Every finding on record at Bedford Care Center of Hattiesburg

Based on observation, interview, record review, and facility policy review, the facility failed to maintain a safe, clean, comfortable, and homelike environment when damaged paint and exposed sheetrock were observed in resident bedrooms for three (3) of (18) sampled resident rooms. Residents #1, #79 and #87.Findings include:A review of the facility's policy, Safe Homelike Environment, revised 7/1/23, revealed .In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment.Policy Explanation and Compliance Guidelines: 1. The facility will create and maintain, to the extent possible, a homelike environment.3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.A review of the facility's policy, Resident Rights, revised 10/2022, revealed .It is the policy of this facility to uphold and comply with the Resident Rights as stated in this policy.Policy Explanation and Compliance Guidelines.8. Safe environment. The resident has the right to a safe, clean, comfortable, and homelike environment.Resident #1A record review of the admission Record revealed the facility admitted Resident #1 on 10/3/23 with diagnoses including Acute Respiratory Failure with Hypoxia.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/27/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of (13), which indicated the resident was cognitively intact.On 3/2/26 at 2:36 PM, during an observation, scarring and exposed sheetrock were observed on the wall behind the recliner in Resident #1's room.On 3/5/26 at 9:20 AM, during an observation and interview, Housekeeping/Maintenance Staff #1 (HKM #1) observed the wall in Resident #1's room and confirmed paint scratches and exposed sheetrock were present.Resident #79A record review of the admission Record revealed the facility admitted Resident #79 on 1/22/24 with diagnoses including Unspecified Atrial Fibrillation.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/17/26 revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident's cognition was severely impaired.On 3/2/26 at 11:40 AM, during an observation, a heavily scuffed wall was observed behind the bed in Resident #79's room. The wall behind the right side of the bed contained extensive scuff marks and visible damage. The damaged wall surface appeared worn and did not present a homelike environment. During the observation, Resident #79 stated he was not sure what had caused the damage.Resident #87A record review of the admission Record revealed the facility admitted Resident #87 on 9/22/23 with diagnoses including Dysphasia following Cerebral Infarction.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/6/26 revealed Resident #87 had a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident's cognition was severely impaired.On 3/2/26 at 12:32 PM, during an observation, chipped paint and scuffs were observed on the wall behind the bed in Resident #87's room. The damaged paint and scuffs made the wall appear worn and not homelike.On 3/5/26 at 8:50 AM, during an interview, Housekeeping/Maintenance Staff #1 (HKM #1) stated monthly room checks were conducted, and repairs were completed through maintenance work orders or invoice requests. HKM #1 stated that when entering resident rooms he observed for needed repairs, including checking call lights and other room fixtures. HKM #1 further stated that each department had assigned rooms to check daily and acknowledged several rooms required repair and repainting. HKM #1 stated that with movable furniture and beds that raise and lower, wall damage and scratches can occur over time. HKM #1 further stated that prior to the survey team entering the facility there was no plan in place to patch or repaint the damaged walls in the identified resident rooms.On 3/5/26 at 9:20 AM, during an observation and interview, Housekeeping/Maintenance Staff #1 (HKM #1) observed the wall in Resident #87's room and confirmed paint scratches were present.On 3/5/26 at 1:59 PM, during an interview, the Administrator stated the facility had difficulty hiring a painter and stated this had been an issue since approximately November or December 2025. The Administrator stated each department conducted daily room rounds to monitor needed repairs and staff assigned to complete these checks rotated approximately every two weeks to allow for a fresh review of resident rooms. The Administrator further stated the plan and expectation was to repair the most damaged rooms first and then continue repairing and maintaining paint in other resident rooms.

Based on interview, record review, and facility policy review, the facility failed to assist a resident's representative with formulating an advance directive in a timely manner for one (1) of (18) sampled residents. Resident #4.Findings include:A review of the facility's policy, Resident's Rights Regarding Treatment and Advance Directives, revised 11/1/22, revealed, .It is the policy of this facility to support and facilitate a resident right to.formulate an advanced directive.Policy Explanation and Compliance Guidelines: 1. On admission, the facility will determine if the resident has executed an advanced directive, and if not, determine whether the resident would like to formulate an advanced directive. 2. The facility will provide the resident's representative with information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advanced directive.A record review of the admission Record revealed the facility admitted Resident #4 on 8/22/23 with diagnoses that included End Stage Renal Disease.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/25 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident's cognition was severely impaired.A record review of the Acknowledgement of Advance Directives Decisions, Rights and Information, dated 6/11/24, revealed Resident #4's Resident Representative (RR) requested assistance with formulating an advance directive.On 03/04/26 at 9:59 AM, during an interview, Resident #4's daughter stated she received information regarding the resident's code status; however, she had not been assisted with understanding or formulating an advance directive and stated she did not understand the difference between the documents.On 03/04/26 at 10:00 AM, during an interview, the Licensed Master Social Worker (LMSW) she stated she was not the social worker assigned when Resident #4 was admitted to the facility and confirmed there was no documentation indicating the resident's representative had been assisted with formulating an advance directive.On 03/04/26 at 12:05 PM, during an interview, the Administrator stated she expects staff to assist residents and their representatives with formulating advance directives when assistance is requested.

Based on observation, interview, record review, and facility policy review, the facility failed to revise a resident's comprehensive care plan after the discontinuation of psychotropic and antidepressant medications for one (1) of two (2) residents sampled for mood and behaviors. Resident #11.Findings include:A review of the facility's policy, Care Plan Revisions Upon Status Change, revised 8/2/22, revealed .The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan . f. Care plans will be modified as needed by the MDS (Minimum Data Set) Coordinator or other designated staff member . h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs .A record review of the Care Plan Report with a revision date of 1/9/26 revealed active care plan problems which stated, Problem: The resident uses psychotropic medications r/t (related to) Impulsive Aggression . Interventions: Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness Q (every) shift . and .Problem: The resident uses antidepressant medication r/t Depression/Anxiety . Interventions: Administer antidepressant medication as ordered by physician. Monitor/document side effects and effectiveness Q-shift .A record review of the admission Record revealed the facility admitted Resident #11 on 9/20/21 with diagnoses including Schizophrenia, Unspecified with onset date of 8/12/22, Major Depressive Disorder, Recurrent, Mild with onset date of 8/15/22, and Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety with onset date of 10/2/22.A record review of Resident #11's Order Summary Report revealed there were no active orders for psychotropic or antidepressant medications related to the resident's diagnoses of Schizophrenia or Depression.A record review of the Clinical Physician Orders with last order review dated 2/24/26 revealed previously ordered psychotropic and antidepressant medications had been discontinued. Mirtazapine was discontinued on 6/10/25, Sertraline HCL was discontinued on 5/30/25, and Risperidone was discontinued on 12/16/24.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/27/26 revealed Resident #11 was rarely/never understood and required a Staff Assessment for Mental Status. The resident's daily cognitive decision-making skills were assessed as severely impaired. Section I revealed diagnoses of Non-Alzheimer's Dementia, Depression (other than Bipolar), and Schizophrenia.On 3/2/26 at 11:11 AM, during an observation, Resident #11 was lying in bed with the bed in the lowest position. Resident #11 did not speak when spoken to.On 3/3/26 at 1:24 PM, during an interview, Licensed Practical Nurse (LPN) #2 stated Resident #11 was nonverbal and had not demonstrated combative behaviors but could occasionally be resistant when receiving medications. LPN #2 stated Resident #11 currently received Memantine and an Exelon patch for Dementia and confirmed the resident was not receiving any psychotropic medications.On 3/5/26 at 1:51 PM, during a record review and interview, LPN #3 stated residents' care plans were updated and revised as changes occurred in physician orders or resident status. LPN #3 confirmed Resident #11 had a care plan revision on 1/9/26 and a Quarterly MDS with an Assessment Reference Date of 1/27/26. After reviewing Resident #11's physician orders and care plan, LPN #3 confirmed the resident was no longer receiving psychotropic or antidepressant medications; however, the care plan continued to include interventions directing staff to administer psychotropic and antidepressant medications and monitor for side effects. LPN #3 stated the interventions were generic and automatically populated during care plan review and acknowledged the care plan had not been resolved after the medications were discontinued.On 3/5/26 at 2:54 PM, during an interview, the Director of Nursing (DON) stated she expected nursing staff responsible for care planning to revise residents' care plans when physician orders changed and ensure care plans accurately reflected the resident's current condition and treatment.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident was administered an inhaler medication in accordance with professional standards and manufacturer guidelines for one (1) of three (3) inhaler medication administrations observed. Resident #38.Findings include:A review of the facility's Administration of Metered-Dose Inhaler, dated 4/4/24, revealed, .It is the policy of this facility to ensure medications are administered.in accordance with professional standards of practice.Policy Explanation and Guidelines.16. If using a corticosteroid, allow resident to rinse and gargle with water if desired, to remove medication from mouth and back of throat.On 03/03/26 at 8:30 AM, during an observation, Licensed Practical Nurse (LPN) #2 administered Trelegy Ellipta inhaler aerosol 100-62.5-25 MCG/ACT (micrograms/actuation), one puff orally, to Resident #38 and did not instruct the resident to rinse their mouth with water after the medication was inhaled.A record review of the manufacturer's guidelines for Trelegy Ellipta revealed, .Step 6.Rinse your mouth with water after you have inhaled the medication. Do not swallow the water.On 03/03/26 at 3:30 PM, during an interview, LPN #2 confirmed she did not instruct Resident #38 to rinse his mouth after administering the corticosteroid inhaler and stated she was unaware of the potential side effects.On 03/03/26 at 3:45 PM, during an interview, the Director of Nursing (DON) stated staff should instruct residents to rinse their mouths after using corticosteroid inhalers and stated the resident should spit the water out to help prevent oral thrush.On 03/03/26 at 4:00 PM, during an interview, the Administrator stated staff are expected to follow the medication administration policy and manufacturer guidelines when administering medications.A record review of the admission Record revealed the facility admitted Resident #38 on 6/2/25 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD).A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/10/26 revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.A record review of the Order Summary Report revealed Resident #38 had a Physician's order, dated 6/2/25, for Trelegy Ellipta inhalation aerosol powder breath activated.1 (one) puff inhale orally one time a day for COPD.A record review of the Medication Administration Record for March 2026 revealed Resident #38 was administered Trelegy Ellipta inhaler on 3/3/26 at 8:30 AM.

Based on observation, interview, record review, and facility policy review, the facility failed to properly store oxygen cylinders and post required cautionary signage related to an oxygen cylinder stored in a resident's room for one (1) of (18) sampled residents. Resident #15.Findings include:A review of the facility's policy, Medication Storage, revised 07/17/23, revealed, .Policy Explanation and Compliance Guidelines.6 .Oxygen Cylinders will be stored in a designated Oxygen storage room.On 03/02/26 at 12:13 PM, during an observation, an oxygen concentrator and an oxygen cylinder were in the corner of Resident #15's room. There was no oxygen cautionary signage on the resident's door. Resident #15 was lying in bed asleep. The oxygen cylinder nor the oxygen concentrator were in use by the resident. On 03/03/26 at 3:20 PM, during an observation, the oxygen concentrator and cylinder continued to be stored in the corner of Resident #15's room and there was no oxygen signage outside of the door.A record review of the admission Record revealed the facility admitted Resident #15 on 11/17/25 with diagnoses including Unspecified Dementia.A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/25 revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 00, indicating her cognition was severely impaired.A record review of the Medication Review Report revealed that Resident #15 had no physician orders for oxygen therapy. There was a physician's order, dated 12/5/25, for Resident #15 to be admitted to hospice services on 12/5/2025. On 03/03/26 at 3:31 PM, during an observation and interview, Licensed Practical Nurse (LPN) #1 confirmed an oxygen concentrator and cylinder were stored in Resident #15's room and confirmed there was no oxygen sign posted on the door. LPN #1 stated she did not know why the equipment was in the resident's room and stated the resident did not have a facility order for oxygen.On 03/03/26 at 3:55 PM, during an observation and interview, Registered Nurse (RN) #1 confirmed an oxygen concentrator and cylinder were located in Resident #15's room and confirmed there was no oxygen cautionary sign on the door. RN #1 stated the hospice company may have brought the equipment and stated she did not know why the equipment was stored in the resident's room.On 03/03/26 at 4:20 PM, during an observation and interview, the Director of Nursing (DON) confirmed an oxygen concentrator and cylinder were located in Resident #15's room and there was no oxygen cautionary sign on the door. The DON stated the equipment should not remain stored in the resident's room and stated oxygen signage should be posted where oxygen equipment is present.On 03/03/26 at 4:30 PM, during an interview, the Administrator stated staff are expected to follow the facility's oxygen storage and safety policies to ensure resident safety.

Based on observation, interview, and facility policy review, the facility failed to store reusable medical equipment in a manner to prevent the possible spread of infection as evidenced by mechanical lift batteries stored in the biohazard room on the rehabilitation hall for one (1) of two (2) biohazard storage rooms reviewed. Findings include: A review of the facility's policy, Infection Prevention and Control Program, revised 6/15/23, revealed, Policy: This facility has established and maintained an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines .Policy Explanation and Compliance Guidelines .10. Equipment Protocol .a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with current procedures . During an observation on 10/24/24 at 10:11 AM, of the biohazard room located on the Rehabilitation Hall, there was two (2) mechanical lift batteries on charging stations and two (2) batteries stored in the room. On 10/24/24 at 11:00 AM, in an interview and observation with Certified Nurse Aide (CNA) #1, the mechanical lift battery charging station and batteries were in the biohazard room on the Rehabilitation Hall. CNA #1 explained that the biohazard room was considered a dirty area and where she would place batteries that needed to be charged and would get the charged batteries as needed. There were no cleaning supplies available in area for sanitizing the batteries before using them on the mechanical lifts. On 10/24/24 at 11:08 AM, in an interview and observation with the Director of Nursing (DON), Registered Nurse (RN) #2, and RN #3 (Infection Control Team) they confirmed the mechanical lift charging stations and batteries were stored in the biohazard room on the Rehabilitation Hall and that any items retrieved from the contaminated room should be cleaned before re-using. The infection control team also confirmed there were no cleaning supplies in the area for the staff to clean the batteries before using. On 10/24/24 at 11:14 AM, in an interview with the Administrator, she stated she expected the facility staff to not store clean items in an area that is considered contaminated.

Based on record review, staff interview, and facility policy review, the facility failed to accurately complete a Minimum Data Set (MDS) Discharge assessment for one (1) of nineteen (19) assessments reviewed. Resident #93. Findings Include: A review of the facility's policy titled Conducting an Accurate Resident Assessment, revised in February 2023 and October 2023, revealed: Policy: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. A record review of the Admission Record revealed that the facility admitted Resident #93 on 09/19/24 with diagnoses including Chronic Kidney Disease. A record review of the Order Summary Report revealed Resident #93 had a Physician's Order dated 10/4/24 to discharge to home on 10/6/24. A record review of the Discharge (MDS with an Assessment Reference Date (ARD) of 10/06/24 indicated Resident #93 was discharged to a Short-Term General Hospital. During an interview on 10/22/24 at 11:00 AM, the Director of Nursing (DON) explained that Resident #93 was only at the facility for therapy, and although the discharge was planned, it was sudden due to the resident's insurance status and personal choice. She confirmed that Resident #93 was discharged to his home with his wife. At 1:15 PM on 10/23/24, during an interview with Licensed Practical Nurse (LPN) #1, she confirmed that she completes Section A of the MDS. She initially believed that she coded Resident #93's discharge correctly as discharged home but, after reviewing the Discharge MDS, she confirmed it was coded as though the resident discharged to short-term general hospital, which was not accurate. During an interview on 10/24/24 at 09:50 AM, the DON acknowledged awareness of the inaccurate discharge status for Resident #93 and recognized it as a coding error. She stated that she signs off on assessments for accuracy and completion, explaining that she expects all MDS staff, as well as herself, to complete assessments accurately and correctly. The DON confirmed that the discharge status for Resident #93 was completed in error and emphasized her expectation of accuracy in all assessments conducted by the facility staff.

Based on observation, interviews, record review, and facility policy review, the facility failed to implement care plan interventions for one (1) of nineteen (19) sampled residents. Resident #6. Findings Include: A review of the facility policy titled Comprehensive Care Plans, revised 8/24/22 revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs as identified in the resident's comprehensive assessment . A record review of the comprehensive care plan for Resident #6 revealed a Problem of The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs with Interventions including Provide the resident with materials for individual activities as desired. The resident likes the following independent activities: Spanish word search puzzles .add content of interest i.e. Spanish speaking programs . A record review of the Admission Record revealed the facility admitted Resident #6 on 03/04/21 with diagnoses including Parkinson's Disease. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/20/24 revealed Resident #6's preferred language was Spanish, and she had a Brief Interview for Mental Status (BIMS) score of four (4), which indicated her cognition was severely impaired. On 10/21/24 at 11:01 AM, during an observation, Resident #6 was lying in bed, awake, with the television on an English-language channel. Upon asking Resident #6 if she would prefer the television to be on a Spanish-speaking channel, she nodded affirmatively. On 10/21/24 at 1:16 PM, in an interview, the Activities Assistant explained that the primary in-room activity she engaged in with Resident #6 involved brief visits to chat about family topics, including children and grandchildren. The Activities Assistant noted that the resident preferred staying in her room and did not participate in group activities. She added that Resident #6 enjoyed music, Spanish puzzles, coloring sheets, and watching television; however, she admitted that the television was set to English channels and that no attempts had been made to explore Spanish-language options. She acknowledged that no in-room activities were currently available that catered to Resident #6's cultural preferences. On 10/22/24 at 11:25 AM, during an observation and interview, the Activities Director confirmed that the facility had no culturally specific activities for Resident #6, who is Spanish speaking. While in Resident #6's room, she confirmed the presence of a CD player but observed no CDs or materials for the resident to play. The Activities Director stated she knew it was important for the resident to have activities that she specifically enjoyed because this was her home, and it was a part of making her feel loved and considered. On 10/23/24 at 8:13 AM, in an interview, the Administrator stated that she was not aware the activities department was not following the care plan regarding activities for Resident #6. She emphasized the importance of quality and continuity of care for all residents, noting that this is the resident's home, and the facility should cater to Resident #6's preferred activities and cultural preferences to ensure her satisfaction. During an interview on 10/23/24 at 8:45 AM, the Minimum Data Set (MDS) Coordinator explained that the purpose of each care plan is to guide facility staff in providing individualized care to each resident. She stated that not following the care plan for Resident #6's preferred activities was an issue, reinforcing the need for all staff to adhere to the resident's care plan.

Based on observation, interviews, record review, and facility policy review, the facility failed to implement individualized and culturally relevant activities to meet the interests and preferences of one (1) of two (2) Spanish-speaking residents reviewed for activities. Resident #6. Findings Include: A review of the facility's policy, Activities, dated 10/1/22, revealed, Policy: It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on the comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident .Policy Interpretation and Implementation .2. Activities will be designed with the intent to .g. Reflect cultural and religious interests of the residents .4. Activities may be conducted in different ways .b. Person Appropriate - activities relevant to the specific needs, interests, culture, background, etc. for the resident they are developed for . During an observation on 10/21/24 at 11:01 AM, Resident #6 was observed lying in bed, awake, with the television on an English-language channel. Upon asking Resident #6 if she would prefer the television to be on a Spanish-speaking channel, she nodded affirmatively. During an interview on 10/21/24 at 1:16 PM, the Activities Assistant explained that the primary in-room activity she engaged in with Resident #6 involved brief visits to chat about family topics, including children and grandchildren. The Activities Assistant noted that the resident preferred staying in her room and did not participate in group activities. She added that Resident #6 enjoyed music, Spanish puzzles, coloring sheets, and watching television; however, she admitted that the television was set to English channels and that no attempts had been made to explore Spanish-language options. She acknowledged that no in-room activities were currently available that catered to Resident #6's cultural preferences. During an observation and interview on 10/22/24 at 11:25 AM, the Activities Director confirmed that the facility had no culturally specific activities for Resident #6, who is Spanish speaking. While in Resident #6's room, she confirmed the presence of a compact disc (CD) player but observed no CDs or materials for the resident to play. The Activities Director stated she knew it was important for the resident to have activities that she specifically enjoyed because this was her home, and it was a part of making her feel loved and considered. During an interview on 10/23/24 at 8:13 AM, the Administrator stated that she was unaware that the activities department was not providing culturally relevant activities. She emphasized the importance of providing quality and consistent care for all residents, acknowledging that Resident #6's cultural preferences should be respected as part of honoring her home environment. During an interview on 10/24/24 at 9:55 AM, Resident #6's granddaughter, acting as her Resident Representative (RR), shared that in her four years of visiting the facility, she had not observed any activities provided that aligned with her grandmother's cultural background. She expressed that her grandmother would benefit from having television programs or audio content in Spanish, as she believed this would enhance her enjoyment and connection to her heritage. A record review of the Visual/Bedside Kardex Report as of 10/22/24 revealed .Resident Care .Activities .Proved the resident with materials for individual activities as desired. The resident likes the following independent activities: Spanish word search puzzles . A record review of the Admission Record revealed the facility admitted Resident #6 on 03/04/21 with diagnoses including Parkinson's Disease. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/20/24 revealed Resident #6's preferred language was Spanish and she had a Brief Interview for Mental Status score of 4 which indicated her cognition was severely impaired.

Based on staff interview, record review, and facility policy review, the facility failed to accurately document a resident's weight in the medical record for one (1) of 19 sampled residents. Resident #49 Findings include: A review of the facility's policy, Weighing and Measuring the Resident, dated 8/2/22, revealed, .The purpose of this procedure are to determine the resident's weight .to provide .an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident .Documentation .The following information should be recorded in the resident's medical record .2. The .weight of the resident .Reporting 1. Report significant weight loss/weight gain to the nurse supervisor . A record review of the Admission Record revealed the facility admitted Resident #49 on 5/29/2023 with diagnoses including End Stage Renal Disease. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/30/2024 revealed Resident #49 had a weight loss of 5% or more in the last month or loss of 10% or more in last six (6) months. A record review of the Weights and Vitals Summary revealed Resident #49 had a Warning on 5/17/24 of a significant weight increase in which his weight was recorded as 211.4 pounds. On 5/20/24, there was a Warning that Resident #49 had a significant weight loss in which his weight was recorded as 186.5 pounds. On 10/22/2024 at 3:29 PM, in an interview with the Director of Nursing (DON), she explained she was unaware that Resident #49 had triggered a warning for weight loss as it had not been on the weekly weight reports. The DON expressed she believed the weight entered for Resident #49 on 5/17/24 was entered in error and that the resident's weights have been between 175-192 pounds since his admission by the facility. In an interview on 10/23/24 at 2:20 PM, with the Dietary Manger, she explained she was responsible for entering the information to complete Section K of the Minimum Data Set (MDS). She stated that she entered the residents' weights that are given to her from the weight team. She said that she if she saw a weight that looked inaccurate, she would question the weight team. The Dietary Manager expressed that having accurate resident weight information was important because the one inaccuracy can have a negative effect on other parts of the MDS. On 10/23/24 at 3:10 PM, in an interview with Registered Nurse (RN) #1, she explained there were several factors that could contribute to a change in a resident's weight. She further explained that any major weight gains or losses would be triggered by the computer system and the resident would be re-weighed to ensure accuracy. RN #1 reviewed the weights entered into the medical record for Resident #49 and expressed that the weights were not accurate, and she was unsure as to why the resident was not re-weighed.

Based on interviews, observations, and facility policy review the facility failed to prevent the possible spread of infection during medication preparation for one (1) of three (3) medication administration observations. A record review of the facility's policy, Administering Medications, revised 8/2/22, revealed, .Medications shall be administered in a safe .manner .Policy Interpretation and Implementation .19. Staff shall follow established facility infection control procedures . On 2/15/23 at 8:12 AM, during an observation of medication pass with License Practical Nurse #1 (LPN), she prepared medications to be administered by placing medications in a clear medication administration cup. She dispensed Duloxetine HCI capsule 30 mg (milligrams) from a medication card into her bare hand, and then placed the capsule into a clear medication administration cup, along with medications she had previously placed in the cup for the resident. LPN #1 entered the Resident #342's room and administered the medications to the resident. Record review of the Order Summary Report for Resident #342, included an order dated 2/3/23, for Duloxetine HCI capsule delayed release particles 30 mg. Give 1 capsule by mouth one time a day for (Depression). On 2/15/23 at 8:45 AM, in an interview with LPN #1, she stated that she should not have put the medication into her bare hand and that she was not paying attention to what she was doing. She confirmed that she should have dispensed the medication directly into the cup and that she had contaminated the other medications she had previously placed in the cup. On 2/15/23 at 9:49 AM, in an interview with the Director of Nursing (DON), she stated that when LPN #1 touched the medication with her hands, it was an infection control issue, and she should have discarded the medication. On 2/15/23 at 10:09 AM, in an interview with Registered Nurse #1 (RN)/Infection Prevention Nurse/Staff Development Nurse, she stated that LPN #1 should have discarded the medication when she touched it with her bare hand and that these actions increased the resident's chance of getting an infection because, Whatever was on the nurses' hands was on the medications when she gave them to the resident. A record review of the .Nurse Skills Checkoff List revealed LPN #1 completed a skills checkoff that included Medication Administration and was signed by LPN #1 and an Evaluator on 8/5/22. A record review of the facility document Infection Control for Medication Cart, dated 8/5/22, revealed the facility provided training to LPN #1 which included, Do not touch pills without gloves on hands .

Based on observation, staff interview, and facility policy review, the facility failed to post the daily staffing for public viewing on three (3) of four (4) days reviewed for staff posting. A record review of the facility's policy Posting Direct Care Daily Staffing Numbers revised 07/21/22 revealed .Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Policy Interpretation and Implementation 1. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) (Registered Nurses, Licensed Practical Nurses, and Licensed Vocational Nurses) and the number of unlicensed nursing personnel (CNAs) (Certified Nurse Aides) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) .5. Within two (2) hours of the beginning of the shift, the shift supervisor shall compute the number of direct care staff and complete the .form and post the staffing information in the location(s) designated by the Administrator .9. Staffing information during the recorded time period shall be made available to residents, family members, and the public . Findings include: Observations on 02/13/23 at 11:13 AM, 02/14/23 at 09:30 AM, and 02/15/23 at 03:30 PM revealed the daily staffing was not visible for public viewing. On 02/14/23 at 02:30 PM, the Director of Nursing (DON) stated the daily staffing is posted outside of the staffing office. An observation revealed this area is located in a corner at the back of the facility, behind the Rehabilitation Unit. Facility staff had access to the area, but visitors and residents did not. On 02/15/23 at 03:30 PM, in an interview and observation with the Administrator and the DON, confirmed the daily staffing continued to be posted outside of the staffing office and was not visible for public viewing. On 02/16/23 at 10:30 AM, during an interview with Staffing #1, she confirmed that she had been posting the daily staffing numbers outside of her office door and it was not visible to visitors or residents.

Based on interview and record review, the facility failed to ensure one (1) resident received showers at least three times a week for one (1) of three (3) sampled residents who are dependent on staff for assistance with Activities of Daily Living (ADLs). (Resident #1) Findings: Record review of the facility's policy, Activities of Daily Living (ADLs), Supporting, revised on 8/10/05 revealed, Policy Statement .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Record review of Resident #1 Admission Record revealed, the facility admitted Resident #1 on 12/23/21 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/23/22, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated she is cognitively intact, and reviw of Section G revaled she was totally dependent upon staff for bathing. On 3/23/22 at 9:0 AM, an interview with Resident #1 revealed she had only received a shower four (4) times this month (March 2022), and she is scheduled to receive a shower at least three (3) times a week. She stated it made her feel bad if she did not get a shower. A record review of the Task for Resident #1 for Schedule for March 2022 revealed no documentation of a shower or bath given on 3/1/22, 3/3/22, 3/12/22, 3/15/22, 3/17/22, 3/19/22, and 3/22/22 as scheduled, which means Resident #1 received four (4) showers from 3/1/22 through 3/23/22. On 3/23/22 at 11:00 AM, an interview with the Social Worker revealed Resident #1 had previously complained of not receiving her showers and that she only received four (4) so far in March of 2022, which is causing her discomfort. On 3/23/22 at 11:30 AM, an interview with the Director of Nurses (DON) revealed Resident #1 is scheduled to receive a shower three (3) times a week on the 3-11 shift on Tuesday, Thursday, and Saturday. She said that the resident may have refused, but the Certified Nurses Assistants (CNA's) are to document and notify their nurses, if the resident refuses. The DON verified, according to the CNA Task Schedule, Resident #1 received four (4) showers from 3/1/22 through 3/23/2022 which is 4 times in 23 days. She confirmed that Resident #1 not receiving baths could have caused the resident to have skin issues. On 3/24/22 at 11:00 AM, an interview with Certified Nurse Assistant (CNA) #1 revealed that if a resident refuses a bath or shower, the CNA notifies the nurse and documents the refusal in the computer system. The CNA's document on the residents' ADLs and they know when residents are scheduled to have a bath or shower because it comes up on their tasks in the computer. .

Based on resident interviews, observations, and facility statement, the facility failed to ensure residents were aware of the location and availability of the most recent survey results, for four (4) of five (5) residents who attended the group meeting. Findings include: Review of the facility statement, signed by the Administrator, dated 9/26/19, revealed: One (1) of the Resident's rights is to have survey results, with plans of correction, for the past three (3) years, posted in a place accessible to residents. Per the Resident Rights, these results are in the facility at each nurse's station. During the group meeting on 9/24/2019 at 1:30 PM, four (4) of five (5) residents did not know where the survey results were located in the facility. During an interview, on 09/25/19 at 2:45 PM, Social Worker #1 did not know where last year's survey results were posted. Social Worker #1 stated she did not know how the residents were being educated as to where the survey results were posted. During an interview on 09/25/19 at 2:50 PM, Activity Director #1 stated that Social Services conducts Resident Council meetings. Activity Director #1 stated she had not educated the residents on where last year's survey results were posted. Observation on 09/25/19 at 9:30 AM, revealed survey results were posted on the table in the front lobby. There was a sign on the wall in the South Nursing Station, that survey results are posted in the front lobby. A sign was not posted on the North Hall or on the Rehabilitation unit, indicating where survey results were posted.

Based on observation, record review, facility policy review, and staff interview, the facility failed to prevent the possible spread of infection, during medication preparation for two (2) of five (5) nurses observed administering medications. Findings include: Review of the facility's Administering Medications, policy, dated 12/2017, revealed staff should follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) when these apply to the administration of medications. Review of the facility's Infection Control Guidelines for All Nursing Procedures, dated (MONTH) (YEAR), revealed the purpose of this document is to provide guidelines for general infection control while caring for residents. The document indicated standard and transmission-based precautions are used to prevent the spread of infection. The document noted that employees must wash their hands. The document noted in most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. The document noted the alcohol based hand rub is to be used before preparing or handling medications. During an observation on 9/24/2019 at 9:15 AM, Licensed Practical Nurse (LPN) #1 prepared to administer oral medications to a resident. LPN #1 placed her ungloved right (R) index finger into a bottle of Aspirin to retrieve a tablet. LPN #1 placed the tablet with her bare hand from the bottle into the medication cup. LPN #1 placed seven (7) additional pills into the same medication cup. LPN #1 administered all of the medications from the medication cup to a resident. During an interview on 9/24/2019 at 9:29 AM, LPN #1 confirmed that she had retrieved the Aspirin tablet with her bare hand and put it in the medication cup for a resident. LPN #1 stated, That was stupid, I knew I shouldn't have done that. LPN #1 stated that you should never touch a medication with your bare hands to give to a resident. LPN #1 stated that touching medications with your bare hands could cause the spread of infection. During an observation on 9/25/2019 at 9:07 AM, LPN #2 prepared oral medications for a resident. LPN #2 placed each oral medication, from it's respective bubble pack, into the palm of her bare hand, and then into the medication cup. LPN #2 prepared a total of nine (9) oral medications in this manner. LPN #2 administered all nine (9) oral medications to the resident. During an interview on 9/25/2019 at 9:20 AM, LPN #2 confirmed she had placed each pill, for a total of nine (9) oral medications, into her bare hand, placed the medication into the cup, and administered the medication to the resident. LPN #2 stated there could have been bacteria on her hands, and it could have spread to the resident. LPN #2 stated she had been trained on the correct way to dispense medications. During an interview on 9/24/2019 at 11:50 AM with the Director of Nursing (DON), the DON stated that nurses should never touch the oral medications with their bare hands. The DON stated that touching medications with bare hands would be an infection control concern. During an interview on 9/26/2019 at 11:46 AM, the Director of Nursing (DON) confirmed that touching or placing medications into your bare hands is not how she would expect the nurse to prepare and give oral medications. Review of the facility's in-service documentation records revealed LPN #1 and LPN #2 had both been trained on the steps and process to follow proper infection control techniques during medication administration. LPN #1 on 10/17/18, and LPN #2 on 9/6/19.

CI MS# Based on interview, record review, policy review, and facility investigation review, the facility failed to report the elopement and lack of supervision of Resident #4 to the State Agency (SA), when made aware, to ensure corrective actions were completed. This affected one (1) of three (3) residents reviewed for elopement risk. Resident #4, a demented resident with a past history of exit-seeking behaviors, assessed and care planned for an elopement risk, attempted to rise from the wheelchair and grab the front door exit approximately seven (7) times and actually eloped from the facility's front door, with assistance of a visitor, on 9/30/18. The Receptionist, responsible to monitor the door, to ensure residents did not exit the facility without supervision, was observed on video looking at her cell phone and was unaware of the resident's attempts and actual exit through the front door. The sidewalk in front of the building where Resident #4 was found by a visitor, was approximately 11 steps from the street and had a curb that was approximately three (3) inches high. Resident #4 had propelled down the sidewalk, in front of the North Hall door facing the front of the building, and was approximately 34 steps from the front door. The resident was outside the facility from three (3) to five (5) minutes without supervision. The facility's failure to report the elopement/lack of supervision to the State Agencies as required, to ensure corrective actions were taken, placed Resident #4 and other residents at risk for elopement, in a situation that was likely to cause serious harm, injury, impairment, or death. This situation was determined to be and Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/30/18, when Resident #4, a demented resident, assessed and care planned as an elopement risk, exited the building from the front door while the Receptionist, responsible to monitor the front door, sat at the front desk, within vision of the front door/resident, on a cell phone. The Receptionist was neglectful of her duty to monitor the front door and report the resident's attempts to leave the facility, as well as the actual elopement. On 11/29/18 at 3:48 PM, the SA notified the facility's Administrator of the IJ and SQC. The facility submitted an acceptable Allegation of Compliance (A[NAME]) on 12/3/18, in which the facility alleged all corrective actions were completed on 12/1/18, and the IJ removed on 12/2/18. The SA validated the A[NAME] on 12/4/18, and determined the IJ was removed prior to exit. Therefore the scope and severity for 42 CFR(s) 483.12 (c)-Reporting, F609, was lowered from a J to a scope and severity of a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the policy titled, Policies and Procedures for Abuse Prevention, Investigation and Reporting, dated 2/15/10, revealed: The facility will report allegations of abuse, neglect or exploitation and shall be reported pursuant to the state Vulnerable Adults Act and appropriate action will be taken based on results of the investigation. Review of the facility investigative report revealed on 9/30/18, Resident #4, per video, had attempted to rise from her wheelchair to open the front door exit seven (7) times and then was assisted out the front door. The Receptionist was observed on the cell phone, with her head down and not aware Resident #4 had exited the building. This investigation revealed another visitor was leaving and found Resident #4 on the sidewalk and came back in the facility and reported to the nursing staff that the resident was outside alone. The investigation revealed Resident #4 was outside alone less than five (5) minutes. Observation and review of the video revealed the sidewalk in front of the building where Resident #4 was found, was approximately 11 steps to the street and had a curb that was approximately three (3) inches high. Resident #4 had propelled down the sidewalk, in front of the North Hall door facing the front of the building, and was approximately 34 steps from the front door when she was found by the daughter of another resident. Resident #4 was returned to the facility by LPN #1 without injury. Review of the video on 11/19/18 at 9:20 AM, revealed on 9/30/18 at approximately 2:55 PM, Resident #4 attempted to rise and exit the door seven (7) times before actually exiting the building with assistance of a visitor. The resident and the visitor was identified on the video by LPN #2. In an interview on 11/29/18 at 3:03 PM, the Receptionist on duty on 9/30/18, revealed she was not aware that Resident #4 had exited the building until she was being brought back in by the facility staff. The Receptionist confirmed she was on the phone ordering food when Resident #4 was assisted out of the building by a visitor, and did not see her. The receptionist acknowledged Resident #4 had attempted to get out of locked doors before, confirming the risk. The receptionist confirmed that part of her duty was to monitor the front exit door. Interview with the Administrator on 11/29/18 at 3:30 PM, revealed he wrote a statement of what occurred when Resident #4 exited the building on 9/30/18. The Administrator stated he was notified at home of the event and further stated the he did not determine Resident #4 exiting the building unsupervised as an elopement. The Administrator stated it was discussed with the Director of Operations and The Cooperate Nurse and determined not to be an elopement and not a reportable event. The Administrator also stated an emergency Quality Assurance (QA) meeting was not held because it was determined not to be an elopement. The Administrator stated, Our determination of elopement is when they leave the premises. The Administrator confirmed he did not report the elopement/lack of supervision event to the SA. Interview with the Director of Operations on 11/29/18 at 2:35 PM, confirmed during the investigation it was determined not to be an elopement since Resident #4 never left the premises and thus was not reported to the SA. Interview with the Assistant Director of Nursing (ADON) #1 on 11/27/18 at 11:05 AM, revealed during the investigation when Resident #4 exited the building, the video was reviewed and showed a visitor assisted the resident out the front door and the resident going down the sidewalk in her wheelchair. She stated the video also revealed Receptionist #1 sitting at the front desk with her head down. ADON #1 stated she would consider this a reportable incident because no one was aware of Resident #4 being outside until notified by Visitor #1, who found the resident outside unsupervised. ADON #1 stated Resident #4 was care planned for elopement and assessed as an elopement risk. The facility provided an Acceptable Allegation of Compliance, which included: Resident #4, a cognitively impaired resident, exited the front entrance of the facility with the assistance of a visitor at approximately 2:33 PM on 9/30/18. The investigation revealed that the Receptionist, who was responsible for monitoring the front entrance, was at the desk viewing her cell phone and was not aware that Resident #4 exited through the front entrance. Resident #4 was found sitting in her wheelchair, unsupervised, on the front sidewalk approximately 34 steps from the front entrance by a visitor at approximately 2:37 PM. The visitor alerted the nursing staff. Resident #4 was taken to South Nurses' Station area by Licensed Practical Nurse (LPN) #1, where she was visually monitored. Resident #4's Elopement Risk Assessment and care plan was updated on 10/17/14, identifying exit seeking behavior. Resident #4 continued to be care planned for elopement risk with exit seeking behaviors on 8/9/18. Corrective Actions; 1. On 9/30/18 at approximately 2:55 PM, Resident #4 was evaluated by Registered Nurse (RN) #1, with no injuries noted and no complaints voiced. 2. On 9/30/18 at approximately 2:55 PM, Resident #4's Responsible Party, Daughter, Physician, Administrator, and Resident Care Coordinator/Registered Nurse/Infection Control Nurse (RCC/RN/ICN) were notified by RN #1. 3. On 9/30/18 at approximately 3:45 PM, Resident #4 was placed on visual checks every 15 minutes for 24 hours and was observed to be calm and quite for the remainder of the day. 4. On 9/30/18 at approximately 4:40 PM, an investigation was initiated by the Administrator. The investigation revealed that the Receptionist, who was responsible for monitoring the front entrance, was at the desk viewing her cell phone and was not aware that Resident #4 exited through the front entrance assisted by a visitor. 5. On 9/30/18 at approximately 3:00 PM, the other two (2) residents who are at risk for elopement were visually observed in the facility by LPN #2 and LPN #3. 6. On 10/1/18, a magnetic lock and key pad was installed at the front entrance of the facility by an outside vendor, with installation initiated at approximately 9:00 AM, and completed by 3:00 PM. 7. Effective 10/1/18, the Receptionist quit during the investigation process. 8. On 11/29/18 at approximately 2:30 PM, signs were posted by the Administrator at each non-emergency entrance/exit stating ATTENTION: Please check with the Nurse at the Nurses' Station before assisting a resident to exit the facility. Thank you. 9. On 11/30/18 at 8:53 AM, the Minimum Data Set (MDS) Nurse #1 added an intervention to Resident #4's care plan for reporting of exit seeking behaviors to nurse, who will institute visual checks every 30 minutes for 72 hours, and then resume every hour checks if no exit seeking behavior is exhibited. 10. On 12/1/18 starting at approximately 8:00 AM, the MDS Nurse #1, MDS Nurse #2, and MDS Nurse #3, assessed all residents for risk of elopement, including Resident #4 and the other two (2) residents at risk for elopement, and audited all residents' elopement risk care plans for accuracy. No concerns were identified. 11. Summary of Training; *On 10/1/18 at 8:00 AM, training was initiated by the Staff Development Nurse to all facility staff entitled, Elopement, which included resident safety related to elopement and safety of wandering residents. Trained on this date were nine (9) of 11 RNs, nine (9) of 23 LPNs, 16 of 52 CNAs, two (2) of 13 Therapy staff, one (1) of four (4) Activities staff, three (3) of five (5) Administrative staff, two (2) of three (3) Social Services, zero (0) of three (3) Maintenance, zero (0) of seven (7) Laundry staff, zero (0) of 14 Housekeeping staff, zero (0) of 15 Dietary staff, zero (0) of two (2) Medical Records staff, zero (0) of one (1) Central Supply staff, and one (1) of five (5) Nursing Clerical staff. *On 11/1/1 at 7:15 AM, training was initiated by RN #2, employed by another facility, to all facility staff entitled, Abuse, which included abuse, exploitation, neglect, seclusion, and responsibility to report to supervisor. Trained of this date were four (4) of nine (9) RNs, 15 of 24 LPNs, 29 of 51 CNAs, nine (9) of 14 Therapy staff, four (4) of 14 Housekeeping staff, zero (0) of seven (7) laundry staff, three (3) of four (4) Activities staff, one (1) of three (3) Social Services, two (2) of two (2) Medical Records staff, one (1) of 16 Dietary staff, one (1) of four (4) Administrative staff, zero (0) of three (3) Maintenance staff, one (1) of one (1) Central Supply staff, and one (1) of three (3) Nursing Clerical staff. *On 11/29/18 at 6:30 PM, training was initiated by the Acting DON and RCC/RN/ICN to all facility staff entitled, 1. Elopement, which included resident safety related to elopement and safety of wandering residents. 2. Safety and Supervision of Residents, which included the importance of resident supervision related to elopement risk, reporting of exit seeking behaviors to the nurse and required monitoring. When a resident is actively exit-seeking, the staff observing this behavior will maintain visual observation of the resident until the behavior can be reported to the resident's nurse. Trained on this date were six (6) of nine (9) RNs, 12 of 21 LPNs, 30 of 51 CNAs, two (2) of three (3) Social Services, zero (0) of three (3) Maintenance staff, two (2) of 15 Housekeeping staff, one (1) of seven (7) laundry staff, nine (9) of 16 Dietary staff, zero (0) of four (4) Activities staff, three (3) of four (4) Administration, two (2) of two (2) Medical Records staff, four (4) of four (4) Agency LPNs, seven (7) of seven (7) Agency CNAs, 14 of 14 Therapy staff, two (2) of three (3) Nursing Clerical staff, and one (1) of one (1) Central Supply staff. *On 11/29/18 at 6:30 PM, training was initiated by the Acting DON and RCC/RN/ICN to all RNs, LPNs, and Certified Nursing Assistants (CNA) entitled, Using the Care Plan, which included use of the care plan to direct care provided to residents related to elopement. Trained on this date were six (6) of nine (9) RNs, 12 of 21 LPNs, 30 of 51 CNAs, four (4) of four (4) Agency LPNs, and seven (7) of seven (7) Agency CNA staff. *On 11/30/18 at 9:30 AM, training was initiated by a Nursing Home Administrator/Licensed Professional Counselor who is not employed by this facility to all Administrative and Department Head staff entitled, Abuse and Reporting and Accidents/Elopement, which included reporting requirements to Mississippi State Department of Health and the State Attorney General's Office for all alleged violations including abuse, neglect, exploitation, or mistreatment of [REDACTED]. Trained this date were 12 of 14 Administrative key personnel, three (3) of three (3) Corporate Staff, four (4) of four (4) LPNs, one (1) of one (1) RNs, and two (2) of two (2) Ancillary Administrative staff. *On 11/30/18 at 7:00 PM, training was initiated by RN #3, RN #4, and the DON to all staff entitled, Mississippi Vulnerable Persons Act/Abuse, Neglect, Report Requirements/Cell Phone Use, which included cell phone use policy, abuse and neglect, including neglect as it relates to lack of supervision and reporting requirements. Trained on this date were one (1) of nine (9) RNs, six (6) of 21 LPNs, 14 of 51 CNAs, two (2) Agency LPNs, seven (7) Agency CNAs, one (1) of 15 Housekeeping staff, one (1) of seven (7) laundry staff, zero (0) of three (3) Maintenance staff, zero (0) of three (3) Social Services, zero (0) of two (2) Medical Records, one (1) of four (4) Administration, one (1) of three (3) Nursing Clerical, and zero (0) of one (1) Central Supply staff. *On 12/1/18 at 11:30 AM, training was initiated by the Administrator to all staff that have Receptionist and/or Manager on Duty responsibilities entitled, Addendum to Duties of Receptionist or Manager of the Day, which included assistance with access to the front entrance, monitoring of residents with exit seeking behaviors in this area, and use of the Elopement Manual. Trained this date were five (5) of 26 staff members. *No staff will be allowed to work until trained on these topics. 12. A Quality Assurance (QA) Committee meeting was conducted on 11/29/18, at 5:08 PM. Attendees included the Medical Director, Administrator, Acting DON, RCC/RN/ICN, MDS Nurse #1, MDS Nurse #2, MDS Nurse #3, Corporate RN, and Director of Long Term Care Operations. The following policies and procedures were reviewed by the committee with no changes made: Elopement, Using the Care Plan, Safety and Supervision of Residents, and Abuse Prevention, Investigation and Reporting. The committee reviewed the elopement incident involving Resident #4, which occurred on 9/30/18. The committee determined the system failure that allowed Resident #4 to exit the building unsupervised was the Receptionist using her cell phone. The committee reviewed actions taken by the facility to address resident safety related to elopement risk including modifications to the front entry door operation and 15 minute visual checks for Resident #4 for 24 hours, and hourly checks ongoing. The committee was informed by the Administrator that the Receptionist, who had no previous disciplinary actions taken, quit during the investigation process on 10/1/18. The committee recommended education begin immediately on the following policies and procedures: Elopement - all staff, Safety and Supervision of Resident - all staff, Using the Care Plan - nursing staff, and Abuse, neglect and related reporting requirements - all staff. The QA Committee recommended a monitoring system for residents with exit seeking behaviors to be implemented on 11/29/18. Residents, who are actively exit-seeking, will be reported immediately to the nurse. 13. The State Attorney General 's Office was notified on 11/29/18, at 7:23 PM by the Administrator of the incident of elopement involving Resident #4, which occurred on 9/30/18. 14. The facility alleged all corrective action was completed on 12/1/18, and the IJ was removed on 12/2/18. Validation of the Allegation of Compliance included: Based on observation, interviews, record review and facility investigation review, the State Agency (SA) validated that Resident #4, a cognitively impaired resident, exited the front entrance of the facility with the assistance of a visitor at approximately 2:33 PM on 9/30/18. The investigation revealed that the Receptionist, who was responsible for monitoring the front entrance, was at the desk viewing her cell phone and was not aware that Resident #4 exited through the front entrance. Resident #4 was found sitting in her wheelchair, unsupervised, on the front sidewalk approximately 34 steps from the front entrance by a visitor at approximately 2:37 PM. The visitor alerted the nursing staff. Resident #4 was taken to South Nurses' Station area by Licensed Practical Nurse (LPN) #1 where she was visually monitored. The SA validated through record review that Resident #4's Elopement Risk Assessment and care plan was updated on 10/17/14, identifying exit seeking behavior and that Resident #4 continued to be care planned for elopement risk with exit seeking behaviors on 8/9/18, prior to the exit on 9/30/18. Corrective Actions; 1. The SA validated through interview and record review that on 9/30/18 at approximately 2:55 PM, Resident #4 was evaluated by Registered Nurse (RN) #1 with no injuries noted and no complaints voiced. 2. The SA validated through interview with staff and record review that on 9/30/18, Resident #4's RP, Daughter, Physician, Administrator, and Resident Care Coordinator/Registered Nurse/Infection Control Nurse (RCC/RN/ICN) were notified by RN #1, of the resident's elopement. 3. The SA validated through record review and interview with staff, that on 9/30/18 at approximately 3:45 PM, Resident #4 was placed on visual checks every 15 minutes for 24 hours and was observed to be calm and quite for the remainder of the day, without further exit-seeking behaviors. 4. The SA validated through interview and record review that on 9/30/18, an investigation was initiated by the Administrator, and he concluded that the Receptionist, who was responsible for monitoring the front entrance, was at the desk viewing her cell phone and was not aware that Resident #4 exited through the front entrance, assisted by a visitor. 5. The SA validated through interview and record review that on 9/30/18, the other two (2) residents who were at risk for elopement were visually observed in the facility by LPN #2 and LPN #3. 6. The SA validated through observation, interview and record review, that on 10/1/18, a magnetic lock and key pad was installed at the front entrance of the facility by an outside vendor. 7. The SA validated through interview and record review that effective 10/1/18, the Receptionist quit during the investigation process of Resident #4's elopement. 8. The SA validated through observation and interview that on 11/29/18, signs were posted by the Administrator at each non-emergency entrance/exit stating ATTENTION: Please check with the Nurse at the Nurses' Station before assisting a resident to exit the facility. Thank you. 9. The SA validated through record review and interview that on 11/30/18, the Minimum Data Set (MDS) Nurse #1 added an intervention to Resident #4's care plan for reporting of exit seeking behaviors to the nurse, who will institute visual checks every 30 minutes for 72 hours, and then resume every hour checks if no exit seeking behavior is exhibited. 10. The SA validated through interviews and record review that on 12/1/18, MDS Nurse #1, MDS Nurse #2, and MDS Nurse #3 assessed all residents for risk of elopement, including Resident #4 and the other two residents at risk for elopement, and audited all residents' elopement risk care plans for accuracy. No concerns were identified with these residents or their care plans for elopement risk behaviors. 11. The SA validated through interviews and record review the facility conducted the following training: -On 10/1/18-training was initiated by the Staff Development Nurse to all facility staff entitled, Elopement, which included resident safety related to elopement and safety of wandering residents. Review of the sign-in sheets revealed nine (9) RNs, nine (9) LPNs, 16 CNAs, two (2) Therapy staff, one (1) Activity staff, three (3) Administrative staff, two (2) Social Services staff, and one (1) Nursing Clerical staff was trained. -On 11/1/18-training was initiated by RN #2, employed by another facility, to all facility staff entitled, Abuse, which included abuse, exploitation, neglect, seclusion, and responsibility to report to supervisor. Review of the sign-in sheets revealed four (4) RNs, 15 LPNs, 29 CNAs, nine (9) Therapy staff, four (4) Housekeeping staff, three (3) Activities staff, one (1) Social Services staff, two (2) Medical Records staff, one (1) Dietary staff, one (1) Administrative staff, one (1) Central Supply staff, and one (1) Nursing Clerical Staff were trained. -On 11/29/18-training was initiated by the Acting DON and RCC/RN/ICN to all facility staff entitled, 1. Elopement, which included resident safety related to elopement and safety of wandering residents. 2. Safety and Supervision of Residents, which included the importance of resident supervision related to elopement risk, reporting of exit seeking behaviors to the nurse and required monitoring. When a resident is actively exit-seeking, the staff observing this behavior will maintain visual observation of the resident until the behavior can be reported to the resident's nurse. Review of the sign-in sheets revealed six (6) RNs, 12 LPNs, 30 CNAs, two (2) Social Services staff, two (2) Housekeeping staff, one (1) Laundry staff, nine (9) Dietary staff, three (3) Administration, two (2) Medical Records staff, four (4) Agency LPNs, seven (7) Agency CNAs, 14 Therapy staff, two (2) Nursing Clerical, and one (1) Central Supply staff was trained. -On 11/29/18-training was initiated by Acting DON and RCC/RN/ICN to all RNs, LPNs, and Certified Nursing Assistants (CNA) entitled, Using the Care Plan, which included use of the care plan to direct care provided to residents related to elopement. Trained on this date were six (6) RNs, 12 LPNs, 30 CNAs, four (4) Agency LPNs, and seven (7) Agency CNA staff, per review of the sign-in sheets. -On 11/30/18-training was initiated by a Nursing Home Administrator/Licensed Professional Counselor who is not employed by this facility to all Administrative and Department Head staff entitled, Abuse and Reporting and Accidents/Elopement, which included reporting requirements to Mississippi State Department of Health and the State Attorney General's Office for all alleged violations including abuse, neglect, exploitation, or mistreatment of [REDACTED]. Trained this date, per review of the sign-in sheets, were 12 Administrative key personnel, three (3) Corporate staff, four (4) LPNs, one (1) RN, and two (2)Ancillary Administrative staff. -On 11/30/18-training was initiated by RN #3, RN #4, and DON to all staff entitled, Mississippi Vulnerable Persons Act/Abuse, Neglect, Report Requirements/Cell Phone Use, which included cell phone use policy, abuse and neglect, including neglect as it relates to lack of supervision and reporting requirements. Trained on this date, per sign-in sheets, was one (1) RN, six (6) LPNs, 14 CNAs, two (2) Agency LPNs, seven (7) agency CNAs, one (1) Housekeeping staff, one (1) Laundry staff, one (1) Administration, one (1) Nursing clerical staff, and one (1) Central Supply staff. -On 12/1/18-training was initiated by Administrator to all staff that have Receptionist and/or Manager on Duty responsibilities entitled, Addendum to Duties of Receptionist or Manager of the Day, which included assistance with access to the front entrance, monitoring of residents with exit seeking behaviors in this area, and use of the Elopement Manual. Per sign-in sheets, five (5) of the twenty six (26) staff members assigned to this duty were trained. The SA validated through interview with staff and schedules, that no staff was allowed to work without training on these topics. 12. The SA validated through interviews, sign-in sheets and record review, that a Quality Assurance (QA) Committee meeting was conducted on 11/29/18, and the attendees included the Medical Director, Administrator, Acting DON, RCC/RN/ICN, MDS Nurse #1, MDS Nurse #2, MDS Nurse #3, Corporate RN, and Director of Long Term Care Operations. Interviews revealed the committee reviewed the following policies and procedures with no changes made: Elopement, Using the Care Plan, Safety and Supervision of Residents, and Abuse Prevention, Investigation and Reporting. Interviews revealed the committee discussed the elopement incident involving Resident #4 which occurred on 9/30/18, and determined the system failure that allowed Resident #4 to exit the building unsupervised was the Receptionist using her cell phone. Interviews revealed the committee reviewed actions taken by the facility to address resident safety related to elopement risk including modifications to the front entry door operation and 15 minute visual checks for Resident #4 for 24 hours, and hourly checks ongoing. Interviews revealed the committee recommended education for policies and procedures, which included: Elopement - all staff, Safety and Supervision of Resident - all staff, Using the Care Plan - nursing staff, and Abuse, neglect and related reporting requirements - all staff. Interviews also revealed the QA Committee recommended a monitoring system for residents with exit seeking behaviors to be implemented on 11/29/18, that residents, who are actively exit-seeking, will be reported immediately to the nurse. 13. The SA validated through interviews and record review that the State Attorney General's Office was notified on 11/29/18, by the Administrator, of the incident of elopement involving Resident #4, which occurred on 9/30/18. The SA validated that all corrective actions were completed on 12/1/18, and the IJ was removed on 12/2/18.

CI MS# Based on observation, interview, record review and policy review, the facility failed to implement the plan of care to ensure residents didn't exit the facility unsupervised and secure exits for one (1) of three (3) residents at risk for elopement, of seven (7) care plans reviewed; Resident #4. The facility also failed to develop a care plan for the actual elopement of Resident #4 on 9/30/18. Resident #4 a demented resident, care planned for the risk of elopement, with a past history of exit-seeking behaviors, eloped from the facility's front door on 9/30/18, assisted by a visitor, after attempting to exit by herself, and was found approximately 34 walked steps from the facility by another visitor. Resident #4 was assessed by the Registered Nurse with no injury. A staff person, the Receptionist responsible to monitor the door to ensure residents did not exit the facility without supervision, was observed on video looking at her cell phone and did not see the resident attempt and/or exit the building. The sidewalk in front of the building where Resident #4 was found, was approximately 11 steps to the street and had a curb that was approximately three (3) inches high. Resident #4 had propelled her wheelchair down the sidewalk, in front of the North Hall door facing the front of the building, when she was found by the daughter of another resident. Resident #4 had a history of [REDACTED]. The facility's failure to implement the care plan to have secured exit doors and supervision for residents with a known history of exit seeking behavior, placed this and other residents at risk for elopement in a situation that was likely to cause serious harm, injury, impairment, or death. This situation was determined to be and Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/30/18, when Resident #4 exited the building from the front door, assisted by a visitor, while the Receptionist sat at the front desk (a few feet away) on a cell phone and unaware that Resident #4 had attempted or actually left the building unsupervised. Resident #4 was found by a visitor on the sidewalk approximately 34 walked steps from the front door, who notified the nursing staff, and brought the resident back into the building. On 11/29/18 at 3:48 PM, the SA notified the facility's Administrator of the IJ and SQC. The facility submitted an acceptable Allegation of Compliance (A[NAME]) on 12/3/18, in which the facility alleged all corrective actions were completed on 12/1/18, and the IJ removed on 12/2/18. The SA validated the A[NAME] on 12/4/18, and determined the IJ was removed prior to exit. Therefore the scope and severity for 42 CFR(s) 483.21 (b)(1)-Comprehensive Care Plans, F656, was lowered from a J to a scope and severity of a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the policy for Care Plans, reviewed by the facility (MONTH) (YEAR), revealed: The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. Review of Resident #4's Care Plan dated 10/17/14, revealed the facility identified Resident #4 with a history of wandering and at times will exit seek, due to confusion related to Dementia and remained at greater than ten (10) on the Elopement Risk. This Care Plan listed a goal to decrease the resident's risk factors of attempting to exit the facility without staff knowledge through the next review, effective 10/9/18. On 2/20/18, an intervention was listed to have secured exits. Resident #4 continued to be care planned for elopement risk with exit seeking behaviors on 8/9/18. Review of the cumulative physician's orders [REDACTED].#4 every hour, with an onset date of 1/3/18, related to elopement risk. Review of the elopement risk assessment, dated 8/17/18, revealed Resident #4 scored 14. Any score greater than 10 indicated a high risk for elopement. Review of the facility's investigation revealed Resident #4 exited the front door on 9/30/18, assisted by a visitor, while the Receptionist sat at the front desk on the phone, not aware the resident had exited the building, thus not securing the exit. The staff was notified that Resident #4 was outside alone by another visitor, Visitor #1, and the staff went outside and returned Resident #4 to the facility. Resident #4 was assessed for injuries and none were noted. Resident #4 was placed on every fifteen (15) minute checks while the RP, and the Physician was notified. Review of the video on 11/29/18 at 9:20 AM, for 9/30/18, revealed Resident #4 attempted to rise and exit the door seven (7) times, then was assisted to exit the building by a visitor. The video revealed the Receptionist was looking down and was not aware of the resident attempting and/or exiting the door. The resident and visitor was identified on the video by LPN #2. In an interview on 11/27/18 at 4:15 PM, LPN #1 revealed Resident #4 was assessed as an elopement risk and had to be checked every one (1) hour, per the care plan. LPN #1 confirmed Resident #4's Care Plan had not been followed because she made it out the door. In an interview on 11/3/18 at 10:50 AM, LPN #2 (Minimum Data Set Nurse), stated she was informed by the Administrator that when Resident #4 exited the building it was not considered an elopement, so the care plan was not updated or reviewed for elopement. LPN #2 stated visual checks are done every one (1) hour for Resident #4 per the care plan, and all the exit doors were secured except the one in the front, but it's now locked. In an interview on 11/27/18 at 11:05 AM, the Assistant Director of Nursing (ADON) #1 stated Resident #4 was care planned for elopement and assessed as an elopement risk. The ADON #1 confirmed a new lock had been placed at the front door to secure the door and cannot be opened without a badge, a switch or code. She stated the Med Cart Nurse is responsible to check Resident #4 every one (1) hour and document visual observation, per the care plan. The ADON #1 confirmed Resident #4's care plan had not changed since the elopement on 9/30/18, to reflect an actual elopement. In an interview on 11/29/18 at 3:03 PM, the Receptionist on duty 9/30/18, revealed she was not aware that Resident #4 had exited the building until she was being brought back in by the facility staff. She acknowledged part of her duty was to monitor the front exit door to ensure residents did not exit without supervision. The facility provided an Acceptable Allegation of Compliance, which included: Resident #4, a cognitively impaired resident, exited the front entrance of the facility with the assistance of a visitor at approximately 2:33 PM on 9/30/18. The investigation revealed that the Receptionist, who was responsible for monitoring the front entrance, was at the desk viewing her cell phone and was not aware that Resident #4 exited through the front entrance. Resident #4 was found sitting in her wheelchair, unsupervised, on the front sidewalk approximately 34 steps from the front entrance by a visitor at approximately 2:37 PM. The visitor alerted the nursing staff. Resident #4 was taken to South Nurses' Station area by Licensed Practical Nurse (LPN) #1, where she was visually monitored. Resident #4's Elopement Risk Assessment and care plan was updated on 10/17/14, identifying exit seeking behavior. Resident #4 continued to be care planned for elopement risk with exit seeking behaviors on 8/9/18. Corrective Actions; 1. On 9/30/18 at approximately 2:55 PM, Resident #4 was evaluated by Registered Nurse (RN) #1, with no injuries noted and no complaints voiced. 2. On 9/30/18 at approximately 2:55 PM, Resident #4's Responsible Party, Daughter, Physician, Administrator, and Resident Care Coordinator/Registered Nurse/Infection Control Nurse (RCC/RN/ICN) were notified by RN #1. 3. On 9/30/18 at approximately 3:45 PM, Resident #4 was placed on visual checks every 15 minutes for 24 hours and was observed to be calm and quite for the remainder of the day. 4. On 9/30/18 at approximately 4:40 PM, an investigation was initiated by the Administrator. The investigation revealed that the Receptionist, who was responsible for monitoring the front entrance, was at the desk viewing her cell phone and was not aware that Resident #4 exited through the front entrance assisted by a visitor. 5. On 9/30/18 at approximately 3:00 PM, the other two (2) residents who are at risk for elopement were visually observed in the facility by LPN #2 and LPN #3. 6. On 10/1/18, a magnetic lock and key pad was installed at the front entrance of the facility by an outside vendor, with installation initiated at approximately 9:00 AM, and completed by 3:00 PM. 7. Effective 10/1/18, the Receptionist quit during the investigation process. 8. On 11/29/18 at approximately 2:30 PM, signs were posted by the Administrator at each non-emergency entrance/exit stating ATTENTION: Please check with the Nurse at the Nurses' Station before assisting a resident to exit the facility. Thank you. 9. On 11/30/18 at 8:53 AM, the Minimum Data Set (MDS) Nurse #1 added an intervention to Resident #4's care plan for reporting of exit seeking behaviors to nurse, who will institute visual checks every 30 minutes for 72 hours, and then resume every hour checks if no exit seeking behavior is exhibited. 10. On 12/1/18 starting at approximately 8:00 AM, the MDS Nurse #1, MDS Nurse #2, and MDS Nurse #3, assessed all residents for risk of elopement, including Resident #4 and the other two (2) residents at risk for elopement, and audited all residents' elopement risk care plans for accuracy. No concerns were identified. 11. Summary of Training; *On 10/1/18 at 8:00 AM, training was initiated by the Staff Development Nurse to all facility staff entitled, Elopement, which included resident safety related to elopement and safety of wandering residents. Trained on this date were nine (9) of 11 RNs, nine (9) of 23 LPNs, 16 of 52 CNAs, two (2) of 13 Therapy staff, one (1) of four (4) Activities staff, three (3) of five (5) Administrative staff, two (2) of three (3) Social Services, zero (0) of three (3) Maintenance, zero (0) of seven (7) Laundry staff, zero (0) of 14 Housekeeping staff, zero (0) of 15 Dietary staff, zero (0) of two (2) Medical Records staff, zero (0) of one (1) Central Supply staff, and one (1) of five (5) Nursing Clerical staff. *On 11/1/1 at 7:15 AM, training was initiated by RN #2, employed by another facility, to all facility staff entitled, Abuse, which included abuse, exploitation, neglect, seclusion, and responsibility to report to supervisor. Trained of this date were four (4) of nine (9) RNs, 15 of 24 LPNs, 29 of 51 CNAs, nine (9) of 14 Therapy staff, four (4) of 14 Housekeeping staff, zero (0) of seven (7) laundry staff, three (3) of four (4) Activities staff, one (1) of three (3) Social Services, two (2) of two (2) Medical Records staff, one (1) of 16 Dietary staff, one (1) of four (4) Administrative staff, zero (0) of three (3) Maintenance staff, one (1) of one (1) Central Supply staff, and one (1) of three (3) Nursing Clerical staff. *On 11/29/18 at 6:30 PM, training was initiated by the Acting DON and RCC/RN/ICN to all facility staff entitled, 1. Elopement, which included resident safety related to elopement and safety of wandering residents. 2. Safety and Supervision of Residents, which included the importance of resident supervision related to elopement risk, reporting of exit seeking behaviors to the nurse and required monitoring. When a resident is actively exit-seeking, the staff observing this behavior will maintain visual observation of the resident until the behavior can be reported to the resident's nurse. Trained on this date were six (6) of nine (9) RNs, 12 of 21 LPNs, 30 of 51 CNAs, two (2) of three (3) Social Services, zero (0) of three (3) Maintenance staff, two (2) of 15 Housekeeping staff, one (1) of seven (7) laundry staff, nine (9) of 16 Dietary staff, zero (0) of four (4) Activities staff, three (3) of four (4) Administration, two (2) of two (2) Medical Records staff, four (4) of four (4) Agency LPNs, seven (7) of seven (7) Agency CNAs, 14 of 14 Therapy staff, two (2) of three (3) Nursing Clerical staff, and one (1) of one (1) Central Supply staff. *On 11/29/18 at 6:30 PM, training was initiated by the Acting DON and RCC/RN/ICN to all RNs, LPNs, and Certified Nursing Assistants (CNA) entitled, Using the Care Plan, which included use of the care plan to direct care provided to residents related to elopement. Trained on this date were six (6) of nine (9) RNs, 12 of 21 LPNs, 30 of 51 CNAs, four (4) of four (4) Agency LPNs, and seven (7) of seven (7) Agency CNA staff. *On 11/30/18 at 9:30 AM, training was initiated by a Nursing Home Administrator/Licensed Professional Counselor who is not employed by this facility to all Administrative and Department Head staff entitled, Abuse and Reporting and Accidents/Elopement, which included reporting requirements to Mississippi State Department of Health and the State Attorney General's Office for all alleged violations including abuse, neglect, exploitation, or mistreatment of [REDACTED]. Trained this date were 12 of 14 Administrative key personnel, three (3) of three (3) Corporate Staff, four (4) of four (4) LPNs, one (1) of one (1) RNs, and two (2) of two (2) Ancillary Administrative staff. *On 11/30/18 at 7:00 PM, training was initiated by RN #3, RN #4, and the DON to all staff entitled, Mississippi Vulnerable Persons Act/Abuse, Neglect, Report Requirements/Cell Phone Use, which included cell phone use policy, abuse and neglect, including neglect as it relates to lack of supervision and reporting requirements. Trained on this date were one (1) of nine (9) RNs, six (6) of 21 LPNs, 14 of 51 CNAs, two (2) Agency LPNs, seven (7) Agency CNAs, one (1) of 15 Housekeeping staff, one (1) of seven (7) laundry staff, zero (0) of three (3) Maintenance staff, zero (0) of three (3) Social Services, zero (0) of two (2) Medical Records, one (1) of four (4) Administration, one (1) of three (3) Nursing Clerical, and zero (0) of one (1) Central Supply staff. *On 12/1/18 at 11:30 AM, training was initiated by the Administrator to all staff that have Receptionist and/or Manager on Duty responsibilities entitled, Addendum to Duties of Receptionist or Manager of the Day, which included assistance with access to the front entrance, monitoring of residents with exit seeking behaviors in this area, and use of the Elopement Manual. Trained this date were five (5) of 26 staff members. *No staff will be allowed to work until trained on these topics. 12. A Quality Assurance (QA) Committee meeting was conducted on 11/29/18, at 5:08 PM. Attendees included the Medical Director, Administrator, Acting DON, RCC/RN/ICN, MDS Nurse #1, MDS Nurse #2, MDS Nurse #3, Corporate RN, and Director of Long Term Care Operations. The following policies and procedures were reviewed by the committee with no changes made: Elopement, Using the Care Plan, Safety and Supervision of Residents, and Abuse Prevention, Investigation and Reporting. The committee reviewed the elopement incident involving Resident #4, which occurred on 9/30/18. The committee determined the system failure that allowed Resident #4 to exit the building unsupervised was the Receptionist using her cell phone. The committee reviewed actions taken by the facility to address resident safety related to elopement risk including modifications to the front entry door operation and 15 minute visual checks for Resident #4 for 24 hours, and hourly checks ongoing. The committee was informed by the Administrator that the Receptionist, who had no previous disciplinary actions taken, quit during the investigation process on 10/1/18. The committee recommended education begin immediately on the following policies and procedures: Elopement - all staff, Safety and Supervision of Resident - all staff, Using the Care Plan - nursing staff, and Abuse, neglect and related reporting requirements - all staff. The QA Committee recommended a monitoring system for residents with exit seeking behaviors to be implemented on 11/29/18. Residents, who are actively exit-seeking, will be reported immediately to the nurse. 13. The State Attorney General 's Office was notified on 11/29/18, at 7:23 PM by the Administrator of the incident of elopement involving Resident #4, which occurred on 9/30/18. 14. The facility alleged all corrective action was completed on 12/1/18, and the IJ was removed on 12/2/18. Validation of the Allegation of Compliance included: Based on observation, interviews, record review and facility investigation review, the State Agency (SA) validated that Resident #4, a cognitively impaired resident, exited the front entrance of the facility with the assistance of a visitor at approximately 2:33 PM on 9/30/18. The investigation revealed that the Receptionist, who was responsible for monitoring the front entrance, was at the desk viewing her cell phone and was not aware that Resident #4 exited through the front entrance. Resident #4 was found sitting in her wheelchair, unsupervised, on the front sidewalk approximately 34 steps from the front entrance by a visitor at approximately 2:37 PM. The visitor alerted the nursing staff. Resident #4 was taken to South Nurses' Station area by Licensed Practical Nurse (LPN) #1 where she was visually monitored. The SA validated through record review that Resident #4's Elopement Risk Assessment and care plan was updated on 10/17/14, identifying exit seeking behavior and that Resident #4 continued to be care planned for elopement risk with exit seeking behaviors on 8/9/18, prior to the exit on 9/30/18. Corrective Actions; 1. The SA validated through interview and record review that on 9/30/18 at approximately 2:55 PM, Resident #4 was evaluated by Registered Nurse (RN) #1 with no injuries noted and no complaints voiced. 2. The SA validated through interview with staff and record review that on 9/30/18, Resident #4's RP, Daughter, Physician, Administrator, and Resident Care Coordinator/Registered Nurse/Infection Control Nurse (RCC/RN/ICN) were notified by RN #1, of the resident's elopement. 3. The SA validated through record review and interview with staff, that on 9/30/18 at approximately 3:45 PM, Resident #4 was placed on visual checks every 15 minutes for 24 hours and was observed to be calm and quite for the remainder of the day, without further exit-seeking behaviors. 4. The SA validated through interview and record review that on 9/30/18, an investigation was initiated by the Administrator, and he concluded that the Receptionist, who was responsible for monitoring the front entrance, was at the desk viewing her cell phone and was not aware that Resident #4 exited through the front entrance, assisted by a visitor. 5. The SA validated through interview and record review that on 9/30/18, the other two (2) residents who were at risk for elopement were visually observed in the facility by LPN #2 and LPN #3. 6. The SA validated through observation, interview and record review, that on 10/1/18, a magnetic lock and key pad was installed at the front entrance of the facility by an outside vendor. 7. The SA validated through interview and record review that effective 10/1/18, the Receptionist quit during the investigation process of Resident #4's elopement. 8. The SA validated through observation and interview that on 11/29/18, signs were posted by the Administrator at each non-emergency entrance/exit stating ATTENTION: Please check with the Nurse at the Nurses' Station before assisting a resident to exit the facility. Thank you. 9. The SA validated through record review and interview that on 11/30/18, the Minimum Data Set (MDS) Nurse #1 added an intervention to Resident #4's care plan for reporting of exit seeking behaviors to the nurse, who will institute visual checks every 30 minutes for 72 hours, and then resume every hour checks if no exit seeking behavior is exhibited. 10. The SA validated through interviews and record review that on 12/1/18, MDS Nurse #1, MDS Nurse #2, and MDS Nurse #3 assessed all residents for risk of elopement, including Resident #4 and the other two residents at risk for elopement, and audited all residents' elopement risk care plans for accuracy. No concerns were identified with these residents or their care plans for elopement risk behaviors. 11. The SA validated through interviews and record review the facility conducted the following training: -On 10/1/18-training was initiated by the Staff Development Nurse to all facility staff entitled, Elopement, which included resident safety related to elopement and safety of wandering residents. Review of the sign-in sheets revealed nine (9) RNs, nine (9) LPNs, 16 CNAs, two (2) Therapy staff, one (1) Activity staff, three (3) Administrative staff, two (2) Social Services staff, and one (1) Nursing Clerical staff was trained. -On 11/1/18-training was initiated by RN #2, employed by another facility, to all facility staff entitled, Abuse, which included abuse, exploitation, neglect, seclusion, and responsibility to report to supervisor. Review of the sign-in sheets revealed four (4) RNs, 15 LPNs, 29 CNAs, nine (9) Therapy staff, four (4) Housekeeping staff, three (3) Activities staff, one (1) Social Services staff, two (2) Medical Records staff, one (1) Dietary staff, one (1) Administrative staff, one (1) Central Supply staff, and one (1) Nursing Clerical Staff were trained. -On 11/29/18-training was initiated by the Acting DON and RCC/RN/ICN to all facility staff entitled, 1. Elopement, which included resident safety related to elopement and safety of wandering residents. 2. Safety and Supervision of Residents, which included the importance of resident supervision related to elopement risk, reporting of exit seeking behaviors to the nurse and required monitoring. When a resident is actively exit-seeking, the staff observing this behavior will maintain visual observation of the resident until the behavior can be reported to the resident's nurse. Review of the sign-in sheets revealed six (6) RNs, 12 LPNs, 30 CNAs, two (2) Social Services staff, two (2) Housekeeping staff, one (1) Laundry staff, nine (9) Dietary staff, three (3) Administration, two (2) Medical Records staff, four (4) Agency LPNs, seven (7) Agency CNAs, 14 Therapy staff, two (2) Nursing Clerical, and one (1) Central Supply staff was trained. -On 11/29/18-training was initiated by Acting DON and RCC/RN/ICN to all RNs, LPNs, and Certified Nursing Assistants (CNA) entitled, Using the Care Plan, which included use of the care plan to direct care provided to residents related to elopement. Trained on this date were six (6) RNs, 12 LPNs, 30 CNAs, four (4) Agency LPNs, and seven (7) Agency CNA staff, per review of the sign-in sheets. -On 11/30/18-training was initiated by a Nursing Home Administrator/Licensed Professional Counselor who is not employed by this facility to all Administrative and Department Head staff entitled, Abuse and Reporting and Accidents/Elopement, which included reporting requirements to Mississippi State Department of Health and the State Attorney General's Office for all alleged violations including abuse, neglect, exploitation, or mistreatment of [REDACTED]. Trained this date, per review of the sign-in sheets, were 12 Administrative key personnel, three (3) Corporate staff, four (4) LPNs, one (1) RN, and two (2)Ancillary Administrative staff. -On 11/30/18-training was initiated by RN #3, RN #4, and DON to all staff entitled, Mississippi Vulnerable Persons Act/Abuse, Neglect, Report Requirements/Cell Phone Use, which included cell phone use policy, abuse and neglect, including neglect as it relates to lack of supervision and reporting requirements. Trained on this date, per sign-in sheets, was one (1) RN, six (6) LPNs, 14 CNAs, two (2) Agency LPNs, seven (7) agency CNAs, one (1) Housekeeping staff, one (1) Laundry staff, one (1) Administration, one (1) Nursing clerical staff, and one (1) Central Supply staff. -On 12/1/18-training was initiated by Administrator to all staff that have Receptionist and/or Manager on Duty responsibilities entitled, Addendum to Duties of Receptionist or Manager of the Day, which included assistance with access to the front entrance, monitoring of residents with exit seeking behaviors in this area, and use of the Elopement Manual. Per sign-in sheets, five (5) of the twenty six (26) staff members assigned to this duty were trained. The SA validated through interview with staff and schedules, that no staff was allowed to work without training on these topics. 12. The SA validated through interviews, sign-in sheets and record review, that a Quality Assurance (QA) Committee meeting was conducted on 11/29/18, and the attendees included the Medical Director, Administrator, Acting DON, RCC/RN/ICN, MDS Nurse #1, MDS Nurse #2, MDS Nurse #3, Corporate RN, and Director of Long Term Care Operations. Interviews revealed the committee reviewed the following policies and procedures with no changes made: Elopement, Using the Care Plan, Safety and Supervision of Residents, and Abuse Prevention, Investigation and Reporting. Interviews revealed the committee discussed the elopement incident involving Resident #4 which occurred on 9/30/18, and determined the system failure that allowed Resident #4 to exit the building unsupervised was the Receptionist using her cell phone. Interviews revealed the committee reviewed actions taken by the facility to address resident safety related to elopement risk including modifications to the front entry door operation and 15 minute visual checks for Resident #4 for 24 hours, and hourly checks ongoing. Interviews revealed the committee recommended education for policies and procedures, which included: Elopement - all staff, Safety and Supervision of Resident - all staff, Using the Care Plan - nursing staff, and Abuse, neglect and related reporting requirements - all staff. Interviews also revealed the QA Committee recommended a monitoring system for residents with exit seeking behaviors to be implemented on 11/29/18, that residents, who are actively exit-seeking, will be reported immediately to the nurse. 13. The SA validated through interviews and record review that the State Attorney General's Office was notified on 11/29/18, by the Administrator, of the incident of elopement involving Resident #4, which occurred on 9/30/18. The SA validated that all corrective actions were completed on 12/1/18, and the IJ was removed on 12/2/18.

Based on observations, record review, interviews, facility investigation review, and policy review, the facility failed to provide adequate assessment and supervision for a confused, demented resident, with a past history of exit-seeking behaviors. Resident #4 eloped from the facility's front door on 9/30/18, assisted by a visitor, after attempting to exit by herself, and was found approximately 34 walked steps from the facility by another visitor. Resident #4 was returned by Licensed Practical Nurse (LPN) #1 with no injury. The Receptionist, responsible to monitor the door, was observed on video looking at her cell phone and did not see the resident attempt to stand seven (7) times to exit the front door, nor the exit itself, with the assistance of a visitor. There were no signs on the door to alert visitors of wandering residents. The sidewalk in front of the building where Resident #4 was found, was approximately 11 steps to the street and had a curb that was approximately three (3) inches high. Resident #4 had propelled the wheelchair down the sidewalk, in front of the North Hall door facing the front of the building, when she was found by the daughter of another resident. Resident #4 had a history of [REDACTED]. Per video review, Resident #4 was outside without supervision approximately less than five (5) minutes before a visitor saw her, left her unattended on the sidewalk, and got assistance. The facility's failure to implement systems for visitors to be aware of wandering residents and to supervise residents with a known history of exit seeking behavior, placed this and other residents at risk for elopement, in a situation that was likely to cause serious harm, injury, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/30/18, when Resident #4 exited the building, while the Receptionist, who's duty included monitoring the door, sat at the front desk (a few feet away) on a cell phone and was unaware that Resident #4 had left the building, assisted by a visitor, and unsupervised. On 11/29/18 at 3:48 PM, the SA notified the facility's Administrator of the IJ and SQC. The facility submitted an acceptable Allegation of Compliance (A[NAME]) on 12/3/18, in which the facility alleged all corrective actions were completed on 12/1/18 and the IJ removed on 12/2/18. The SA validated the A[NAME] on 12/4/18, and determined the IJ was removed prior to exit. Therefore the scope and severity for 42 CFR(s) 483.25 (d)(2)-Supervision, F689, was lowered from a J to a scope and severity of a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Elopement policy, dated (MONTH) 2012, documented the facility will make every effort to protect the safety of all residents in the facility. Residents that are identified for risk of wandering will have an Elopement Risk Evaluation completed and will be evaluated quarterly and with a significant change. This policy noted it is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical. Review of the facility's policy with a revision date of (MONTH) 2014, and reviewed on (MONTH) (YEAR), titled, Wandering, Unsafe Resident, noted the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. This policy noted the staff will identify and assess residents who are at risk for harm because of unsafe wandering, including elopement. Review of the facility's Elopement Risk Protocol, dated (MONTH) 2013, noted a resident that scored a ten (10) or greater on the risk assessment, are considered an elopement risk The facility's policy titled, Safety and Supervision of Residents, with a revision date of (MONTH) (YEAR), documented: Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. A review of the, Job Title: Receptionist, signed by Receptionist #1 on 2/21/18, revealed: 3. Immediately reports to Nurse any unattended Resident leaving Facility and assists as needed. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/15/18, revealed Resident #4 was unable to complete the Brief Interview for Mental Status (BIMS). Staff assessment identified Resident #4 as severely impaired and never/rarely made decisions. Review of the facility's investigation revealed Resident #4 exited the front door, on 9/30/18, assisted by a visitor, while the Receptionist sat at the front desk on the phone and was not aware the resident had exited the building. The staff was notified that Resident #4 was outside alone by another visitor, Visitor #1, and the staff went outside and returned Resident #4 to the facility. Resident #4 was assessed for injuries and none noted. The resident was placed on every 15 minute checks while the Responsible Party (RP), and the Physician was notified. The Resident Elopement Risk Assessment Tool for Resident #4, dated 8/17/18, had been completed with a score of 14. Any score greater than 10 indicated a high risk for elopement. Review of Resident #4's Care Plan dated 10/17/14, revealed the facility identified the resident had a history of [REDACTED]. This Care Plan had a listed goal to decrease resident risk factors of exiting the facility without staff knowledge thru next review and effective 10/9/18. On 2/20/18, one of the interventions listed was to have secured exits. Review of Resident #4's cumulative physician's orders [REDACTED]. (related to elopement risk). Review of the Nurse's Notes for Resident #4, revealed a note dated 9/30/18 at 4:08 PM, by Licensed Practical Nurse (LPN) #1, that documented at approximately 2:55 PM, Resident #4 was found outside in the front of the main entrance when a visitor was leaving the facility. The Nurses Note documented the RP had been notified and Resident #4 had been assessed for injuries. Review of the Nurses Notes for Resident #4, documented by Registered Nurse (RN) #1, noted on 9/30/18 at 2:55 PM, that she had been informed by LPN #1 that Resident #4 had been found outside of the building by a family member. This Nurses Note documented Resident #4 had no visible injuries and the Administrator, Director of Nursing (DON), Responsible Party (RP) and Medical Doctor (MD) were notified. Observation on 11/29/18 at 4:43 PM, revealed there were no signs posted on the outside or inside of the exit doors to notify visitors to be aware of wandering residents and not to let anyone outside. There were approximately 40 steps from the front door to the outside front North Side door, where resident #4 was found outside. On 11/29/18 at 9:20 AM, review of the video for 9/30/18 at approximately 2:55 PM, revealed Resident #4 sitting in a wheelchair in the lobby with Receptionist #1 sitting behind the desk and on the phone. Resident #4 was observed propelling to the front door and attempting to stand up and grab the handle of the front door. Resident #4 attempted to rise from her wheelchair seven (7) times, then a visitor walked to the front door and assisted her out the front door as he was leaving. Resident #4 was observed propelling herself down the sidewalk towards the left and out of site of the camera. Receptionist #1 continued to sit at the desk with her head down, looking at a cell phone and was not aware Resident #4 had exited the building. A longer video was provided by the facility, and Resident #4 was observed outside of the building, unsupervised for approximately three (3)-five (5) minutes when Visitor #1 found the resident alone on the sidewalk and the visitor came inside. The nurse and other staff were seen on the video rushing outside, and was seen bringing Resident #4 back into the building. At this time the Receptionist looked up and was made aware that Resident #4 had exited the building. There were three (3) cars seen on the video, passing on the street during the time that Resident #4 was outside. In an interview on 11/29/18 at 3:30 PM, the facility Administrator revealed there was an Elopement Book at each Nurses Station and at the front desk. The Administrator stated it was everyone's responsibility to assure resident's safety. The Administrator confirmed Resident #4 was found outside of the building on 9/30/18, in the afternoon with no staff present. The Administrator stated he did not determine this was an elopement. When asked how it was determined this event was not an elopement, the Administrator responded that Resident #4 was assisted out of the building by a visitor and she was found on the sidewalk and did not leave the premises, so therefore did not consider this an elopement. The Administrator continued to say, Our definition of elopement is when they leave the premises. In an interview, on 11/29/18 at 9:35 AM, LPN #2 confirmed the resident seen exiting the front door of the building on the video was Resident #4. In an interview on 11/29/18 at 3:03 PM, the Receptionist that was on duty 9/30/18, Receptionist #1, revealed she was not aware that Resident #4 had exited the building (9/30/18) until she was being brought back in by the facility staff. The Receptionist stated she was on the phone ordering food when Resident #4 was assisted out of the building by a visitor. The receptionist also stated she had observed Resident #4 trying to get out a locked door before, but was not worried because she knew the door was locked and reported this to the nurse. (No time frame was provided). The receptionist stated it was the Certified Nursing Assistant (CNA)s and nurses responsibility to know where their patients are at all times. She acknowledged part of her duty was to monitor the front exit door and to report any resident attempting to leave the building unsupervised. Interview with Visitor #1 on 11/27/18 at 8:50 AM, revealed she was leaving the facility on a Sunday afternoon and found Resident #4 on the sidewalk. Visitor #1 reported that Resident #4 stated, I don't know where I am, where am I? Visitor #1 stated there was no staff around and staff had no idea where she was. Visitor #1 stated Resident #4 was always very confused. Visitor #1 stated she instructed Resident #4 to stay where she was and she ran inside to notify the nurse and they came and got her. When Visitor #1 returned inside, she stated Receptionist #1 stated she hoped she didn't lose her job, she was only ordering pizza or something. Visitor #1 stated the facility had a new locked placed on the front door the next day or so. Interview with Assistant Director of Nursing (ADON) #1 on 11/27/18 at 11:05 AM, revealed during the investigation when Resident #4 exited the building, the video was reviewed and showed a visitor assisted the resident out the front door and the resident going down the sidewalk in her wheelchair. Another visitor, Visitor #1, found Resident #4 alone outside and notified the nursing staff and was returned inside. The video also revealed Receptionist #1 was sitting at the front desk with her head down. ADON #1 stated would consider this a reportable incident because no one was aware of Resident #4 being outside until notified by Visitor #1. ADON #1 stated Resident #4 was care planned for elopement and assessed as an elopement risk. The ADON #1 confirmed a new lock had been placed at the front door and the door cannot be opened without a badge, a switch, or a code. The ADON stated the Med Cart Nurse is responsible to check Resident #4 every one (1) hour and document her whereabouts. She stated there had been Elopement Risk Books at all desks and at the front desk with pictures of all residents at risk for elopement. In an interview on 11/29/18 at 2:20 PM, RN #1 revealed that she was notified that Resident #4 had exited the building and that a visitor had found her on 9/30/18. RN #1 stated she and LPN #1 conducted a body audit and the Administrator, ADON #1, and the RP was notified. She stated visual checks for Resident #4 was initiated and statements obtained. RN #1 confirmed Resident #4 had exited the building and stated, When we came back in the receptionist was completely unaware, of Resident #4 going outside. RN #1 stated Resident #4 had been observed and was calm that day with no observed exit attempts that she knew of. RN #1 confirmed Resident #4 was on every one (1) hour visual checks because she scored high on the Elopement Risk Assessment. In an interview with LPN #1 on 11/27/18 at 4:15 PM, she stated Visitor #1 came running up to her and notified her that Resident #4 was outside and no one was at the desk. LPN #1 stated when she went by the desk there was someone at the desk but she was bent down watching TV on her phone. LPN #1 stated Resident #4 was halfway down the sidewalk in a wheelchair and she brought her back inside. LPN #1 stated that she and RN #1 assessed Resident #4 and called the RP to notify them of the event, then everyone wrote a statement about the event. LPN #1 confirmed Resident was assessed as an elopement risk and had to be checked every one (1) hour. LPN #1 confirmed Resident #4's Care Plan had not been followed, because she made it out the door unsupervised. Interview with LPN #1 on 11/29/18 at 11:38 AM, revealed she had previously observed Resident #4 with her hands on the door, but the doors were locked and Resident #4 could not exit. LPN #1 also stated Resident #4 likes to sit by the doors. LPN #1 stated she had observed Resident #4 earlier that day for every hour checks and had seen her in activities. Interview with LPN #2 on 11/3/18 at 10:50 AM, revealed when Resident #4 was more alert she would go to the door and push on it wanting to leave to Get on the bus. LPN #2 stated Resident #4 did this more in the afternoons. She stated earlier this year, Resident #4 had worn a (name brand) alarm bracelet, but the bracelet was discontinued after a short while. She stated the staff monitored Resident #4 every hour for a visual check and all exit doors had been locked except the front door, but now it is locked after Resident #4 got outside. LPN #1 stated Resident #4 could have fallen out of her wheelchair or she could have gone into the traffic because of the cars going in and out of the street in front of the facility. LPN #2 stated the Receptionist failed to keep an eye on the resident; that's why she got out. Interview with CNA #1 was attempted on 11/29/18 at 11:45 AM, but unsuccessful. CNA #1 was assigned to Resident #4 at the time of the elopement on 9/30/18, and is no longer employed with the facility. In an interview on 11/27/18 at 12:24 PM, Contract Vender #1, a security company employee, stated on 10/3/18, a lock was installed at the front door of the facility because a person eloped. He stated the facility had it on camera, so they were called to install a lock. The Medical Director was interviewed on 11/30/18 at 10:00 AM, and confirmed the facility notified him of the elopement for Resident #4. The Medical Director confirmed he was recently a part of the QA committee meeting where the elopement was discussed and confirmed the care plan and policies had been reviewed. In an interview with the facility's Administrator on 11/29/18 at 11:25 AM, he stated Receptionist #1 quit during the investigation. The Administrator confirmed the Elopement Book was present at the front desk at the time of the investigation. The Administrator also confirmed there was no sign at the front door warning visitors from assisting resident out of the front door. The Administrator also confirmed it was part of the duties of the Receptionist to watch for residents leaving the building. In an interview on 11/29/18 at 4:20 PM, LPN #3 stated she was sitting at the reception desk today and aware of the Elopement Book at the desk. She stated she has no problem seeing residents in a wheelchair in the front lobby when sitting at the desk. The facility provided an Acceptable Allegation of Compliance, which included: Resident #4, a cognitively impaired resident, exited the front entrance of the facility with the assistance of a visitor at approximately 2:33 PM on 9/30/18. The investigation revealed that the Receptionist, who was responsible for monitoring the front entrance, was at the desk viewing her cell phone and was not aware that Resident #4 exited through the front entrance. Resident #4 was found sitting in her wheelchair, unsupervised, on the front sidewalk approximately 34 steps from the front entrance by a visitor at approximately 2:37 PM. The visitor alerted the nursing staff. Resident #4 was taken to South Nurses' Station area by Licensed Practical Nurse (LPN) #1, where she was visually monitored. Resident #4's Elopement Risk Assessment and care plan was updated on 10/17/14, identifying exit seeking behavior. Resident #4 continued to be care planned for elopement risk with exit seeking behaviors on 8/9/18. Corrective Actions; 1. On 9/30/18 at approximately 2:55 PM, Resident #4 was evaluated by Registered Nurse (RN) #1, with no injuries noted and no complaints voiced. 2. On 9/30/18 at approximately 2:55 PM, Resident #4's Responsible Party, Daughter, Physician, Administrator, and Resident Care Coordinator/Registered Nurse/Infection Control Nurse (RCC/RN/ICN) were notified by RN #1. 3. On 9/30/18 at approximately 3:45 PM, Resident #4 was placed on visual checks every 15 minutes for 24 hours and was observed to be calm and quite for the remainder of the day. 4. On 9/30/18 at approximately 4:40 PM, an investigation was initiated by the Administrator. The investigation revealed that the Receptionist, who was responsible for monitoring the front entrance, was at the desk viewing her cell phone and was not aware that Resident #4 exited through the front entrance assisted by a visitor. 5. On 9/30/18 at approximately 3:00 PM, the other two (2) residents who are at risk for elopement were visually observed in the facility by LPN #2 and LPN #3. 6. On 10/1/18, a magnetic lock and key pad was installed at the front entrance of the facility by an outside vendor, with installation initiated at approximately 9:00 AM, and completed by 3:00 PM. 7. Effective 10/1/18, the Receptionist quit during the investigation process. 8. On 11/29/18 at approximately 2:30 PM, signs were posted by the Administrator at each non-emergency entrance/exit stating ATTENTION: Please check with the Nurse at the Nurses' Station before assisting a resident to exit the facility. Thank you. 9. On 11/30/18 at 8:53 AM, the Minimum Data Set (MDS) Nurse #1 added an intervention to Resident #4's care plan for reporting of exit seeking behaviors to nurse, who will institute visual checks every 30 minutes for 72 hours, and then resume every hour checks if no exit seeking behavior is exhibited. 10. On 12/1/18 starting at approximately 8:00 AM, the MDS Nurse #1, MDS Nurse #2, and MDS Nurse #3, assessed all residents for risk of elopement, including Resident #4 and the other two (2) residents at risk for elopement, and audited all residents' elopement risk care plans for accuracy. No concerns were identified. 11. Summary of Training; *On 10/1/18 at 8:00 AM, training was initiated by the Staff Development Nurse to all facility staff entitled, Elopement, which included resident safety related to elopement and safety of wandering residents. Trained on this date were nine (9) of 11 RNs, nine (9) of 23 LPNs, 16 of 52 CNAs, two (2) of 13 Therapy staff, one (1) of four (4) Activities staff, three (3) of five (5) Administrative staff, two (2) of three (3) Social Services, zero (0) of three (3) Maintenance, zero (0) of seven (7) Laundry staff, zero (0) of 14 Housekeeping staff, zero (0) of 15 Dietary staff, zero (0) of two (2) Medical Records staff, zero (0) of one (1) Central Supply staff, and one (1) of five (5) Nursing Clerical staff. *On 11/1/1 at 7:15 AM, training was initiated by RN #2, employed by another facility, to all facility staff entitled, Abuse, which included abuse, exploitation, neglect, seclusion, and responsibility to report to supervisor. Trained of this date were four (4) of nine (9) RNs, 15 of 24 LPNs, 29 of 51 CNAs, nine (9) of 14 Therapy staff, four (4) of 14 Housekeeping staff, zero (0) of seven (7) laundry staff, three (3) of four (4) Activities staff, one (1) of three (3) Social Services, two (2) of two (2) Medical Records staff, one (1) of 16 Dietary staff, one (1) of four (4) Administrative staff, zero (0) of three (3) Maintenance staff, one (1) of one (1) Central Supply staff, and one (1) of three (3) Nursing Clerical staff. *On 11/29/18 at 6:30 PM, training was initiated by the Acting DON and RCC/RN/ICN to all facility staff entitled, 1. Elopement, which included resident safety related to elopement and safety of wandering residents. 2. Safety and Supervision of Residents, which included the importance of resident supervision related to elopement risk, reporting of exit seeking behaviors to the nurse and required monitoring. When a resident is actively exit-seeking, the staff observing this behavior will maintain visual observation of the resident until the behavior can be reported to the resident's nurse. Trained on this date were six (6) of nine (9) RNs, 12 of 21 LPNs, 30 of 51 CNAs, two (2) of three (3) Social Services, zero (0) of three (3) Maintenance staff, two (2) of 15 Housekeeping staff, one (1) of seven (7) laundry staff, nine (9) of 16 Dietary staff, zero (0) of four (4) Activities staff, three (3) of four (4) Administration, two (2) of two (2) Medical Records staff, four (4) of four (4) Agency LPNs, seven (7) of seven (7) Agency CNAs, 14 of 14 Therapy staff, two (2) of three (3) Nursing Clerical staff, and one (1) of one (1) Central Supply staff. *On 11/29/18 at 6:30 PM, training was initiated by the Acting DON and RCC/RN/ICN to all RNs, LPNs, and Certified Nursing Assistants (CNA) entitled, Using the Care Plan, which included use of the care plan to direct care provided to residents related to elopement. Trained on this date were six (6) of nine (9) RNs, 12 of 21 LPNs, 30 of 51 CNAs, four (4) of four (4) Agency LPNs, and seven (7) of seven (7) Agency CNA staff. *On 11/30/18 at 9:30 AM, training was initiated by a Nursing Home Administrator/Licensed Professional Counselor who is not employed by this facility to all Administrative and Department Head staff entitled, Abuse and Reporting and Accidents/Elopement, which included reporting requirements to Mississippi State Department of Health and the State Attorney General's Office for all alleged violations including abuse, neglect, exploitation, or mistreatment of [REDACTED]. Trained this date were 12 of 14 Administrative key personnel, three (3) of three (3) Corporate Staff, four (4) of four (4) LPNs, one (1) of one (1) RNs, and two (2) of two (2) Ancillary Administrative staff. *On 11/30/18 at 7:00 PM, training was initiated by RN #3, RN #4, and the DON to all staff entitled, Mississippi Vulnerable Persons Act/Abuse, Neglect, Report Requirements/Cell Phone Use, which included cell phone use policy, abuse and neglect, including neglect as it relates to lack of supervision and reporting requirements. Trained on this date were one (1) of nine (9) RNs, six (6) of 21 LPNs, 14 of 51 CNAs, two (2) Agency LPNs, seven (7) Agency CNAs, one (1) of 15 Housekeeping staff, one (1) of seven (7) laundry staff, zero (0) of three (3) Maintenance staff, zero (0) of three (3) Social Services, zero (0) of two (2) Medical Records, one (1) of four (4) Administration, one (1) of three (3) Nursing Clerical, and zero (0) of one (1) Central Supply staff. *On 12/1/18 at 11:30 AM, training was initiated by the Administrator to all staff that have Receptionist and/or Manager on Duty responsibilities entitled, Addendum to Duties of Receptionist or Manager of the Day, which included assistance with access to the front entrance, monitoring of residents with exit seeking behaviors in this area, and use of the Elopement Manual. Trained this date were five (5) of 26 staff members. *No staff will be allowed to work until trained on these topics. 12. A Quality Assurance (QA) Committee meeting was conducted on 11/29/18, at 5:08 PM. Attendees included the Medical Director, Administrator, Acting DON, RCC/RN/ICN, MDS Nurse #1, MDS Nurse #2, MDS Nurse #3, Corporate RN, and Director of Long Term Care Operations. The following policies and procedures were reviewed by the committee with no changes made: Elopement, Using the Care Plan, Safety and Supervision of Residents, and Abuse Prevention, Investigation and Reporting. The committee reviewed the elopement incident involving Resident #4, which occurred on 9/30/18. The committee determined the system failure that allowed Resident #4 to exit the building unsupervised was the Receptionist using her cell phone. The committee reviewed actions taken by the facility to address resident safety related to elopement risk including modifications to the front entry door operation and 15 minute visual checks for Resident #4 for 24 hours, and hourly checks ongoing. The committee was informed by the Administrator that the Receptionist, who had no previous disciplinary actions taken, quit during the investigation process on 10/1/18. The committee recommended education begin immediately on the following policies and procedures: Elopement - all staff, Safety and Supervision of Resident - all staff, Using the Care Plan - nursing staff, and Abuse, neglect and related reporting requirements - all staff. The QA Committee recommended a monitoring system for residents with exit seeking behaviors to be implemented on 11/29/18. Residents, who are actively exit-seeking, will be reported immediately to the nurse. 13. The State Attorney General 's Office was notified on 11/29/18, at 7:23 PM by the Administrator of the incident of elopement involving Resident #4, which occurred on 9/30/18. 14. The facility alleged all corrective action was completed on 12/1/18, and the IJ was removed on 12/2/18. Validation of the Allegation of Compliance included: Based on observation, interviews, record review and facility investigation review, the State Agency (SA) validated that Resident #4, a cognitively impaired resident, exited the front entrance of the facility with the assistance of a visitor at approximately 2:33 PM on 9/30/18. The investigation revealed that the Receptionist, who was responsible for monitoring the front entrance, was at the desk viewing her cell phone and was not aware that Resident #4 exited through the front entrance. Resident #4 was found sitting in her wheelchair, unsupervised, on the front sidewalk approximately 34 steps from the front entrance by a visitor at approximately 2:37 PM. The visitor alerted the nursing staff. Resident #4 was taken to South Nurses' Station area by Licensed Practical Nurse (LPN) #1 where she was visually monitored. The SA validated through record review that Resident #4's Elopement Risk Assessment and care plan was updated on 10/17/14, identifying exit seeking behavior and that Resident #4 continued to be care planned for elopement risk with exit seeking behaviors on 8/9/18, prior to the exit on 9/30/18. Corrective Actions; 1. The SA validated through interview and record review that on 9/30/18 at approximately 2:55 PM, Resident #4 was evaluated by Registered Nurse (RN) #1 with no injuries noted and no complaints voiced. 2. The SA validated through interview with staff and record review that on 9/30/18, Resident #4's RP, Daughter, Physician, Administrator, and Resident Care Coordinator/Registered Nurse/Infection Control Nurse (RCC/RN/ICN) were notified by RN #1, of the resident's elopement. 3. The SA validated through record review and interview with staff, that on 9/30/18 at approximately 3:45 PM, Resident #4 was placed on visual checks every 15 minutes for 24 hours and was observed to be calm and quite for the remainder of the day, without further exit-seeking behaviors. 4. The SA validated through interview and record review that on 9/30/18, an investigation was initiated by the Administrator, and he concluded that the Receptionist, who was responsible for monitoring the front entrance, was at the desk viewing her cell phone and was not aware that Resident #4 exited through the front entrance, assisted by a visitor. 5. The SA validated through interview and record review that on 9/30/18, the other two (2) residents who were at risk for elopement were visually observed in the facility by LPN #2 and LPN #3. 6. The SA validated through observation, interview and record review, that on 10/1/18, a magnetic lock and key pad was installed at the front entrance of the facility by an outside vendor. 7. The SA validated through interview and record review that effective 10/1/18, the Receptionist quit during the investigation process of Resident #4's elopement. 8. The SA validated through observation and interview that on 11/29/18, signs were posted by the Administrator at each non-emergency entrance/exit stating ATTENTION: Please check with the Nurse at the Nurses' Station before assisting a resident to exit the facility. Thank you. 9. The SA validated through record review and interview that on 11/30/18, the Minimum Data Set (MDS) Nurse #1 added an intervention to Resident #4's care plan for reporting of exit seeking behaviors to the nurse, who will institute visual checks every 30 minutes for 72 hours, and then resume every hour checks if no exit seeking behavior is exhibited. 10. The SA validated through interviews and record review that on 12/1/18, MDS Nurse #1, MDS Nurse #2, and MDS Nurse #3 assessed all residents for risk of elopement, including Resident #4 and the other two residents at risk for elopement, and audited all residents' elopement risk care plans for accuracy. No concerns were identified with these residents or their care plans for elopement risk behaviors. 11. The SA validated through interviews and record review the facility conducted the following training: -On 10/1/18-training was initiated by the Staff Development Nurse to all facility staff entitled, Elopement, which included resident safety related to elopement and safety of wandering residents. Review of the sign-in sheets revealed nine (9) RNs, nine (9) LPNs, 16 CNAs, two (2) Therapy staff, one (1) Activity staff, three (3) Administrative staff, two (2) Social Services staff, and one (1) Nursing Clerical staff was trained. -On 11/1/18-training was initiated by RN #2, employed by another facility, to all facility staff entitled, Abuse, which included abuse, exploitation, neglect, seclusion, and responsibility to report to supervisor. Review of the sign-in sheets revealed four (4) RNs, 15 LPNs, 29 CNAs, nine (9) Therapy staff, four (4) Housekeeping staff, three (3) Activities staff, one (1) Social Services staff, two (2) Medical Records staff, one (1) Dietary staff, one (1) Administrative staff, one (1) Central Supply staff, and one (1) Nursing Clerical Staff were trained. -On 11/29/18-training was initiated by the Acting DON and RCC/RN/ICN to all facility staff entitled, 1. Elopement, which included resident safety related to elopement and safety of wandering residents. 2. Safety and Supervision of Residents, which included the importance of resident supervision relat

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure Resident #25's dignity as evidenced by failure to provide coverage for the resident's indwelling urinary catheter drainage bag, for one (1) of four (4) residents reviewed with an indwelling urinary catheter bag. Findings include: A review of the facility's policy, titled, Quality of Life-Dignity, revised (MONTH) 2006, revealed: Staff shall promote dignity and assist residents as needed by helping residents to keep urinary catheter bags covered. On 8/13/18 at 5:40 PM, an observation revealed, Resident #25 had an indwelling urinary catheter connected to a gravity drainage bag, and there was no privacy bag covering the drainage bag. On 8/14/18 at 11:45 AM, an observation revealed, Resident #25 was sitting in his room in his wheelchair with an indwelling urinary catheter connected to a drainage bag, and there was no dignity bag covering his drainage bag. On 8/14/18 at 2:00 PM, an interview with Certified Nursing Assistant (CNA) #1 revealed Resident #25 does not have a dignity bag over his catheter bag. CNA #1 stated Resident #25 was not here this morning because he had an appointment. CNA #1 stated, it is a dignity issue (referring to the catheter drainage bag not covered by a privacy bag), and she will make sure she takes care of this issue. On 8/14/18 at 2:33 PM, an interview with the Director of Nurses (DON) revealed, it is a dignity issue not to have a privacy bag covering the catheter drainage bag. On 8/15/18 at 8:10 AM, interview with CNA #4 revealed, it is a dignity issue for the resident not to have a privacy bag covering the urinary catheter drainage bag. Record review of the Medication Administration Record [REDACTED]. Review of the Physician order [REDACTED]. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of (MONTH) 13, (YEAR), section H for bowel and bladder continence was coded for an indwelling catheter. The Brief Interview for Mental Status (BIMS) revealed, Resident #25 had a BIMS score of 12, which indicated moderate cognitive impairment. Review of the facility's Record of Admission revealed Resident #25 was admitted by the facility, on 8/6/18, with a [DIAGNOSES REDACTED].

Based on observation, record review, facility policy review, and staff interview, the facility failed to follow Resident #22's comprehensive care plan related to pressure ulcers, for (1) one of 30 resident care plans reviewed. Findings include: Review of the facility's policy, titled, Using the Care Plan, revised (MONTH) 2006, revealed, the care plan shall be used in developing the resident's daily care routines, and will be available to staff personnel who have responsibility for providing care or services to the resident. Review of Resident #22's Care Plan revealed the Problem for the Potential for Altered Skin Integrity, with an original date of 05/29/18, and on 06/05/18 a Deep Tissue Injury (DTI) to the right heel, and on 07/22/18, a stage three (3) to the right heel. Interventions, dated 05/29/18, included pressure relieving mattress to the bed, and cushion to the chair, observe for new onset of skin complications/breakdown, weekly body audits, and provide treatment to the stage three (3) pressure injury to the right heel as ordered until healed. On 06/07/18, an intervention to apply heel protectors to bilateral feet and float heels while in bed was added. Further review of the Care Plan revealed the Problem for Requiring Assist with ADLs (Activities of Daily Living) due to left sided [MEDICAL CONDITION]/involuntary tremors dated 05/29/18. The Interventions, dated 05/29/18, included extensive assist x 2 (times two) with bed mobility. Interventions, dated 08/09/18, included extensive assist x 1 (times one) with bathing, wheel chair mobility, and hygiene, and on 08/15/18, extensive assist x 2 (times two) with toileting. Review of Resident #22's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/04/18, revealed there were no pressure ulcers present, and Resident #22 was at risk for developing pressure ulcers. Review of Resident #22's 60 Day Scheduled Assessment MDS, with an ARD of 07/24/18, revealed the presence of a stage three (3) pressure ulcer On 8/14/18 at 12:05 PM, an observation revealed Registered Nurse (RN) #2, assisted by Certified Nursing Assistant (CNA) #5, provided wound care to Resident #22's right heel. Resident #22's right heel was noted to be pink with no drainage. On 8/15/18 at 12:15 PM, an interview with Registered Nurse (RN) #1 revealed she would expect staff to follow the resident's care plan. A review of the Admission Record revealed, Resident #22 was admitted by the facility, on 5/28/18, with a [DIAGNOSES REDACTED]. Review of Resident #22's Admission MDS, with an ARD of 06/04/18, revealed a Basic Interview for Mental Status (BIMS) score was 5, which indicated severe cognitive impairment.

CI MS #8904 Based on observation, interview, record and document review, the facility failed to follow the facility lift policy and the Resident's plan of care for one (1) of six (6) Residents in the sample (Resident #4) to prevent injury from falls. A Nurse Aide in Training transferred the Resident without assistance, failing to follow facility policy and the plan of care. This failure allowed Resident #4 to sustain an avoidable fall to the floor, sustaining multiple rib fractures, left chest contusion, left elbow abrasion and right knee contusion. Findings Include: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medications included Vitamin Supplements, Cymbicort Inhalants, Fosamax, Zestril and Iron Supplements. A comprehensive assessment dated [DATE] reflected that the Resident had no memory problems and could make cognitive decisions. Resident #4 was identified to be able to wheel self in a wheelchair but required assistance with transfers. A care plan dated 6/2/10 identified a problem: "At risk for falls" with a goal stating: "free from falls." Interventions stated to "transfer with assistance of two (2) CNA's with a stand-up lift." . Review of a Fall Risk Assessments completed on 11/20/10 and 12/16/10 reflected a score of "10", which represented a "High Risk" for falls. Review of the facility "Lift/Transfer Policy" reflected the facility is to provide a safe work environment, only Nursing Staff, therapist and Nursing Assistants are authorized to lift and transfer and that two nurse aides are to use the lift. A Nurse's Note at 5:45 a.m. on 12/10/10 reflected a Nurse was called to Resident #4's room by a Nursing Aide. The Resident was noted on the floor beside the stand-up lift, complaining of left side rib pain and stated "I fell off the lift." The Nurse Aide reported stepping back into the doorway to call for help, after putting the resident on the lift without assistance. The Physician ordered a transfer to the hospital and X-rays revealed no fractures. On 12/10/10 at 5:45 a.m. Resident #4 was sent back to the emergency room and had a CT scan which revealed: "Multiple left rib fractures, involving the 12th posterior, 11th, 10th, 9th, 8th and 7th, extending completely from posterior to lateral." The Physician's history and physical revealed that the patient was complaining of shortness of breath, pleuritic type chest pain and pain in the left elbow. X-ray revealed a laceration of the left elbow with no acute injury. Review of the facility investigative report reflected that on 12/9/10 the Nurse was called to the Resident's room and found Resident #4 on the floor beside the lift, complaining of left side pain. The Resident's Physician was notified and actions taken as noted above. The document recorded the results or actions taken: "A NAT (Nurse Aide in Training) was using the lift at the time of the incident and did not follow policy to have two (2) CNAs which resulted in the NAT's termination." Attempts at 10:35 a.m. on 1/19/11 to reach the NAT by telephone resulted in no answer and no voice mail to leave a message for a return call. Interview and observation on 1/19/11 at 10:15 a.m. revealed that Resident #4 was up in a wheelchair. Resident #4 was stated that the fall in December 2010 was from a stand-up lift. Resident #4 stated: "All my ribs were broken and my shoulder. Resident #4 stated that they got a Nurse in here and they wouldn't pick me up, they waited for the paramedics. Resident #4 stated that his ribs still hurt." Interview with the Director of Nursing (DON) on 1/19/11 at 12:45 p.m. revealed that the NAT told her he thought he could do the transfer alone but that the resident "flails out" and that the resident fell and was injured. The DON stated that they fired the NAT for not following protocol.