the nurses about the toenails, and there is a communication book, but usually they tell the nurses. An interview, on 02/19/2020 at 3:08 PM, with LPN #1 revealed Resident's #50's care plan was not followed if her nails were not kept trimmed. LPN #1 reported Resident #50 required assistance with cutting her nails. LPN #1 stated she would ensure tasks were done according to the care plan by making rounds to see if CNAs had completed tasks assigned or doing the tasks herself. LPN #1 stated sometimes the CNAs would ask the nurse to assist in completing nail care and that dependent residents relied on staff to complete hygiene tasks. LPN #1 stated she had not been informed Resident #50's nails needed trimming by anyone, but the CNAs generally trimmed the nails or asked the nurse to. During an interview and review of the care plan, on 02/19/2020 at 4:00 PM, the DON stated nurses don't usually trim toenails and CNAs were generally responsible for trimming nails. The DON stated that if the care plan stated CNAs or nursing were listed as responsible for trimming nails, and the resident's nails were not trimmed, the care plan was not followed. An interview, on 02/19/2020 at 2:50 PM, revealed CNA #2 said Resident #50 required total care assistance. CNA #1 stated she knows the resident's care needs because the resident's ADL care is listed in the Kiosk (computer system). CNA #1 stated nail care is provided during the resident's bath. On 02/19/2020 at 4:00 PM, an interview with the DON revealed the weekly skin assessments and body audits do not specifically address fingernails and toenails. The skin assessments and body audits address whether skin is intact or not intact. The DON stated the staff just knows nail care should be done, it is a part of what they should be doing. The DON reported a Podiatrist visits the facility every three (3) months to provide nail care also. Review of Resident #50's last Podiatry Note, dated 05/28/2019, revealed Resident #50 was examined by the Podiatrist and would need to be seen again as needed or per physician's order or sooner if any adverse changes in foot condition or foot status. Review of the Face Sheet revealed Resident #50 was admitted by the facility, on 10/27/2010, and re-admitted on [DATE], with the included diagnoses Essential Hypertension, Heart Failure, Psoriasis and Idiopathic Peripheral Autonomic Neuropathy. Review of Resident #50 Quarterly MDS, with an ARD of 01/20/2020, revealed a BIMS score of 4, which indicated severe cognitive impairment. The MDS further revealed Resident #50 required extensive assistance with two person physical assist with bed mobility, transfers, dressing and toileting. Resident #50 required extensive assistance with one person physical assist with locomotion on and off the unit, and was totally dependent on staff for bathing. Resident #50 only required limited assistance with one person physical assist with eating. Resident #50's vision was impaired and she could only see large print, but not regular print in newspapers or magazines. The resident's speech and hearing was not impaired, and she was able to make herself understood to others and she was able to understand others. The facility's accepted Immediate Jeopardy Removal Plan: Haven Hall Healthcare Center Administrator and Director of Nursing were notified of Immediate Jeopardy and Substandard Quality of Care on, 2/17/2020 at 7:50 p.m. related to the facility admitting Resident #214 on 1/24/2020 with a Tracheostomy and (1) Failure to assess resident during routine Tracheostomy care performed per resident, (2) Failure to develop and implement a care plan for the care of resident's tracheostomy, and (3) Failure to provide around the clock Registered Nurse (RN) or Respiratory Therapist (RT) coverage to provide deep suctioning and emergency Tracheostomy care, placed the resident at risk for serious injury, harm, impairment. Immediately upon notification: The Director of Nursing put in place for Registered Nurse coverage to be 24/7. An emergency Quality Assurance meeting was called on 2/17/2020 at 8:14 PM to discuss (1) Failure to assess resident during routine Tracheostomy care performed per resident, (2) Failure to develop and implement a care plan for the care of resident's tracheostomy, and (3) Failure to provide around the clock Registered Nurse (RN) or Respiratory Therapist (RT) coverage to provide deep suctioning and emergency Tracheostomy care, placed the resident at risk for serious injury, harm, impairment. Those in attendance were the Medical Director, Administrator, Director of Nursing, Nurse Consultant, Assistant Director of Nursing, Minimal- Data Set Nurse, Care Plan Nurse, Social Worker, and Admissions/Medicare Nurse. Policy and Procedure on Tracheostomy Care was reviewed on 2/17/20, by the Director of Nursing with no policy changes implemented. This policy was revised 8/2013. Facility identified through record review by the Director of Nursing on 2/17/20 at 9:00 P.M., that Resident #214 is the only resident in the facility that has a Tracheostomy, Review of Resident# 214's Care Plan was conducted by the Director of Nursing and the Care Plan Nurse developed a plan of care on 2/17/20 at 8:00 p.m, to include specific needs and staff involved to. provide needed services according to the resident's wishes. (1) Potential for complications related to Tracheostomy: Deep suction as needed for thick or copious amounts of secretions the resident is unable to expel, per Registered Nurse or Respiratory Therapist. If resident becomes de-cannulated, cannula to be replaced using sterile technique, per Registered Nurse or Respiratory Therapist. Respiratory Therapist to assess resident each visit to the facility and will be available for consultation as needed. Assess for signs and symptoms of respiratory distress to include but not limited to labored breathing, cyanosis, low blood pressure, restlessness, dyspnea, decreased oxygen saturations, rattling breath sounds, etcetera, as needed per Registered Nurse or Respiratory Therapist. Notify Medical Director of any negative findings, per Nurse. Keep Ambu bag at bedside, per Nurse or Registered Nurse. Keep oxygen saturation monitor at bedside, per Nurse. Keep suction machine at bedside, per Nurse. (2) At risk for aspiration related to tracheostomy:: Change out tracheostomy tubing and mask weekly on Thursday, per Nurse. Suction tracheostomy as needed using aseptic technique, Resident to perform as needed for increased secretions, per Resident. Tracheostomy care, using aseptic technique every shift, per Resident, Registered Nurse to be in room in case of complications, Registered Nurse. Change out tracheostomy tubing and mask weekly, on Thursday, per Nurse. Resident is to be maintained in an upright or sitting position while eating, per Nurse. Assess for signs and symptoms of respiratory distress to include but not limited to labored breathing, rapid breathing, cyanosis, low blood pressure, restlessness, dyspnea, decreased oxygen saturation, rattling breath sounds, etcetera, as needed per Registered Nurse and/or Respiratory Therapist. Assess for signs and symptoms of aspirations to include but not limited to fever, cough, shortness of breath, fatigue, etcetera, as needed, per Registered Nurse and Respiratory Therapist. Notify Medical Doctor of any negative findings, per Nurse. Keep Ambu bag at bedside, per Nurse or Registered Nurse. Keep oxygen saturation monitor at bedside, per Nurse. Keep suction machine at bedside, per Nurse. Oxygen saturation taken, every shift, and notify Physician if oxygen saturation is less than 90 percent, per Nurse. (3) Resident prefers to perform her own Tracheostomy care, per Resident. Allow Resident to perform own Tracheostomy care, as desired, with Registered Nurse present, per resident. Honor Residents right to perform own Tracheostomy care, per Nurse. Registered Nurse staffing 24 hours 7 days a week in case of emergency Tracheostomy care needed, per Nurse. Encourage Resident to notify Licensed Practical Nurse or Registered Nurse prior to performing Tracheostomy care, per Nurse. Review of Registered Nurse scheduling was done on 2/17/20 at 8 :30 P.M. by the Director of Nursing to ensure that the facility had 24/7 Registered Nurse coverage. We will continue to hire Registered Nurses. While we are in the process of hiring the Registered Nurses to cover the around the clock Registered Nurse positions, we will reach out and utilize the resources of our Nurse Consultant (Registered Nurse), Director of Clinical Service (Registered Nurse), or our Clinical Respiratory Therapist, in the event one of the Registered Nurses are unable to perform their duties. We have a Contract in place, effective 2/18/2020, with a Staffing Agency for Registered Nurse coverage. The initial date they will be on site for Registered Nurse coverage is, Friday, 2/21/2020, 3/11 shift. They will be trained prior to working on the floor, Friday 2/21/2020, on facility Policies related to Tracheostomy Care and Deep Suctioning by the Director of Nursing. Registered Nurses (6 Registered Nurses) in-serviced per Director of Nursing on 2/17/2020 at 9:00 P.M. on policy for assessing the residents for self care related to Tracheostomy care and suctioning. No nurse will be allowed to work until they have received the above in-service education. Care plan nurse re-in-serviced per Director of Nursing on 2/17/2020 at 9:45 P.M. on the policy for completing comprehensive care plans. This nurse was not allowed to work until she had received the above in-service education. Resident was assessed to ensure that she is able to perform her own Tracheostomy care on 2/18/2020 at 6:30 P.M. per Respiratory Therapist. Respiratory Therapist was able to confirm that Resident #214's ability to safely perform her own Tracheostomy care. In-services were initiated on 2/18/2020 at 7 :22 p.m. by the Assistant Director of Nursing with Certified Nursing Assistants (17 Certified Nursing Assistants), Licensed Practical Nurses (10 Licensed Practical Nurses), and Registered Nurses (6 Registered Nurses) on the signs and symptoms of respiratory distress. The information reviewed was provided to them. No Certified Nursing Assistant or Nurse will be allowed to work until they have received the above in-service education. Staff in-services initiated, 2/18/2020, at 7 :30 p.m. by the Director of Nursing with Nursing, Housekeeping, Laundry, Dietary, Maintenance, and Administrative Staff (69 employees), related to Immediate Jeopardy citations and signs and symptoms of Respiratory Distress. In-service education and competency training was provided on 2/18/2020 at 9:20 p.m., by the Respiratory Therapist, on the policy for deep suctioning with Registered Nurse (6 Registered Nurses) and Tracheostomy care with Licensed Practical Nurses and Registered Nurses (12 Licensed Practical Nurses and 6 Registered Nurses) and copy of the policies and procedures reviewed to ensure that nursing staff will be provided this information. No nurse will be allowed to work until they have received the above in-service education Haven Hall Healthcare Center alleges that, on 2/19/2020, the Immediate Jeopardy regarding Resident #214 has been removed. SA VALIDATIONS The State Agency (SA) validated by record review of the Registered Nurses (RN) schedule dated 02/19/20 revealed RN coverage twenty-four hours a day seven (7) days a week. The SA validated the Quality Assurance meeting was held on 02/17/20 by record review of sign in sheet contained containing the following signatures for: Medical Director, Director of Nursing, Assistant Director of Nursing, Minimum Data Set Nurse, Care Plan Nurse, Nurse Consultant, Social Worker, and Admission/Medicare Nurse. The SA validated no changes in the facility policy by record review with a revision date of 8/2013. The SA validated the current matrix and census by record review revealed there was no other tracheostomy residents in the facility. The SA validated by record review a comprehensive care plan was developed for Resident #214, dated 02/17/20, with interventions for tracheostomy care, resident's self trach care and RN/RT coverage 24 hours a day seven (7) days a week. The SA validated, on 02/20/20 ,by interview the Medical Director revealed that staff was informed to contact the Medical Director for any negative findings. The SA validated that Resident #214 room contained the Ambu bag, oxygen saturation monitor, and the suction machine was at bedside by observation. The SA validated agency contract by record review, dated 02/18/20, with an initial start date 02/21/20 on the 3-11 shift. The SA validated the Resident #214 declined observation of trach self care, on 02/20/20, by interview with the DON. The SA validated by interview and record review the Respiratory Therapist assessed Resident #214, on 02/18/20 at 6:30 PM, and determined the resident was competent and comfortable to perform her own trach care. The SA validated by record review of the Medication Administration Record the change out of the tubing and mask is to be done on Thursdays. The SA validated all residents (Resident #214 was the only trach resident in the facility) at risk for aspiration related to tracheostomy by interview and record review of the MAR and person- centered care comprehensive care plan. The SA validated by interview that the RT is available for consultation as needed. The SA validated that Resident #214 was capable of performing self trach care by interview with the RT. The SA validated six (6) RN's was in-serviced by record review of sign in sheet on tracheostomy care, signs and symptoms of respiratory distress. The SA validated 10 Licensed Practical Nurses was in-serviced on tracheostomy care, signs and symptoms, of respiratory distress by interview and sign in sheet and interview. The SA validated thirteen Certified Nursing Assistance was in-serviced on Respiratory Distress signs and symptoms by interview and in-service attendance sign sheet. The SA validated interview and review of in-service attendance sign in sheet that six (6) Housekeeping/Laundry staff were in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet two (2) Human Resources staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet one (1) Occupational Therapist in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet one (1) Account Payable Staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet one (1) lawn service staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet two (2) Maintenance staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet two (2) Activities staff was in-serviced on Respiratory Distress sign and symptoms. The SA validated by interview and attendance sign in sheet one (1) Medical Record staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet one (10 Physical Therapist Assistant was in-serviced on Respiratory Distress sign and symptoms. The SA validated by interview and attendance sign in sheet one (1) Speech Language Pathologist was in-serviced on Respiratory Distress sign and symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, facility policy review, and review of the Mississippi (MS) State Board of Nursing website, the facility failed to ensure qualified staff, a Registered Nurse (RN) and/or Respiratory Therapist (RT), were available 24 hours a day seven days a week to provide deep suctioning or emergency tracheostomy (trach) care for one of one (1 of 1) residents reviewed with a trach and the only resident in the facility with a trach. Resident #214 was admitted to the facility, on [DATE], with an established tracheostomy. Observations and interviews, with Resident #214 on [DATE] and [DATE] revealed Resident #214 had a tracheostomy, and she stated the facility told her she would have to provide her own trach care. Review of the facility's nursing schedule, RN time cards, and daily staffing sheets from [DATE] to [DATE], revealed 23 days out of the 24 days did not have RN/RT coverage 24 hours per day seven days per week to provide deep suctioning or other possible emergency trach care if needed. The lack of RN/RT coverage was identified on all shifts, 7 AM to 3 PM, 3 PM to 11 PM and 11 PM to 7 AM. The facility's failure to provide 24 hour per day seven days per week RN/RT coverage to provide deep suctioning and other possible emergency tracheostomy care placed Resident #214 and other possible tracheostomy residents at risk for serious harm, injury, impairment, or death. The SA identified Immediate Jeopardy (IJ) which began on [DATE], and was present until [DATE], due to the facility did not provide RN or RT coverage 24 hours per day seven days per week. The SA notified the Administrator and the Director of Nurses of the IJ, on [DATE] at 7:50 PM. The facility submitted an acceptable Immediate Jeopardy Removal Plan on [DATE], in which the facility alleged all corrective actions were completed on [DATE], and the IJ was removed as of [DATE]. The SA validated the Immediate Jeopardy Removal Plan on [DATE] and determined the IJ was removed prior to exit on [DATE]. Findings include: Review of the facility's policy titled, Competency of Nursing Staff, revised [DATE], revealed that all nursing staff must meet the specific competency requirements of their respective licensures and certification requirements defined by state law. The policy's Interpretation and Implementation included: 1. Is designated to train nursing staff to deliver individualized, safe, quality of care and services for the residents. 2. The following factors are considered in the creation of the competency-based staff development and training program included-Specialized skills or training needed based on the resident population. 4. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as: d. Person centered care; f. Basic nursing skills; l. Identification of changes in condition. Review of the Mississippi State Board of Nursing (BON) website, revealed frequently asked questions (FAQ's). The BON's statement regarding the LPN's scope of practice with Tracheostomy care revealed: It is within the scope of practice of the LPN to perform Trach care and suction secretions from the Trach tube. However, it is not within the scope of practice for the LPN to perform deep right main stem suctioning. If deep suctioning is required for a patient, a Registered Nurse (RN) must perform the procedure. A review of the facility's policy titled Care Plans, Comprehensive Person-Centered, with a revision date of [DATE], revealed 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain the resident's highest practicable physical, mental, and psychological well-being; g. Incorporate identified problem areas; l. Identify the professional services that are responsible for each element of care; o. Reflect currently recognized standards of practice for problem areas and conditions. 10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS/Minimum Data Set). 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. Review of the Face Sheet revealed Resident #214 was admitted by the facility, on [DATE], with the included diagnoses Metabolic Encephalopathy, Chronic Obstructive Pulmonary Disease, Tracheostomy, Paralysis of Bilateral Vocal Cords and Larynx, and Pneumonia. Review of Resident #214's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed the Special Treatments/Programs section was checked for oxygen (O2) use and tracheostomy care. Suctioning was not checked. Resident #214's Basic Interview for Mental Status (BIMS) score was 11, which indicated moderate cognitive impairment. The MDS also revealed Resident #214 did not have any vision, hearing or speech deficits, and was able to make herself understood to others, and she was able to understand others. Review of Resident #214's Comprehensive Care Plan revealed the facility did not address Resident #214's tracheostomy care regarding her self trach care or RN/RT requirements to provide deep suctioning and other possible emergency trach care. The Baseline Care Plan dated, [DATE], included trach care daily, but did not identify who was to provide the trach care or designate specific staff roles in the trach care. The facility did not develop a care plan regarding resident #214's self trach care, or the need for a RN/RT to provide the deep suctioning and other possible emergency trach care until [DATE], when the SA identified the IJ regarding no RN/RT coverage 24 hours per day seven days per week. Review of Resident #214's Physician's Orders revealed an order, dated [DATE], for the resident to perform her own trach care and suctioning as needed to remove excess secretions. Review of the facility's nursing staff schedule, from [DATE] to [DATE], revealed 23 of the 24 days, the facility did not have RN and/or RT coverage for all shifts, 7 AM to 3 PM, 3 PM to 11 PM or 11 PM to 7 AM to provide deep tracheal suctioning or emergency trach care if needed for Resident #214. Review of the facility's Daily Nurse Staffing sheets, from [DATE] to [DATE], revealed one Registered Nurse (RN) was scheduled for the day shift - 6 AM to 2 PM and 7 AM to 3 PM, and there was no RN scheduled for the evening shift - 2 PM to 10 PM and 3 PM to 11 PM or the night shift - 10 PM to 6 AM and 11 PM to 7 AM. Review of the hospital's admission notes by the Physician revealed, on [DATE], Resident #214 was brought to the hospital by her husband due to alteration in mental status, and the assessment by the physician was Acute Metabolic Encephalopathy. Resident #214 was previously hospitalized for Pneumonia from [DATE] to [DATE]. Resident #214's husband brought her back to the hospital, on [DATE] because she was sleeping a lot, and was confused when she was awake since she was discharged on [DATE]. The hospital Physician's History Note, dated [DATE], revealed Resident #214 had a tracheostomy in 2007, and has paralysis of her bilateral vocal cords and larynx. On [DATE] at 4:09 PM, an interview and observation revealed Resident #214 said the facility had told her she would have to provide her own trach care. Resident #214 had a tracheostomy in place, and there was no distress noted. Resident #214 also said she had taken care of her trach for many years. The Administrator and the Director of Nurses (DON) was interviewed on [DATE] at 4:00 PM, and they both confirmed the facility did not have RN coverage 24 hours per day seven days per week in the event Resident #214 required deep suctioning or emergency trach care. The DON stated Resident #214 was providing her own trach care at home and had been for several years. The DON also stated Resident #214 preferred to do her own trach care, and had been providing it at the facility. On [DATE] at 3:00 PM, an interview with the Administrator and the DON revealed the DON just did not realize they needed a RN/RT scheduled 24 hours per day seven days a week for a tracheostomy resident. She had not thought about it since Resident #214 was admitted . The DON also stated in the event Resident #214 needed deep suctioning and the RN was not here, the LPN would have to call for an ambulance to transfer her to the hospital, which would take five (5) minutes to get to the facility and another two (2) minutes to get to the hospital, that would be seven (7) minutes, and could result in possible brain damage. The Medical Director's interview, on [DATE] at 5:30 PM, revealed he had no knowledge the facility did not have RN coverage to provide deep suctioning if it was needed. The Medical Director did confirm he would expect the RN to provide deep suctioning if it was needed, and he just assumed they would have coverage that was required. The Medical Director stated he was trusting the staff to do what was needed to provide care for Resident #214. The Medical Director also revealed he knew the resident was admitted to the facility from the hospital with a tracheostomy and Pneumonia, which could cause further respiratory issues. An interview, on [DATE] at 4:34 PM, revealed the Assistant Director of Nurses (ADON) said she was aware Resident #214 was admitted with a tracheostomy. The ADON stated the DON makes the nursing schedules and decides who to admit to the facility. The ADON said without 24 hour a day seven (7) days a week RN coverage the resident was at risk for death. An interview, on [DATE] at 5:17 PM, with LPN #2, revealed she had not received any training from the facility regarding trach care since she has been employed at the facility. LPN #2 said she did receive trach care training in nursing school. LPN #2 stated the RN provided supervision when she's here and the LPNs and RNs are charge nurses. On [DATE] at 4:05 PM, an interview with Licensed Practical Nurse (LPN) #2, revealed she would not do anything that was not in her scope of practice. LPN #2 said if Resident #214 needed deep suctioning she would provide some type of care to keep the resident alive until the paramedics got to the facility. LPN #2 said she would check the oxygen level, raise the head of the bed, and she would suction around the trach that didn't work and stay at the resident's bed side until help arrived. LPN #2 said she would call the medical doctor after she got the resident's vital signs. LPN #2 said if the cannula came out, she would keep the airway open and keep the resident oxygenated until the paramedics arrived. LPN #2 did not mention notifying the RN. An interview, on [DATE] at 3:26 PM, revealed LPN #3 works the 7 AM to 3 PM shift on the [NAME] Wing and sometimes to 7 PM. LPN #3 stated she has been employed at the facility for nine (9) years, and there has not been a trach patient here until now. LPN #3 said Resident #214 does her own trach care. LPN #2 said no one does trach care here, and Resident #214 does her own trach care. LPN #3 reported she has not received any training by the facility on trach care and there has not been any training provided by the facility for trach care. LPN #3 said if Resident #214 needed deep suctioning she would notify the RN if she was here, if the RN was not here she would call the RN and see if she wanted her to send Resident #214 out. On [DATE] at 1:55 PM, an interview with LPN #4, revealed the last training for trach care was provided by the corporate nurse back in October or November of last year. They watched the corporate nurse and then did a return demonstration. LPN #4 stated the LPNs can suction, but only the RNs can deep suction the trachs. LPN #4 stated if the resident exhibited signs and symptoms (s/s) of respiratory distress such as facial grimacing, she would try to get them to calm down, get their Oxygen Saturation (O2 Sat), and get their vital signs (v/s). LPN #4 stated if the resident needed deep suctioning and the RN was not here, she would suction the resident, keep the airway open, and call 911. On [DATE] at 4:17 PM, an interview with the DON revealed the corporate respiratory therapist trained the staff on care of a tracheostomy about a couple of weeks ago. Record review revealed the only In-Service Attendance Sheet the facility provided for trach care, suctioning the upper airway, oxygen therapy and administration and Chronic Obstructive Pulmonary Disease (COPD) was dated [DATE]. The sign in sheet revealed the signature of one person. The training was provided by the RT. On [DATE] at 1:50 PM, an interview with RN #1/Minimum Data Set (MDS) Nurse, revealed she was aware the LPNs could not deep suction trachs. RN #1 also stated if a resident needed deep suctioning and did not get it, the resident could die. RN #1 also reported she did not have anything to do with the nurse staffing or scheduling to ensure RN coverage 24 hours per day seven (7) days per week to provide deep suctioning or trach emergency care if needed. RN #1 stated the Director of Nurses (DON) does the nursing staff schedule. RN #1 also said it would take about seven (7) minutes for the ambulance to get here and the resident could die in seven (7) minutes. RN #1 said she has had training for tracheostomy care. She stated the last training prior to survey was around [DATE], and she also had training by the DON on [DATE]. Certified Nursing Assistant (CNA) #3 was interviewed, on [DATE] at 3:46 PM. CNA #3, stated she has been employed at the facility since March of 2019, and she works swing shift, she works 2 PM to 10 PM on the weekends and 6 AM to 2 PM the other days. CNA #3 revealed she has not worked with a resident with a trach before, however Resident #214 was assigned to her today, and nor has she had any prior training to take care of a resident with a trach. CNA #3 stated she was currently Cardiopulmonary Resuscitation (CPR) certified. CNA #3 said she did know the resident did everything for herself. CNA #3 said however if Resident #214 was having respiratory difficulty the first thing she would do is call for help, she would not leave her. If the resident was gasping for breath or not breathing she would call for help, shake her to see if she was OK and then call for help. The facility's accepted Immediate Jeopardy Removal Plan: Haven Hall Healthcare Center Administrator and Director of Nursing were notified of Immediate Jeopardy and Substandard Quality of Care on, [DATE] at 7:50 p.m. related to the facility admitting Resident #214 on [DATE] with a Tracheostomy and (1) Failure to assess resident during routine Tracheostomy care performed per resident, (2) Failure to develop and implement a care plan for the care of resident's tracheostomy, and (3) Failure to provide around the clock Registered Nurse (RN) or Respiratory Therapist (RT) coverage to provide deep suctioning and emergency Tracheostomy care, placed the resident at risk for serious injury, harm, impairment. Immediately upon notification: The Director of Nursing put in place for Registered Nurse coverage to be 24/7. An emergency Quality Assurance meeting was called on [DATE] at 8:14 PM to discuss (1) Failure to assess resident during routine Tracheostomy care performed per resident, (2) Failure to develop and implement a care plan for the care of resident's tracheostomy, and (3) Failure to provide around the clock Registered Nurse (RN) or Respiratory Therapist (RT) coverage to provide deep suctioning and emergency Tracheostomy care, placed the resident at risk for serious injury, harm, impairment. Those in attendance were the Medical Director, Administrator, Director of Nursing, Nurse Consultant, Assistant Director of Nursing, Minimal- Data Set Nurse, Care Plan Nurse, Social Worker, and Admissions/Medicare Nurse. Policy and Procedure on Tracheostomy Care was reviewed on [DATE], by the Director of Nursing with no policy changes implemented. This policy was revised 8/2013. Facility identified through record review by the Director of Nursing on [DATE] at 9:00 P.M., that Resident #214 is the only resident in the facility that has a Tracheostomy. Review of Resident# 214's Care Plan was conducted by the Director of Nursing and the Care Plan Nurse developed a plan of care on [DATE] at 8:00 p.m, to include specific needs and staff involved to provide needed services according to the resident's wishes. (1) Potential for complications related to Tracheostomy: Deep suction as needed for thick or copious amounts of secretions the resident is unable to expel, per Registered Nurse or Respiratory Therapist. If resident becomes de-cannulated, cannula to be replaced using sterile technique, per Registered Nurse or Respiratory Therapist. Respiratory Therapist to assess resident each visit to the facility and will be available for consultation as needed. Assess for signs and symptoms of respiratory distress to include but not limited to labored breathing, cyanosis, low blood pressure, restlessness, dyspnea, decreased oxygen saturations, rattling breath sounds, etcetera, as needed per Registered Nurse or Respiratory Therapist. Notify Medical Director of any negative findings, per Nurse. Keep Ambu bag at bedside, per Nurse or Registered Nurse. Keep oxygen saturation monitor at bedside, per Nurse. Keep suction machine at bedside, per Nurse. (2) At risk for aspiration related to tracheostomy: Change out tracheostomy tubing and mask weekly on Thursday, per Nurse. Suction tracheostomy as needed using aseptic technique, Resident to perform as needed for increased secretions, per Resident. Tracheostomy care, using aseptic technique every shift, per Resident, Registered Nurse to be in room in case of complications, Registered Nurse. Change out tracheostomy tubing and mask weekly, on Thursday, per Nurse. Resident is to be maintained in an upright or sitting position while eating, per Nurse. Assess for signs and symptoms of respiratory distress to include but not limited to labored breathing, rapid breathing, cyanosis, low blood pressure, restlessness, dyspnea, decreased oxygen saturation, rattling breath sounds, etcetera, as needed per Registered Nurse and/or Respiratory Therapist. Assess for signs and symptoms of aspirations to include but not limited to fever, cough, shortness of breath, fatigue, etcetera, as needed, per Registered Nurse and Respiratory Therapist. Notify Medical Doctor of any negative findings, per Nurse. Keep Ambu bag at bedside, per Nurse or Registered Nurse. Keep oxygen saturation monitor at bedside, per Nurse. Keep suction machine at bedside, per Nurse. Oxygen saturation taken, every shift, and notify Physician if oxygen saturation is less than 90 percent, per Nurse. (3) Resident prefers to perform her own Tracheostomy care, per Resident. Allow Resident to perform own Tracheostomy care, as desired, with Registered Nurse present, per resident. Honor Residents right to perform own Tracheostomy care, per Nurse. Registered Nurse staffing 24 hours 7 days a week in case of emergency Tracheostomy care needed, per Nurse. Encourage Resident to notify Licensed Practical Nurse or Registered Nurse prior to performing Tracheostomy care, per Nurse. Review of Registered Nurse scheduling was done on [DATE] at 8:30 P.M. by the Director of Nursing to ensure that the facility had 24/7 Registered Nurse coverage. We will continue to hire Registered Nurses. While we are in the process of hiring the Registered Nurses to cover the around the clock Registered Nurse positions, we will reach out and utilize the resources of our Nurse Consultant (Registered Nurse), Director of Clinical Service (Registered Nurse), or our Clinical Respiratory Therapist, in the event one of the Registered Nurses are unable to perform their duties. We have a Contract in place, effective [DATE], with a Staffing Agency for Registered Nurse coverage. The initial date they will be on site for Registered Nurse coverage is, Friday, [DATE], 3/11 shift. They will be trained prior to working on the floor, Friday [DATE], on facility Policies related to Tracheostomy Care and Deep Suctioning by the Director of Nursing. Registered Nurses (6 Registered Nurses) in-serviced per Director of Nursing on [DATE] at 9:00 P.M. on policy for assessing the residents for self care related to Tracheostomy care and suctioning. No nurse will be allowed to work until they have received the above in-service education. Care plan nurse re-in-serviced per Director of Nursing on [DATE] at 9:45 P.M. on the policy for completing comprehensive care plans. This nurse was not allowed to work until she had received the above in-service education. Resident was assessed to ensure that she is able to perform her own Tracheostomy care on [DATE] at 6:30 P.M. per Respiratory Therapist. Respiratory Therapist was able to confirm that Resident #214's ability to safely perform her own Tracheostomy care. In-services were initiated on [DATE] at 7 :22 p.m. by the Assistant Director of Nursing with Certified Nursing Assistants (17 Certified Nursing Assistants), Licensed Practical Nurses (10 Licensed Practical Nurses), and Registered Nurses (6 Registered Nurses) on the signs and symptoms of respiratory distress. The information reviewed was provided to them. No Certified Nursing Assistant or Nurse will be allowed to work until they have received the above in-service education. Staff in-services initiated, [DATE], at 7:30 p.m. by the Director of Nursing with Nursing, Housekeeping, Laundry, Dietary, Maintenance, and Administrative Staff (69 employees), related to Immediate Jeopardy citations and signs and symptoms of Respiratory Distress. In-service education and competency training was provided on [DATE] at 9:20 p.m., by the Respiratory Therapist, on the policy for deep suctioning with Registered Nurse (6 Registered Nurses) and Tracheostomy care with Licensed Practical Nurses and Registered Nurses (12 Licensed Practical Nurses and 6 Registered Nurses) and copy of the policies and procedures reviewed to ensure that nursing staff will be provided this information. No nurse will be allowed to work until they have received the above in-service education Haven Hall Healthcare Center alleges that, on [DATE], the Immediate Jeopardy regarding Resident #214 has been removed. SA VALIDATIONS The State Agency (SA) validated by record review of the Registered Nurses (RN) schedule dated [DATE] revealed RN coverage twenty-four hours a day seven (7) days a week. The SA validated the Quality Assurance meeting was held on [DATE] by record review of sign in sheet contained containing the following signatures for: Medical Director, Director of Nursing, Assistant Director of Nursing, Minimum Data Set Nurse, Care Plan Nurse, Nurse Consultant, Social Worker, and Admission/Medicare Nurse. The SA validated no changes in the facility policy by record review with a revision date of 8/2013. The SA validated the current matrix and census by record review revealed there was no other tracheostomy residents in the facility. The SA validated by record review a comprehensive care plan was developed for Resident #214, dated [DATE], with interventions for tracheostomy care, resident's self trach care and RN/RT coverage 24 hours a day seven (7) days a week. The SA validated, on [DATE] ,by interview the Medical Director revealed that staff was informed to contact the Medical Director for any negative findings. The SA validated that Resident #214 room contained the Ambu bag, oxygen saturation monitor, and the suction machine was at bedside by observation. The SA validated agency contract by record review, dated [DATE], with an initial start date [DATE] on the 3-11 shift. The SA validated the Resident #214 declined observation of trach self care, on [DATE], by interview with the DON. The SA validated by interview and record review the Respiratory Therapist assessed Resident #214, on [DATE] at 6:30 PM, and determined the resident was competent and comfortable to perform her own trach care. The SA validated by record review of the Medication Administration Record the change out of the tubing and mask is to be done on Thursdays. The SA validated all residents (Resident #214 was the only trach resident in the facility) at risk for aspiration related to tracheostomy by interview and record review of the MAR and person- centered care comprehensive care plan. The SA validated by interview that the RT is available for consultation as needed. The SA validated that Resident #214 was capable of performing self trach care by interview with the RT. The SA validated six (6) RN's was in-serviced by record review of sign in sheet on tracheostomy care, signs and symptoms of respiratory distress. The SA validated 10 Licensed Practical Nurses was in-serviced on tracheostomy care, signs and symptoms, of respiratory distress by interview and sign in sheet and interview. The SA validated thirteen Certified Nursing Assistance was in-serviced on Respiratory Distress signs and symptoms by interview and in-service attendance sign sheet. The SA validated interview and review of in-service attendance sign in sheet that six (6) Housekeeping/Laundry staff were in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet two (2) Human Resources staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet one (1) Occupational Therapist in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet one (1) Account Payable Staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet one (1) lawn service staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet two (2) Maintenance staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet two (2) Activities staff was in-serviced on Respiratory Distress sign and symptoms. The SA validated by interview and attendance sign in sheet one (1) Medical Record staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet one (10 Physical Therapist Assistant was in-serviced on Respiratory Distress sign and symptoms. The SA validated by interview and attendance sign in sheet one (1) Speech Language Pathologist was in-serviced on Respiratory Distress sign and symptoms.

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

Based on observation, resident interview, staff interview, record review, review of the Mississippi State Board of Nursing website and the Nurse Practice Act, the facility failed to provide qualified, consistent and sufficient staff, a Registered Nurse (RN) and/or a Respiratory Therapist (RT), 24 hours per day seven (7) days per week to provide deep tracheal suctioning and emergency trach care if needed to ensure respiratory care for one of one (1 of 1) residents reviewed with a tracheostomy (trach), Resident #214. Review of the facility's nursing staff schedule from 01/24/2020 to 02/17/2020 revealed the facility did not have 24 hours per day seven (7) days per week RN or RT coverage for 23 of the 24 days on the 7 AM to 3 PM, 3 PM to 11 PM, and 11 PM to 7 AM shifts. Resident #214 was admitted from the hospital to the facility, on 01/24/2020, with diagnoses of Pneumonia and Chronic Obstructive Pulmonary Disease (COPD) and an established tracheostomy she was taking care of herself at home. Resident #214 was admitted for therapy for weakness and planned to return home. Resident #214 had a Physician's Order dated 01/28/2020 for the resident to provide her own trach care and suctioning as needed to remove excess secretions. The hospital records revealed Resident #214 had a Tracheostomy in 2007 and has paralysis of her bilateral vocal cords and larynx. The facility's failure to provide 24 hour per day RN and/or RT staffing, for possible deep suctioning and other emergency tracheostomy tube care, placed Resident #214 and other possible tracheostomy residents at risk for serious harm, injury, impairment or death. The State Agency (SA) identified the Immediate Jeopardy (IJ), on 02/17/2020, when the facility failed to ensure qualified staff, a RN and/or RT, were present 24 hours per day seven (7) days per week to provide deep tracheal suctioning and emergency trach care if needed for Resident #214. The SA notified the facility's Administrator and Director of Nurses (DON) of the IJ on 02/17/2020 at 7:50 PM. The facility submitted an acceptable Immediate Jeopardy Removal Plan on 02/19/2020. The facility alleged all corrective actions were completed on 02/19/2020 and the IJ was removed on 02/19/2020. The SA validated the Immediate Jeopardy Removal Plan on 02/20/2020 and determined the IJ was removed prior to exit on 02/20/2020. Findings Include: The facility did not have a policy specific to sufficient staffing or adequate staffing. Review of the facility's policy titled, Competency of Nursing Staff, dated revised May 2019, revealed that all nursing staff must meet the specific competency requirements of their respective licensures and certification requirements defined by state law. The policy's Interpretation and Implementation included: 1. Is designated to train nursing staff to deliver individualized, safe, quality of care and services for the residents. 2. The following factors are considered in the creation of the competency-based staff development and training program included-Specialized skills or training needed based on the resident population. 4. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as: d. Person centered care; f. Basic nursing skills; l. Identification of changes in condition. Review of the Mississippi State Board of Nursing (BON) website, revealed frequently asked questions (FAQs): The BON's statement regarding the LPN's scope of practice with Tracheostomy care revealed, It is within the scope of practice of the LPN to perform Trach care and suction secretions from the Trach tube. However, it is not within the scope of practice for the LPN to perform deep right main stem suctioning. If deep suctioning is required for a patient, a Registered Nurse (RN) must perform the procedure. Review of the Mississippi (MS) Board of Nursing Laws and Rules Administrative Code Part 2830 Practice of Nursing Title 30: Professions and Occupations Chapter 2, Functions of the Licensed Practical Nurse, (LPN) revealed: Rule 2. 1-LPN Supervision, The LPN gives nursing care which does not require the specialized skill, judgement, and knowledge required of an RN. Advanced Practice Registered Nurse (APRN), Licensed Physician, or Licensed Dentist. Review of the facility's nursing staff schedule, from 01/24/2020 to 02/17/2020, revealed 23 of the 24 days, the facility did not have RN and/or RT coverage for all shifts, 7 AM to 3 PM, 3 PM to 11 PM or 11 PM to 7 AM to provide deep tracheal suctioning or emergency trach care if needed for Resident #214. Review of the facility's Daily Nurse Staffing sheets, from 02/10/2020 to 02/16/2020, revealed one Registered Nurse (RN) was scheduled for the day shift - 6 AM to 2 PM and 7 AM to 3 PM, and there was no RN scheduled for the evening shift - 2 PM to 10 PM and 3 PM to 11 PM or the night shift - 10 PM to 6 AM and 11 PM to 7 AM. Review of the hospital's admission notes by the Physician revealed, on 01/18/2020, Resident #214 was brought to the hospital by her husband due to alteration in mental status, and the assessment by the physician was Acute Metabolic Encephalopathy. Resident #214 was previously hospitalized for Pneumonia from 01/08/2020 to 01/14/2020. Resident #9's husband brought her back to the hospital, on 01/18/2020 because she was sleeping a lot, and was confused when she was awake since she was discharged on 01/14/2020. The hospital Physician's History Note, dated 01/18/2020, revealed Resident #214 had a tracheostomy in 2007, and has paralysis of her bilateral vocal cords and larynx. On 02/17/2020 at 4:09 PM, an interview and observation revealed Resident #214 had a tracheostomy, and Resident #214 reported they (the facility) told her she would have to take care of her trach herself, and she had taken care of her trach at home for many years. Review of Resident #214's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/30/2020, revealed the Special Treatments/Programs section was checked for oxygen (O2) use and tracheostomy care. Suctioning was not checked. Resident #214's Basic Interview for Mental Status (BIMS) score was 11, which indicated moderate cognitive impairment. The MDS also revealed Resident #214 did not have any vision, hearing or speech deficits, and was able to make herself understood to others, and she was able to understand others. During an interview with the Administrator and the Director of Nurses (DON), on 02/17/2020 at 4:00 PM, they confirmed the facility did not have RN coverage 24 hours per day seven days per week in the event Resident #24 required deep suctioning or emergency trach care. The DON stated Resident #214 prefers to take care of her trach herself, and she was doing her trach care at home for years and was providing it herself at the facility. On 02/18/2020 at 3:00 PM, an interview with the Administrator and the DON, confirmed in the event that Resident #214 needed deep suctioning and the RN was not here, the LPN would have to call for an ambulance to transfer her to the hospital. The DON also confirmed it would take the ambulance five (5) minutes to get to the facility and another two (2) minutes to get to the hospital, that would be seven (7) minutes, and could result in possible brain damage. The DON said when Resident #214 was admitted and since her admission she just did not think about 24 hour a day RN coverage to provide deep suctioning or emergency trach care if needed. An interview, on 02/19/2020 at 5:30 PM, revealed the Medical Director was not aware the facility did not have RN coverage to provide deep suctioning if it was needed and that he just assumed they would have coverage that was required. He further stated he would expect the RN to perform the deep suctioning as needed. The Medical Director stated he was trusting the staff to do what was needed to provide care for Resident #214. The Medical Director also revealed he knew the resident was admitted to the facility from the hospital with a tracheostomy and Pneumonia, which could cause further respiratory issues. An interview, on 02/19/2020 at 4:34 PM, revealed the Assistant Director of Nurses (ADON) stated the DON makes the nursing schedules and decides who to admit to the facility. The ADON said she was aware Resident #214 had a tracheostomy, and without 24 hour a day seven (7) days a week RN coverage the resident was at risk for death. Review of the Face Sheet revealed Resident #214 was admitted by the facility, on 01/24/2020, with the included diagnoses Metabolic Encephalopathy, Chronic Obstructive Pulmonary Disease, Tracheostomy, Paralysis of Bilateral Vocal Cords and Larynx, and Pneumonia. Review of Resident #214's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/20/2020, revealed the resident required extensive assistance with one person physical assist for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. The facility's accepted Immediate Jeopardy Removal Plan: Haven Hall Healthcare Center Administrator and Director of Nursing were notified of Immediate Jeopardy and Substandard Quality of Care on, 2/17/2020 at 7:50 p.m. related to the facility admitting Resident #214 on 1/24/2020 with a Tracheostomy and (1) Failure to assess resident during routine Tracheostomy care performed per resident, (2) Failure to develop and implement a care plan for the care of resident's tracheostomy, and (3) Failure to provide around the clock Registered Nurse (RN) or Respiratory Therapist (RT) coverage to provide deep suctioning and emergency Tracheostomy care, placed the resident at risk for serious injury, harm, impairment. Immediately upon notification: The Director of Nursing put in place for Registered Nurse coverage to be 24/7. An emergency Quality Assurance meeting was called on 2/17/2020 at 8:14 PM to discuss (1) Failure to assess resident during routine Tracheostomy care performed per resident, (2) Failure to develop and implement a care plan for the care of resident's tracheostomy, and (3) Failure to provide around the clock Registered Nurse (RN) or Respiratory Therapist (RT) coverage to provide deep suctioning and emergency Tracheostomy care, placed the resident at risk for serious injury, harm, impairment. Those in attendance were the Medical Director, Administrator, Director of Nursing, Nurse Consultant, Assistant Director of Nursing, Minimal- Data Set Nurse, Care Plan Nurse, Social Worker, and Admissions/Medicare Nurse. Policy and Procedure on Tracheostomy Care was reviewed on 2/17/20, by the Director of Nursing with no policy changes implemented. This policy was revised 8/2013. Facility identified through record review by the Director of Nursing on 2/17/20 at 9:00 P.M., that Resident #214 is the only resident in the facility that has a Tracheostomy. Review of Resident# 214's Care Plan was conducted by the Director of Nursing and the Care Plan Nurse developed a plan of care on 2/17/20 at 8:00 p.m, to include specific needs and staff involved to. provide needed services according to the resident's wishes. (1) Potential for complications related to Tracheostomy: Deep suction as needed for thick or copious amounts of secretions the resident is unable to expel, per Registered Nurse or Respiratory Therapist. If resident becomes de-cannulated, cannula to be replaced using sterile technique, per Registered Nurse or Respiratory Therapist. Respiratory Therapist to assess resident each visit to the facility and will be available for consultation as needed. Assess for signs and symptoms of respiratory distress to include but not limited to labored breathing, cyanosis, low blood pressure, restlessness, dyspnea, decreased oxygen saturations, rattling breath sounds, etcetera, as needed per Registered Nurse or Respiratory Therapist. Notify Medical Director of any negative findings, per Nurse. Keep Ambu bag at bedside, per Nurse or Registered Nurse. Keep oxygen saturation monitor at bedside, per Nurse. Keep suction machine at bedside, per Nurse. (2) At risk for aspiration related to tracheostomy:: Change out tracheostomy tubing and mask weekly on Thursday, per Nurse. Suction tracheostomy as needed using aseptic technique, Resident to perform as needed for increased secretions, per Resident. Tracheostomy care, using aseptic technique every shift, per Resident, Registered Nurse to be in room in case of complications, Registered Nurse. Change out tracheostomy tubing and mask weekly, on Thursday, per Nurse. Resident is to be maintained in an upright or sitting position while eating, per Nurse. Assess for signs and symptoms of respiratory distress to include but not limited to labored breathing, rapid breathing, cyanosis, low blood pressure, restlessness, dyspnea, decreased oxygen saturation, rattling breath sounds, etcetera, as needed per Registered Nurse and/or Respiratory Therapist. Assess for signs and symptoms of aspirations to include but not limited to fever, cough, shortness of breath, fatigue, etcetera, as needed, per Registered Nurse and Respiratory Therapist. Notify Medical Doctor of any negative findings, per Nurse. Keep Ambu bag at bedside, per Nurse or Registered Nurse. Keep oxygen saturation monitor at bedside, per Nurse. Keep suction machine at bedside, per Nurse. Oxygen saturation taken, every shift, and notify Physician if oxygen saturation is less than 90 percent, per Nurse. (3) Resident prefers to perform her own Tracheostomy care, per Resident. Allow Resident to perform own Tracheostomy care, as desired, with Registered Nurse present, per resident. Honor Residents right to perform own Tracheostomy care, per Nurse. Registered Nurse staffing 24 hours 7 days a week in case of emergency Tracheostomy care needed, per Nurse. Encourage Resident to notify Licensed Practical Nurse or Registered Nurse prior to performing Tracheostomy care, per Nurse. Review of Registered Nurse scheduling was done on 2/17/20 at 8:30 P.M. by the Director of Nursing to ensure that the facility had 24/7 Registered Nurse coverage. We will continue to hire Registered Nurses. While we are in the process of hiring the Registered Nurses to cover the around the clock Registered Nurse positions, we will reach out and utilize the resources of our Nurse Consultant (Registered Nurse), Director of Clinical Service (Registered Nurse), or our Clinical Respiratory Therapist, in the event one of the Registered Nurses are unable to perform their duties. We have a Contract in place, effective 2/18/2020, with a Staffing Agency for Registered Nurse coverage. The initial date they will be on site for Registered Nurse coverage is, Friday, 2/21/2020, 3/11 shift. They will be trained prior to working on the floor, Friday 2/21/2020, on facility Policies related to Tracheostomy Care and Deep Suctioning by the Director of Nursing. Registered Nurses (6 Registered Nurses) in-serviced per Director of Nursing on 2/17/2020 at 9:00 P.M. on policy for assessing the residents for self care related to Tracheostomy care and suctioning. No nurse will be allowed to work until they have received the above in-service education. Care plan nurse re-in-serviced per Director of Nursing on 2/17/2020 at 9:45 P.M. on the policy for completing comprehensive care plans. This nurse was not allowed to work until she had received the above in-service education. Resident was assessed to ensure that she is able to perform her own Tracheostomy care on 2/18/2020 at 6:30 P.M. per Respiratory Therapist. Respiratory Therapist was able to confirm that Resident #214's ability to safely perform her own Tracheostomy care. In-services were initiated on 2/18/2020 at 7:22 p.m. by the Assistant Director of Nursing with Certified Nursing Assistants (17 Certified Nursing Assistants), Licensed Practical Nurses (10 Licensed Practical Nurses), and Registered Nurses (6 Registered Nurses) on the signs and symptoms of respiratory distress. The information reviewed was provided to them. No Certified Nursing Assistant or Nurse will be allowed to work until they have received the above in-service education. Staff in-services initiated, 2/18/2020, at 7:30 p.m. by the Director of Nursing with Nursing, Housekeeping, Laundry, Dietary, Maintenance, and Administrative Staff (69 employees), related to Immediate Jeopardy citations and signs and symptoms of Respiratory Distress. In-service education and competency training was provided on 2/18/2020 at 9:20 p.m., by the Respiratory Therapist, on the policy for deep suctioning with Registered Nurse (6 Registered Nurses) and Tracheostomy care with Licensed Practical Nurses and Registered Nurses (12 Licensed Practical Nurses and 6 Registered Nurses) and copy of the policies and procedures reviewed to ensure that nursing staff will be provided this information. No nurse will be allowed to work until they have received the above in-service education. Haven Hall Healthcare Center alleges that, on 2/19/2020, the Immediate Jeopardy regarding Resident #214 has been removed. SA VALIDATIONS The State Agency (SA) validated by record review of the Registered Nurses (RN) schedule dated 02/19/2020 revealed RN coverage twenty-four hours a day seven (7) days a week. The SA validated the Quality Assurance meeting was held on 02/17/2020 by record review of sign in sheet contained containing the following signatures for: Medical Director, Director of Nursing, Assistant Director of Nursing, Minimum Data Set Nurse, Care Plan Nurse, Nurse Consultant, Social Worker, and Admission/Medicare Nurse. The SA validated no changes in the facility policy by record review with a revision date of 8/2013. The SA validated the current matrix and census by record review revealed there was no other tracheostomy residents in the facility. The SA validated by record review a comprehensive care plan was developed for Resident #214, dated 02/17/2020, with interventions for tracheostomy care, resident's self trach care and RN/RT coverage 24 hours a day seven (7) days a week. The SA validated, on 02/20/2020 ,by interview the Medical Director revealed that staff was informed to contact the Medical Director for any negative findings. The SA validated that Resident #214 room contained the Ambu bag, oxygen saturation monitor, and the suction machine was at bedside by observation. The SA validated agency contract by record review, dated 02/18/2020, with an initial start date 02/21/2020 on the 3-11 shift. The SA validated the Resident #214 declined observation of trach self care, on 02/20/2020, by interview with the DON. The SA validated by interview and record review the Respiratory Therapist assessed Resident #214, on 02/18/2020 at 6:30 PM, and determined the resident was competent and comfortable to perform her own trach care. The SA validated by record review of the Medication Administration Record the change out of the tubing and mask is to be done on Thursdays. The SA validated all residents (Resident #214 was the only trach resident in the facility) at risk for aspiration related to tracheostomy by interview and record review of the MAR and person- centered care comprehensive care plan. The SA validated by interview that the RT is available for consultation as needed. The SA validated that Resident #214 was capable of performing self trach care by interview with the RT. The SA validated six (6) RN's was in-serviced by record review of sign in sheet on tracheostomy care, signs and symptoms of respiratory distress. The SA validated 10 Licensed Practical Nurses was in-serviced on tracheostomy care, signs and symptoms, of respiratory distress by interview and sign in sheet and interview. The SA validated thirteen Certified Nursing Assistance was in-serviced on Respiratory Distress signs and symptoms by interview and in-service attendance sign sheet. The SA validated interview and review of in-service attendance sign in sheet that six (6) Housekeeping/Laundry staff were in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet two (2) Human Resources staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet one (1) Occupational Therapist in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet one (1) Account Payable Staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet one (1) lawn service staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet two (2) Maintenance staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet two (2) Activities staff was in-serviced on Respiratory Distress sign and symptoms. The SA validated by interview and attendance sign in sheet one (1) Medical Record staff was in-serviced on Respiratory Distress signs and symptoms. The SA validated by interview and attendance sign in sheet one (10 Physical Therapist Assistant was in-serviced on Respiratory Distress sign and symptoms. The SA validated by interview and attendance sign in sheet one (1) Speech Language Pathologist was in-serviced on Respiratory Distress sign and symptoms.