Every finding on record at Brandon Community Care Center

Based on observation, interview, record review and facility policy review the facility failed to ensure the resident environment remained as free as possible from accident hazards and that each resident received adequate supervision and assistance to prevent accidents for one (1) of four (4) sampled residents reviewed for falls. Resident # 1. Findings include:Record review of the facility policy Safety and Supervision of Residents, undated, revealed, Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Record review of the facility policy Homelike Environment undated, revealed, Policy Statement: Residents are provided a safe.homelike environment.Record review of the Facility Self-Reported Incident for Resident #1 dated 12/26/25, revealed that Resident #1 had a fall in her room. Staff heard the resident crying and entered the room and found the resident lying face down on the floor in a pool of blood. The resident was assessed and noted to have discoloration to the left and right eye, noted bruising to her left knee. The resident was sent out to the emergency department where she received six sutures to the laceration of the forehead. The resident also received a computed tomography (CT) of the head that identified an acute orbital blowout fracture of the left orbital floor. There was no surgical intervention recommended. During a reenactment the facility determined the housekeeper went in to clean Resident #1's room and thought the resident was bedridden and was also asleep. The housekeeper did not place wet floor signs in place. Record review of a Witness Statement from Housekeeper # 1 dated December 23, 2024, at 11:47 AM, revealed the housekeeper entered the room at approximately 10:30 AM while the resident was asleep. The housekeeper cleaned and mopped the floor, left the door open to dry, and did not place a wet floor sign because none were available and the housekeeper believed the resident was bedridden. The housekeeper stated it was their first time working on the unit.Record review of the Progress Notes *NEW* dated 12/23/25 at 11:54 AM revealed staff heard Resident #1 crying and upon entering the room observed that the floor was wet and the resident was lying face down on the floor with hair and face covered in blood. Upon assessment it was discovered the resident had a 2 centimeter (cm) laceration to the top of the head, a .75 cm laceration to the forehead, a .25 cm laceration on the bridge of the nose, black and bluish discoloration to the left eye, discoloration to the right lower eyelid, and bluish/black discoloration to the left knee. Emergency officials were notified and Resident# 1 was sent out to the emergency department due to multiple head injuries. Record review of the Progress Note-History dated 12/23/25 and signed by the Family Nurse Practitioner (FNP) revealed Resident #1 was seen on the floor with blood pooled around her head. She had a laceration on her left forehead one to her nose. She has a contusion over the left eye forming.Record review of the local hospital History and Physical dated 12/23/25 and signed by a physician revealed Resident #1 experienced a fall at skilled nursing facility and sustained facial trauma, orbital fracture and suspected concussion and was admitted to the acute care hospital. The laceration required sutures. A computed tomography (CT) of the head and cervical spine indicated no fractures but Resident #1 did not require urgent maxillofacial surgical evaluation, but conservative management. Resident #1 admitted to some pain involving left eye and orbit. On 1/12/26 at 10:15 AM, during an interview the Director of Nursing stated Resident #1 experienced a fall on 1/23/25. The resident was last seen at approximately 10:55 AM and was found around 11:00 AM lying face down on the floor. She confirmed the floor was wet due to recent mopping by housekeeping and no wet floor sign had been placed. She stated the housekeeper assumed the resident was asleep and not mobile. She confirmed the resident sustained multiple lacerations and an orbital fracture and was transported to the emergency room. She stated the housekeeper was disciplined and housekeeping staff were reeducated on wet floor signage.On 1/12/26 at 11:06 AM, during an interview with the Environmental Services supervisor, she stated she was notified of the fall and informed the Administrator and Director of Nursing. She later observed the same housekeeper had mopped two additional rooms with soaked floors and no wet floor signs in place. She reminded the housekeeper that wet floor signs are available on every unit and must be placed before mopping and remain until floors are dry.In an interview conducted on 01/12/2026 at 11:07 AM, Certified Nursing Assistant (CNA) # 1 stated she last saw the resident after assisting her with a shower and returning her to her room. CNA # 1 stated that Resident #1 had been sitting up watching television. She later heard someone calling out for help, walked toward the sound, and entered the resident's room to find her lying face down on the floor, crying. CNA # 1 reported that the floor was wet and no sign was in place, and that housekeeping was contacted to assess it. She remained with the resident until the emergency medical services (EMS) arrived. On 1/12/26 at 11:15 AM, during an interview with Licensed Practical Nurse (LPN) #1, she stated she was alerted by the crying resident. Upon entering the room, she stumbled and questioned why the floor was wet. She observed the resident lying face down on the floor with blood on her face and hair. Resident #1 was assessed, injuries were identified, the Resident Representative was notified, and EMS were contacted.On 01/12/26, at 1:06 PM, during an interview, the Licensed Nursing Home Administrator (LNHA) stated that on 12/23/25, Resident # 1 was discovered lying face down on the floor in her room by nursing staff after they were alerted by the resident's audible cries. The fall was determined to have occurred shortly after 10:55 AM, as that was the last time the resident had been seen by staff. At the time of discovery, the floor was wet from a recent mopping, and no wet floor signage had been placed. The LNHA confirmed that the housekeeper had entered the room around 10:30 AM and mopped the floor without posting a wet floor caution sign. The housekeeper later reported assuming the resident was in bed asleep and did not expect her to get up unassisted. The LNHA acknowledged this assumption was inappropriate and a direct violation of training and facility policy. The LNHA stated that the housekeeper was terminated due to noncompliance with facility policy and failure to adhere to prior training regarding environmental safety, specifically the use of wet floor signage and awareness of resident mobility risks. The LNHA further confirmed that staff failed to identify the wet floor as a potential hazard prior to the incident.Record review of the admission Record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and unsteadiness on feet.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/25 revealed staff assessed the resident for mental status and documented the resident had memory problems and had some difficulty in new situations only.

Based on observations, interviews, record review and facility policy review, the facility failed to report allegations of abuse for one (1) of three (3) residents reviewed. Resident #1Findings include: A record review of the facility's Abuse Prevention policy with a revision date of 1/25 revealed alleged violations involving abuse, neglect. are reported immediately, but not later than 2 hours after the allegation is made.On 10/2/25 at 11:15 AM in an interview with the Director of Nursing (DON) she stated that on 9/7/25 Certified Nursing Assistant (CNA) #2 told her that CNA #1 asked for help giving Resident #1 a bed bath. She stated the resident is blind and deaf. She stated they communicate by writing simple words in the resident hands with their fingers to let her know what they are doing. CNA #1 tried to sit the resident up on the side of the bed and the resident's foot was stuck in the bedrail. The resident sleeps at the foot of the bed. She stated CNA #1 did not see that the resident's right foot was stuck in the bedrail. CNA #2 saw it and told CNA #1 to stop. She stated the resident became combative during care. She started to swing her arms. She stated CNA #1 stopped, and CNA #2 rubbed the resident's arm attempting to get her to calm down. CNA #2 did not report it to the nurse on duty. She stated at that time CNA #2 did not tell her that CNA #1 hit the resident. She stated they gave resident time to calm down. Resident #1 started swinging at staff again and hit CNA #2 in the face and left eye. She stated CNA #2 continued with care and CNA #1 grabbed the resident's arm to stop her from hitting them. She told CNA #1 that she needed a written statement. DON stated she was off on 9/10/25. She stated she was only told about resident hitting staff. She stated what CNA #2 told her on 9/8/25 was different than what she wrote in her statement. She stated she did not read CNA #2's written statement until 9/11/25 when she returned to work.On 10/2/25 at 11:43 AM in an interview with CNA #2 stated CNA #1asked her to help her give Resident #1 a shower. She stated CNA #1 tried to sit Resident #1 up on the side of the bed. The resident's foot was stuck in the bedrail. She told CNA #1 to stop due to the resident's foot being stuck. She stated she removed Resident #1's foot from the rail. CNA #1 was trying to remove the resident's bra, undershirt and pajama top all at the same time. Resident #1became combative. She hit her in the eye, and she stopped and backed up. Resident #1 was throwing hands into the air and CNA #1started to hit resident back. She stated she did not say or do anything she was in shock. She stated CNA #1stated out loud This is why I only have one child, because of bitches like you. She stated she told CNA #1 to stop, and she rubbed resident's shoulder, and she completed the care. The resident calmed down and let her complete care. CNA #1 would not assist with complete care. She stated she did not feel comfortable telling the nurses on duty. She stated the resident became combative because of the way CNA #1 was handling the resident rough. CNA #2 said she told DON about CNA #1 hitting resident on 9/8/25.On 10/2/25 at 1:29 PM an interview with the Executive Director of the facility stated that the DON told her CNA #2 only told her about Resident #1's foot getting stuck in the rail on 9/8/25 and was supposed to write a statement. She stated the statement was written on 9/8/25 and turned it in to the Assistant Executive Director (AED) #1 on 9/10/25. She stated she did not know about it until 9/11/25. She stated CNA #2 gave the statement to another CNA and that CNA gave it to AED #1 She stated AED #1 did not read the statement, she gave it to AED #2 on 9/11/25. She stated AED #2 slid it under her door of her office and she got it 9/11/25 that morning. She stated that she reported it to the State Agency (SA), started the investigation, and contacted the family. She confirmed that the facility must report an allegation of abuse within two hours of finding out about the alleged incident. She stated she was not aware of the alleged incident until she got the note that was slid under her door on 9/11/25. She stated the Resident Representative (RR) was in the building and she spoke with her on that day. She stated she also contacted local police department and the Attorney General's office on 9/11/25.On 10/2/25 at 1:50 PM in an interview with AED #1 stated on 9/8/25 she left the facility for a physician appointment that afternoon and did not return. She stated CNA #2 called her and asked her if she could write on the back of the witness form. She stated she told the CNA yes and talked to the DON. She stated CNA #2 told her about the allegations of abuse. She stated she texted CNA #2's number to the ED on 9/8/25. She stated the ED received the message and responded back and asked her which CNA was this. AED #1 looked at her phone and stated my text message to the ED stated CNA #2 name and phone number and included call CNA. She stated CNA #2 called her after her shift. CNA #2 was told to write a statement on 9/8/25 but did not write the statement until 9/10/25. She stated CNA #2 gave her a statement and she did not read it. She thought that it was about the CNAs assignment on unit 4. She stated CNA #2 was complaining earlier that day about her assignment. She stated AED #2 is over unit 4. She stated she gave the statement to AED #2. She stated it was not sealed in an envelope. She stated the written statement was given to ED #2 on 9/10/25 in the morning.On 10/2/25 at 2:12 PM in a phone interview with CNA #1 stated Resident #1 is blind, and combative. She stated she went to get help from CNA #2 to give Resident #1 a bed bath. She stated CNA #2 was holding the resident's hands. They were trying to do care. We were doing peri care on the bottom and the resident started fighting us. She stated resident kicked her in the stomach. She stated they have been trained to hold residents' hands if they become combative during care. She stated we don't have time to rub her during care to calm her down. She stated she was told to make to get resident bathe no matter what the outcome is. She stated during care that day the resident kicked her in the stomach, scratched her cheek and spit on her. She stated the resident can hear and see some. She stated she reported to the nurse after care about the resident scratching her cheek and becoming combative. She stated the nurse told her she would make a note of it. She denied hitting, cursing and handling her rough.On 10/2/25 at 2:29 PM in an interview with AED #2 stated she received a statement from AED #1 about CNA #1 pulling resident up roughly, Resident #1 swinging at staff and CNA #1 was hitting resident on the arm. She stated she gave the statement to the ED Tuesday or Wednesday morning. She stated CNA #2 gave the statement to AED #1 and AED #1 gave it to her. She stated she read the statement and gave it directly to the ED. She stated I put the statement in the ED's hand. I did not slide it under the door.On 10/2/25 at 3:09 PM in an interview with AED #1 stated she can address the allegation, report it to the State Agency (SA) and suspend staff.On 10/2/25 at 3:21 PM in an interview with AED #2 stated the ED is the Abuse Coordinator and has been told she can report it if the ED is absent. She stated, The ED was here, and I gave it to her.On 10/2/25 at 4:30 PM in an interview with the ED stated the DON or any assistant can do the report.On 10/2/25 at 4:32 PM in an interview with the DON stated she was told by the previous ED that she could report allegations of abuse or neglect. She stated she has not been told that by the present ED.A record review of Resident #1 admission Record revealed an admission date of 7/22/20 with diagnosis of Epilepsy, unspecified, not intractable, without status Epilepticus. Cerebral Edema, Neurofibromatosis, Type 2 Unspecified Visual Loss and Unspecified Hearing Loss Unspecified Ear.A record review of Resident #1 Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/13/25 revealed section C revealed that Resident #1 is rarely/never understood.A record review of the facility 'Supervisor Investigation Summary form revealed the investigation was initiated on 9/8/25 when CNA #2 notified the Director of Nursing (DON) of the incident.A record review of the facility fax confirmation of the initial submission notification to SA revealed it was done on 9/12/25 with the incident date of 9/7/25.A record review of the Police Department report revealed it was done 9/12/25.

Based on interviews, record review and facility policy review, the facility failed to ensure staff honored a resident's preference to be put back to bed after therapy, resulting in the resident experiencing pain and emotional distress for one (1) of (35) sampled residents. Resident #216.Findings include:A review of the facility's policy, Resident [NAME] of Rights, no date, A .1 .15. Self-determination, which the facility must promote and facilitate through support of resident choice, consistent with his or her interest, assessment and plan of care and make other choices about aspect of his or life in the facility that are significant to the resident. Including but not limited to: activities, healthcare schedules (including sleeping, waking, bathing and eating times) and how she or he spends time .On 7/28/25 at 2:34 PM, Resident #216 shared that she typically attends therapy around 8:00 AM and finishes by 10:30 AM or 11:00 AM, after which therapy staff assist her in returning to her room. She reported that after therapy, she requested her assigned Certified Nursing Assistant (CNA) to place her back in bed due to comfort and health needs. However, she expressed that some CNAs respond dismissively, refusing to assist her. Resident #216 explains that these delays can last for hours, even after she activates her call light multiple times, staff will enter her room, turn off the light, and leave without explanation. She adds that there have been occasions when she has contacted her daughter for help. She also noted that she has brought the issue to the attention of the facility's administration, who have made temporary improvements, but a lasting solution has not yet been achieved.On 7/29/25 at 2:30 PM, during a follow-up interview, Resident #216 reported a comparable experience that day. She stated she finished therapy at approximately 11:00 AM and was taken to her room. She requested assistance from CNA #2 to return to bed but was told to wait. The resident noted discomfort due to her spinal condition when sitting for extended periods and said she was placed back in bed around 1:30 PM.On 7/30/25 at 8:36 AM, during an interview with Certified Nursing Assistant (CNA) #1, she confirmed that Resident #216's preference is to be laid back down after therapy sessions. CNA #1 stated the resident had made it known that she experiences pain when left sitting in her wheelchair for extended periods. She further stated it is common knowledge among most of the CNAs assigned to the unit that the resident wants to be in bed after therapy. Despite this knowledge, she added that some staff members refuse the resident's request and instead wait until their two o'clock rounds. CNA #1 acknowledged that staff should honor the resident's request, stating, It's not right to treat residents that way.On 7/30/25 at 8:50 AM, during an interview with CNA #2, she confirmed being assigned to Resident #216 on 7/29/25 and acknowledged awareness that the resident prefers to be put to bed after therapy. However, she stated she did not return the resident to bed until approximately 1:30 PM.On 7/31/25 at 8:30 AM, during an interview with the member of the Therapy team, she reported that it has been an ongoing challenge to get assigned CNAs to honor Resident #216's preference of lying down after therapy. She stated the resident repeatedly complains of pain and emotional turmoil from sitting too long in her wheelchair. The therapist emphasized that because the therapy sessions are physically demanding, the resident is usually tired and uncomfortable and should be returned to bed when requested.On 7/31/25 at 10:30 AM, during an interview with the Director of Nursing (DON), she stated she had no prior knowledge that Resident #216 had concerns about not being put back to bed after therapy. However, she acknowledged it is the CNAs' responsibility to honor resident preferences regardless of whether they are passing trays or engaged in other tasks.On 7/31/25 at 12:51 PM, during an interview with Resident #216's daughter, who is the Resident Representative, she stated that although she had not witnessed it personally, her mother frequently calls her in tears after therapy, reporting that the CNAs will not return her to bed. The daughter stated she had contacted the Administrator and DON multiple times, and although they resolved it temporarily, the issue continued to recur without a lasting solution.On 7/31/25 at 2:31 PM, during an interview with the Administrator, she stated she was not aware of any complaints from the resident or her daughter regarding not being returned to bed after therapy. She acknowledged that it is the responsibility of the CNAs to follow the needs and preferences of the residents.A record review of the admission Record revealed the facility admitted the resident on 5/21/25 with diagnoses including, Spondylosis, Lumbar Region and Idiopathic Scoliosis, Thoracic Region. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/28/25 revealed a Brief Interview Mental Score (BIMS) of (15), indicating the resident was cognitively intact.

Based on observation, interview and facility policy review, the facility failed to practice hand hygiene in accordance with professional standards for food services as evidenced by the District Dietary Manager (DDM) placing her fingers in food on the food line for one (1) of three (3) kitchen observations. Findings include:Record review of the facility policy, Proper Hand Washing and Glove Use, 2016, revealed, All employees will use proper hand washing procedures and glove usage in accordance with State and Federal Sanitation Guidelines.Procedures.5.Gloves are to be used whenever direct food contact is required.On 7/30/25 at 11:11AM, during an observation and interview with kitchen staff the District Dietary Manager (DDM) used her bare finger to poke holes in the aluminum foil which covered the pans sitting on the hot food line and peel it back to expose the food. During the tray preparation the DDM was observed holding plates in such a way as to allow rolls to touch her bare hands at the thumb. In an interview with DDM, she failed to acknowledge the need for glove use during tray service. The DDM stated we don't have to wear gloves because that's not in our policy, we are only supposed to wear gloves if our hands might come into contact with foods we are serving or are serving ready-to-eat items such as sandwiches. When the SA informed her that she was observed touching the rolls multiple times, she stated I don't think they did, but I guess it is possible if you saw it, and gloves would have prevented this or possible contamination. The DDM noted that the dietary staff attend in-services on infection control once monthly on the 29th each month; however, she does not attend in-services training because she is rarely in the building.On 07/31/2025 at 2:11 PM, an Interview with the Infection Preventionist (IP) Nurse she confirmed that dietary staff should wear gloves during the process of plating food and serving in case they are asymptomatic with certain illnesses like covid and flu which could spread very easily as the plates and food are touched by bare hands and plates are passed from the bare hands of the dietary staff to Certified Nursing Assistants (CNAs) to the residents because their hands might not have been clean.On 7/31/25 at 2:13 PM, an interview with the Administrator acknowledged the unsanitary handling of ready-to-eat food in the kitchen. The Administrator reported it is her expectation that policy be followed regarding infection prevention, to protect the residents rather than placing them at risk.Record review of Food Service Glove Usage Competency & Skills Evaluation dated 4/22/2025 and7/22/2025 revealed dietary staff had completed and met handwashing guidelines.

Based on observations, interviews, facility policy review and record review, the facility failed to provide a diet taking into consideration preferences of the resident for one (1) of 35 sampled residents. Resident #42Findings include:Record review of the facility policy revealed residents have a right to reside and receive services in the facility with reasonable accommodation of resident's preferences except when to do so would endanger the health or safety of the resident or other residents.During an observation on 07/29/2025 at 12:27 PM, Resident 42 was served a tray consisting of turkey, dressing, and a sweet potato. During an interview on 7/29/25 at 12:27 PM, Resident #42, asked CNA#4 to exchange her meal for a turkey sandwich. CNA #4 went to the kitchen and brought back a tray consisting of a piece of ham, broccoli and cheese and mandarin fruit cup and black-eyed peas. She stated that she was told by kitchen staff that they were out of sandwiches but would send this instead since it was the alternative. This tray included metal silverware. Resident #42 had previously made the kitchen staff aware that she prefers not to have metal silverware since it doesn't seem clean to her. She stated she's been trying to get a salad since she's stayed here in April but never gets what she wants from the kitchen. She stated the staff doesn't come from the kitchen to address preferences and follow up. Residents do not get a choice prior to the meal arriving, they are simply brought a tray. The residents have to send it back if they don't want it, and if you ask for something else like a sandwich a lot of times the kitchen tells the CNA they're out of it.During an interview on 07/29/2025 at 2:37 PM, the Dietary Manager stated that residents are always allowed to get an alternate tray. They can just send the tray back and tell the staff what the resident wants, or the resident can come and catch us and tell us they'd rather have something else. We always have sandwiches available as well so they can exchange trays for the resident. She stated that there is no time cutoff for notifying the kitchen of wanting the alternate and they can get it. She said that she makes rounds and asks the residents what they want. She confirmed that the resident liked to get plastic silverware but was unsure why or how she was sent metal silverware on the alternate tray rather than the sandwich as was requested. She also stated that she goes often to the residents' rooms to talk to them about preferences and update them and would go talk to Resident #42 later today to update preferences.During an interview on 7/29/25 at 3:05 PM with CAN# 3 who noted that the resident often has asked for a salad and never gets it from the kitchen staff. CNA's go to the kitchen on her behalf but has not gotten but maybe one since she's been staying in the facility, and one time about a month ago. CNA #3 stated she even went to Wal-Mart herself to bring back the resident a salad because she did not get it from the kitchen.During an interview on 7/29/25 at 12:30 PM, CNA # 4 stated that she carried Resident #42's tray to the kitchen but was told sandwiches were unavailable and they could only send the alternate tray. When asked, she said this happens a lot (like every day I work). Staff are told the kitchen is out of something the resident wants, and the facility does not get it for them. She stated there is no process where residents know what is on the menu and can ask ahead of time. It is like the kitchen sends the food and it's up to the residents to send staff to the kitchen to get it changed out for something they like.During an observation on 7/30/25 at 12:40 PM, Resident #42 was served a tray consisting of a pork chop, au gratin potatoes and vegetables.During an interview on 7/30/25 at 12:45 PM, Resident #42 confirmed that she asked staff members again for a salad to come with her lunch tray, but instead she got the primary meal offered of pork chop covered in gravy, mixed veggies and noodles. She confirmed that the prior day she received an alternate tray, instead of the sandwich like she had asked for and never got. She stated she hates to complain, but feels frustrated because this is her home and at home she gets a choice of what she wants to eat but doesn't get it here. She stated she never gets a choice because she eats in her room, and a menu is never brought to her. She stated she must first see what they bring her, then send it back if it's not what she wants and is often told they are out of an alternative or don't have sandwiches by staff.During an interview on 7/31/25 at 2:09 PM, the Dietary Manager confirmed that she had not gone to Resident # 42 yet to update her preferences. She stated that she was unaware that she wanted a salad but had talked to her Monday and told her she would come back today and speak with her about her preferences. She stated it is an easy fix to get resident's what they want, and salad has been available at all times. Anything the residents want we can get. She confirmed that the resident should have been sent a sandwich when she asked for it instead of the alternate meal on 7/29/25. During an interview on 7/31/25 at 2:13 PM, the Administrator shared that her expectation of staff is that facility policy be followed with regards to dietary preferences and choices and resident rights and the facility provide them to the best of their abilities.During an interview on 07/31/2025 at 2:22 PM, the District Dietician Manager and facility Dietary Manager confirmed that the dietary staff attend regular in-services given by staff development from the nursing home staff monthly on the 29th of each month.Record review of a facility in-service dated May 2025 in-service covering resident's rights revealed the Dietary Manager signed and completed on 5/29/25.Record review of the admission Record revealed Resident #42 was admitted on [DATE] with diagnoses that included of Type 2 Diabetes Mellitus, Chronic kidney disease., Record review of Resident #42's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/25/25 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact.

Based on observation, interview, record review and facility policy review, the facility failed to ensure that residents were transferred in a manner that could prevent accidents and potential injury for one (1) of (3) residents reviewed for accident hazards and safety. Resident #11.Findings included:Record review of facility policy titled Accident and Incident Documentation and Investigation Resident Incident History 7/18 revealed .Accidents and incidents will be analyzed for trends or patterns to enable the facility to enhance preventive measures to reduce the occurrence of incidents.On 7/30/25 at 1:15 PM, during an observation, Certified Nurse Aide (CNA) #6 was observed transporting Resident #11 from her room to the day room on the 400-hall using a wooden chair with no wheels. CNA #6 was seen pushing the resident from behind, with no method to stabilize the chair or catch the resident if she were to fall. Resident #11 typically sat in a rolling padded chair to support her trunk. By the end of the transport, Resident #11 had slid dangerously low in the wooden chair after being jostled during transport and required repositioning.On 7/30/25 at 1:18 PM, during an interview, CNA #6 confirmed she pulled and pushed the resident in the wooden chair to get her to the dining room. She stated the resident refused to sit in her rolling chair and kept trying to get out of it, which she also believed was a fall risk.On 7/30/25 at 1:43 PM, during an interview with Licensed Practical Nurse (LPN) #1, she stated that the proper way to transport a resident was using a wheelchair or rolling chair. She explained that using a wooden chair posed a risk for falling, especially for a resident who could not support herself.During an interview on 7/31/25 at 2:00 PM, with the Director of Nursing (DON), she stated that the resident was put at risk by being transported in this manner, she easily could have fallen out of the chair and been hurt. The DON stated that the correct way to transfer the resident would have been to roll in her wheelchair.During an interview with the administrator on 7/31/25 at 2:32 PM, she stated it is her expectation that staff follow facility policy to transfer residents in a manner to prevent accidents and hazards so they can help and not hurt their residents.A record review of Resident #11's admission Record revealed the facility admitted the resident on 3/17/25 with current diagnoses including Dementia.Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/25/25 revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated the resident's cognition was severely impaired and the resident uses a wheelchair for mobility.

Based on observation, interviews, record review and facility policy review, the facility failed to provide adequate supervision and a secure environment to prevent the elopement of one (1) of six (6) sampled residents, Resident #5. On 5/01/25 at approximately 3:00 PM Resident #5 who had documented new wandering and exit seeking behaviors for at least a week exited the facility unnoticed and was outside unsupervised for approximately fifteen minutes until a staff member located the resident sitting in his unlocked car in an unshaded parking space approximately thirty-five feet from the facility entrance with windows up. The car was in front of a sidewalk that led to a busy four-lane boulevard with no barrier or crosswalk. Documentation of the resident's change of behavior, including wandering had been reported to her primary healthcare provider with new orders noted for a urinalysis to check for urinary tract infection, but the facility failed to identify exit seeking and elopement risk or provide adequate supervision to prevent elopement. The resident was admitted on [DATE] with diagnoses of bipolar disorder, anxiety, schizophrenia and history of fall and was assessed by the facility as at risk for falls and requiring supervision for walking. The facility's failure to provide adequate supervision to prevent the elopement of Resident #5 placed this resident, and other residents at risk for wandering and elopement, in a situation that was likely to cause serious injury, harm, impairment, or death. The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 5/1/25 and existed at 42 CFR(s): 483.25(d)(1)(2) Free of Accidents Hazards/Supervision/Devices (F689) - Scope and Severity of J. The SA notified the facility's Administrator of the IJ and SQC on 5/09/2025 at 3:10 PM and provided the Administrator with the IJ templates. The facility submitted an acceptable Removal Plan on 5/12/2025, in which they alleged all corrective actions to remove the IJ were completed on 5/10/2025 and the IJ removed on 5/11/2025. The SA validated the Removal Plan on 5/12/2025 and determined the IJ was removed on 5/11/2025, prior to exit. Therefore, the scope and severity of 42 CFR(s): 483.25(d)(1)(2) Free of Accidents Hazards/Supervision/Devices (F689) - Scope and Severity (S/S) of J was lowered from a S/S of J to a S/S of D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings: Cross Reference F600, F609, F610, F656 Record review of the facility policy titled, MISSING RESIDENT/ELOPEMENTS with Revision Date 8/04 revealed the policy stated, The Unit charge Nurse is responsible for knowing the location of their residents .RESPONSIBILITY: The Charge Nurses and all other staff. Review of the Admission Record for Resident #5 revealed the facility admitted the resident on 5/23/23 and the resident had diagnoses of bipolar disorder, anxiety disorder, schizophrenia, repeated falls and major depressive disorder. Record review of the Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) 4/10/25 for Resident #5 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. No mood or behavioral issues were noted, including wandering or exit seeking behaviors, during the lookback period. The MDS documented she had no restraints or wander/elopement alarms in use and was able to walk with supervision only for one hundred fifty (150) feet and was at risk for falls. Record review of the Progress Notes for Resident #5 dated 4/25/25 through 5/06/25 revealed that the resident began going to the facility front door with small bags packed with her clothes and reporting family was coming to get her on 4/25/25 after report that she sat up all night with increased confusion. According to Progress Note on 5/01/25 at 1:40 PM (13:40) by LPN #9, Resident #5 had exit seeking behaviors that included confusion about her brother being outside to get her, constant redirection away from the front entrance and walking with a bag of her belongings and the Nurse Practitioner was notified with new order noted for urinalysis and change to insulin orders with family notified. The Progress Notes dated 5/01/25 at 3:15 PM (15:15) by LPN #8 and at 3:30 PM by LPN #9 documented that the resident exited the facility unnoticed by staff and was observed by C.N.A. #9 sitting in his vehicle when the C.N.A. went on break at approximately 3:00 PM and escorted the resident back into the facility. There was no incident report noted. Progress Note dated 5/03/25 at 10:30 AM documented that Resident #5 was placed on one-on-one observation related to elopement attempts. Telephone interview on 5/08/25 at 1:08 PM Contact #1 for Resident #5 stated that she was notified by LPN #9 on 5/01/25 at approximately 1:30 PM that the resident had new orders for a urinalysis due to new behaviors that included wandering and making statements about leaving and again at 3:30 PM LPN #9 notified her that Resident #5 had exited the facility and was found sitting in a staff member's car in the facility parking lot. Interview on 5/08/25 at 2:25 PM LPN #9 stated that she was familiar with Resident #5 and her care and the resident had exit seeking behaviors which included packing her belongings in bags and going to the front door of the facility and talking about leaving for several days at least since 4/24/25. She stated that she had documented her observations in the Progress Notes but had not updated the resident's care plan and there had been no orders for application of wander management device or other supervision resulting from the behavior until after the resident's elopement on 5/01/25 at approximately 3:00 PM. LPN #9 confirmed she was assigned to the care of Resident #5 on 5/01/25 during the day shift. She stated that at approximately 3:15 PM C.N.A. #9 arrived at the nurses station with Resident #5 who was wearing a short-sleeved shirt, long pants and a pair of shoes. She said C.N.A. #9 reported he had gone to his car and found Resident #5 seated in his front passenger's seat. LPN #9 said she had not known the resident had exited the facility and no one had reported the resident missing. LPN #9 confirmed that the Social Services Director was notified of the incident as well as Contact #1 and the primary healthcare provider for Resident #5 who issued new orders for wander guard. She confirmed that she did not complete an incident report and had no request to participate in any investigation into the incident. LPN #9 said that she was not aware of any head count of residents, and she had not participated in any elopement drills since the 5/01/25 incident. She confirmed that the Elopement Binder was missing from the Nurses Station. She confirmed upon review that there was not a Release During Pass form for Resident #5 in the Out on Pass binder at the Unit #1 Nurses' station. On 5/08/25 at 3:00 PM observation and record review revealed the absence of an Elopement Binder at the Unit 1 nurses' station. Resident #5's Release During Pass form was not found in the Out on Pass form was not found in the Unit 1 binder. SA located the form in the binder at the Unit 4 nurses' station with documentation of the last time Resident #5 being signed out on 12/20/24 at 11:16 AM. Interview with CNA #9 on 5/08/25 at 3:10 PM revealed that on 5/01/25 at approximately 3:15 PM he had gone out to his car, which was parked in the first parking spot to the right upon exit from the front door. CNA #9 stated, I looked at my car and saw someone sitting in the passenger seat and thought it wasn't my car, then I realized it was my car, and I opened the drivers' door and asked, 'Mam, you in my car?' and she opened the door and said she thought it was her brother's car. I went around and helped her out and took her inside. CNA #9 reported that the weather was clear, dry and moderate temperature. He said he was not aware of any head count of residents, and he had not participated in any elopement drills since the 5/01/25 incident. Interview with LPN #7 on 5/08/25 at 3:50 PM (the assigned Unit Manager for Resident #5 on 5/01/25 on Unit 1) stated that the procedure for a resident to leave for out on pass was that the person picking the resident up and taking responsibility for the resident had to report to the resident's nurses station and sign them out with date, time, address and telephone number, name and signature prior to exiting the building with the resident. LPN #7 said she worked at least five days a week and had never known the family or any person to sign Resident #5 out on pass. LPN #7 confirmed that Resident #5 had not had any order or application of any wander alarm device and that she had not updated the resident's care plan due to change in behavior/development of wandering/exit seeking behaviors, and that she had not been involved in a head count of residents following the elopement of Resident #5 on 5/01/25 or any investigation into how the resident exited the facility or any elopement drills since. She confirmed that the DON had assessed the resident upon return to the unit and obtained orders for and applied a Wander Guard wander management device to the resident's left ankle and initiated one-on-one supervision for seventy-two hours. Interview with the Executive Director on 5/09/25 at 11:00 AM revealed that the facility had investigated the 5/01/25 elopement of Resident #5 on 5/08/25. The Executive Director stated that the facility did not report the incident to the State Agency because it was determined that it was not an elopement because the resident told staff that her brother was coming to pick her up. The Executive Director confirmed that the facility procedure was for any person taking a resident out on pass was required to go to the nurses' station and sign the resident out in a binder with the date and time. He said he had not been aware that Resident #5 had new wandering/exit-seeking behaviors. He stated that the facility did not have operational security cameras. Interview with the Social Services Director (SSD) on 5/12/25 at 11:26 AM revealed she was made aware through visual observation and interaction with Resident #5 on 5/01/25 that the resident was anxious, made multiple, repeated trips to the front hall of the facility on 5/01/25 throughout the day and packing her belongings, but had not identified exit seeking behavior. She revealed she could clearly see that the resident had increased anxiety. She stated that Resident #5's behavioral changes were discussed on 4/25/25 during a Behavioral Meeting with the resident's primary healthcare provider notified of behavioral changes that at the time were not identified as elopement risk. She stated that on 5/01/25 she updated the Elopement Binders which were supposed to be located at each of the facility's four (4) nurses' stations and added Resident #5 but had not updated the resident's care plan with 'Focus' for elopement risk. She confirmed that there was 18 Residents identified as having wandering behaviors and at risk for elopement. She stated that a Trauma Screen was conducted for Resident #5 on 5/10/25. Interview with the facility Receptionist on 5/09/25 at 1:36 PM revealed she manned the desk at the front entrance and had a button she pressed which released the lock on the front door to allow entrance/exit. She stated that all the other doors required, and the front door could also be opened with numeric code entered into wall-mounted keypad on the inside or outside of the doors. She stated that she was familiar with Resident #5 because the resident had developed the behavior of packing her belongings in bags and coming to the front door prior to the 5/01/25 elopement. She said that Resident #5 had come to the front entrance at least three (3) separate times on 5/01/25 talking about going out, she said that she had to call the nurses station and a C.NA came and got the resident at least twice and escorted her back to her unit. The Receptionist stated that around 3:00 PM she had taken a break and asked someone to fill in for her but that she could not recall whom. She stated that she returned to her desk and shortly thereafter (could not recall time) and CNA #9 came in with Resident #5 and said he had found her sitting in his car in the parking lot. She stated that she notified the Executive Director approximately five to ten minutes later. She stated that the Executive Director checked the entrance door for proper locking on 5/01/25 following the return of Resident #5 and the locks were working correctly. On 5/09/25 at 3:00 PM observation revealed the first parking space on the right approximately fifty-five feet from the front entrance. Observation revealed one ambulance and six other vehicles traveling through the parking lot. The sidewalk which led from the facility's front porch/portico area, along the front of the parking spaces led to a busy four lane boulevard with a speed limit of thirty-five miles per hour and no cross walks; observation revealed one hundred twenty-five (125) vehicles traveling on the boulevard between 3:00 PM and 3:05 PM. Record review of the local weather history according to WWW.Wunderground, Copyright The Weather Channel, for the facility for 3:00 PM on 5/01/25 revealed the temperature was eighty-one degrees Fahrenheit, with zero precipitation, eight mile per hour winds and partly cloudy. Interview with the former DON on 5/12/25 at 4:26 PM by telephone revealed that she confirmed that she became aware that Resident #5 had exited the facility unnoticed and unsupervised on 5/01/25 at approximately 3:15 PM when C.N.A. #9 escorted the resident back into the facility. She said there was no head count done to confirm the safety of other residents, and said she was not aware of any missing resident protocol. She confirmed that the care plan for Resident #5 had not been updated for wandering or exit seeking behaviors prior to the elopement. Removal Plan - IJ The facility was informed by state agency on 05/09/2025 at 5:30 PM of 5 immediate jeopardies. The state agency provided the facility with IJ template for F656, F600, F609, F610 and F689. On 05/01/2025, Resident #1 exited the facility unaccompanied and unnoticed and sitting in a staff member's car with no supervision until the resident was found by staff approximately 15 minutes later. The facility failed to implement a care plan with interventions when Resident #1 exhibited behavioral changes that included wandering and exit seeking and a history of altered mental status. The facility also failed to report the allegation of neglect within the required time frame and complete a thorough investigation. On May 1. 2025 at approximately 2:45-3 :00 PM, a CNA walked to his car on his break and noticed a resident sitting in his passenger seat. The CNA immediately told the resident that she has to come back inside. Calmly and without hesitation, the resident stated ''okay. The CNA walked the resident back inside the building, notified the front desk, and walked the resident to the sitting area on the unit The CNA also let Resident (Proper Name Resident #5) nurse know what happened. The front desk notified the Administrator and the DNS. The Resident was assisted to her room by the evening shift Charge Nurse. A skin assessment was completed by the DNS with no negative findings. Vital signs were obtained. Nurse Practitioner and Sister of Resident# 1 was notified. New orders received by the Nurse Practitioner to included to apply wanderguard signaling device and consult psych services. Resident was also seen by the Physician on 05/01/25 and new orders were received for UA with C&S and Novolog sliding scale change. Resident was also seen by the Psych NP on 05/02/25 and placed 1: 1. An interview with Resident (Proper Name Resident #5) on 05/01/25 who stated that she was going outside to wait on her brother, noticed a car that looked like her brother's and got in on the passenger side to wait until he signed her out. She stated that she exited the facility with other people and that her brother normally comes to take her out. Corrective Actions: The [NAME] President in-serviced the Social Services Department on 05/10/25 on ensuring that care plans and interventions are implemented for Residents with behavioral changes that verbalizing to leave the facility, exit seeking, wandering and packing belongs should be immediately assessed and elopement precautions implemented. On 05/10/25 The Executive Director notified the Mississippi Department of Health of the incident regarding Resident # 1 exiting the facility unaccompanied and unnoticed by staff. On 05/10/25 an audit was completed for all 18 Residents who were determined to be at risk for elopement risk to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses. On 05/10/25 a sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent Residents from leaving the facility without staff knowledge. The Executive Director and Director of Nurses reinterviewed Resident# 1 on 05/10/25. Resident# 1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not recall how many people she followed or give a decription. Letters were mailed to family members on 05/10/25 by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the leaving the facility. The Receptionist who vacated the front desk on 05/01/25 was in-serviced on 05/10/25 by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. In addition to all routine staff who [NAME] the receptionist area was in-serviced on 05/10/25 by the Executive Director. 100% audit of elopement binders were conducted on 05/10/25 by the Social Service Department to ensure the binders information was reflective of all Residents who are deemed as elopement risk. An Emergency Quality Assurance Committee was held on 05/10/25 with the following staff in attendance: [NAME] President, Executive Director, Regional Director of Clincial Services, Director of Nurses (2) Assistant Executive Directors, Social Service Director, (2) Social [NAME] vice Assistants and Medical Director. The IP nurse was present by phone. The facility completed all actions to remove the Immediate Jeopardies on 5/10/25 and alleges the IJ was removed on 5/11/25. On 5/12/25, SA validations were made onsite during the complaint investigation through interviews and record reviews that all corrective actions had been taken by the facility to remove the IJ and the IJ was removed on 5/11/25, prior to exit.

Based on interviews, policy review and record review it was determined that the facility failed to develop a comprehensive care plan for one (2) of six (6) sampled residents, Resident #5 and Resident #6 On 5/01/25, Resident #5 with documented new wandering and exit seeking behaviors for at least a week eloped from the facility unnoticed and was outside unsupervised for approximately fifteen minutes. Documentation of the resident's change of behavior, including wandering had been reported to her primary healthcare provider with new orders noted for urinalysis to check for urinary tract infection, but the facility failed to identify exit seeking and elopement risk or develop her care plan to provide adequate supervision to prevent elopement. While Resident #5 was out of the facility unsupervised in the parking lot of the facility at shift change she got into a person's car unknown to her in front of a sidewalk that led to a busy four-lane boulevard with no barrier or crosswalk. The facility's failure to identify the need for development of an elopement risk care plan contributed to lack of adequate supervision to prevent Resident #5's elopement and placed all residents who developed wandering/exit seeking behaviors at risk for serious injury, impairment, and/or death. During the investigation of the complaint, the SA identified an Immediate Jeopardy (IJ) which began on 5/1/25 and existed at 42 CFR S483.21(b)(1) Develop/Implement Comprehensive Care Plan (F656) S/S of J. The SA notified the facility's Administrator of the IJ on 5/09/2025 at 3:10 PM and provided the Administrator with the IJ templates. The facility submitted an acceptable Removal Plan on 5/12/2025, in which they alleged all corrective actions to remove the IJ were completed on 5/10/25 and the IJ removed on 5/11/2025. The SA validated the Removal Plan on 5/12/2025 and determined the IJ was removed on 5/11/2025, prior to exit. Therefore, the scope and severity of 42 CFR S483.21(b)(1) Develop/Implement Comprehensive Care Plan (F656), was lowered from a S/S of J to a S/S of D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Cross Reference F600, F609, F610, F689 Findings: Record review of the facility policy titled, COMPREHENSIVE PERSON-CENTERED CARE PLANS with Revision Date 1/25 (January 2025) revealed the policy stated, Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team (IDT) will provide care. RESPONSIBILITY: All members of the Interdisciplinary Team monitored by the Executive Director .The Interdisciplinary Team along with the resident and/or Resident Representative will identify problems, needs, strengths, life history, preferences, and goals. For each problem, need, or strength a resident-centered goal id developed. Goals should be measurable .staff approaches to be developed for each problem/strength/need .The comprehensive Person-Centered Care Plan can be reviewed and/or revised at quarterly intervals in conjunction with the completion of MDS quarterly, significant change and annual assessments per the RAI manual .Upon change in condition, the Comprehensive Person-Centered Care Plan or Baseline Care Plan will be updated or an Instant Care Plan will be initiated if applicable. An Instant Care Plan can be completed with a change in resident condition if there is no care plan available or until the Comprehensive Person-Centered Care Pan is updated. Policy review of the facility policy titled, Investigation and Reporting of Violation of laws dated 7/2003, revealed the policy stated, The Director of nursing Services or his/her designee shall initiate a care plan to reflect the resident's condition and measures to be taken to prevent recurrence, where appropriate. Resident 5: On 5/08/25 record review of the comprehensive care plan for Resident #5 and the resident's physical (paper) chart revealed she had a care plan initiated on 11/04/24 for at risk for impaired cognitive function/and impaired thought processes. There were no care plans in place for risk for elopement, wandering or other related behaviors. Review of the Admission Record for Resident #5 revealed the facility admitted the resident on 5/23/23 and the resident had diagnoses of bipolar disorder, anxiety disorder, schizophrenia, and major depressive disorder. Record review of the Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) 4/10/25 for Resident #5 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. No mood or behavioral issues were noted, including wandering or exit seeking behaviors, during the lookback period. The MDS documented she had no restraints or wander/elopement alarms in use and was able to walk with supervision only for one hundred fifty (150) feet and was at risk for falls. Record review of Progress Notes for Resident #5 dated 4/25/25 through 5/06/25 revealed that the resident began going to the facility front door with small bags packed with her clothes and reporting family was coming to get her on 4/25/25 after report that she sat up all night with increased confusion. According to Progress Note on 5/01/25 at 1:40 PM (13:40) by Licensed Practical Nurse (LPN) #9, Resident #5 had exit seeking behaviors that included confusion about her brother being outside to get her, constant redirection away from the front entrance and walking with a bag of her belongings and the Nurse Practitioner was notified with new order noted for urinalysis and change to insulin orders with family notified. The Progress Notes dated 5/01/25 at 3:15 PM (15:15) by LPN #8 and at 3:30 PM by LPN #9 documented that the resident exited the facility unnoticed by staff and was observed by CNA #9 sitting in his vehicle when the CNA went on break at approximately 3:00 PM and escorted the resident back into the facility. Progress Note dated 5/03/25 at 10:30 AM documented that Resident #5 had been placed on one-on-one observation related to elopement attempts on 5/01/25; these interventions were not reflected in the resident's care plan. During an interview on 5/08/25 at 2:25 PM, LPN #9 stated that she was assigned to the care of Resident #5 on 5/01/25 during the day shift and that Resident #5 had exit seeking behaviors which included packing her belongings in bags, going to the front door of the facility and talking about leaving for several days, at least since 4/24/25. LPN #9 confirmed that on 5/01/25 the Social Services Director was notified of the incident as well as Contact #1 and the primary healthcare provider for Resident #5 who issued new orders for wander guard safe wandering device with monitoring of placement and functioning each shift. She stated that she had documented her observations, the incident and new orders in the Progress Notes but had not updated the resident's care plan. During an interview LPN #7 on 5/08/25 at 3:50 PM, the assigned Unit Manager for Resident #5 on 5/01/25 on Unit 1 revealed she had not updated the resident's care plan due to change in behavior/development of wandering/exit seeking behaviors prior to or on 5/01/25. She confirmed that the DON had assessed the resident upon return to the unit and obtained orders for and applied a Wander Guard wander management device to the resident's left ankle and initiated one-on-one supervision for seventy-two hours. On 5/09/25 at 11:00 AM an interview with the Executive Director revealed that the facility had investigated the 5/01/25 elopement of Resident #5 on 5/08/25 and included care plan update in follow up actions to be taken. During an interview on 5/12/25 at 11:26 AM with the Social Services Director (SSD) revealed she was made aware through visual observation and interaction with Resident #5 on 5/01/25 that the resident made multiple, repeated trips to the front hall of the facility on 5/01/25 throughout the day and packing her belongings, but had not identified exit seeking behavior but could clearly see that the resident had increased anxiety. She stated that Resident #5's behavioral changes were discussed on 4/25/25 during a Behavioral Meeting with the resident's primary healthcare provider notified of behavioral changes that at the time were not identified as elopement risk. She stated that on 5/01/25 she updated the Elopement Binders which were supposed to be located at each of the facility's four (4) nurses' stations and added Resident #5 but had not updated the resident's care plan with approaches related to wandering or elopement risk. On 5/12/25 at 12:25 PM an interview with the MDS Coordinator revealed that the interdisciplinary team (IDT) was responsible for updates to the residents' care plans. She stated that the SSD was responsible for updating the social services care plan, including elopement risk. She stated that she was not aware of the elopement of Resident #5 until 5/09/25. She stated that the development and implementation of care plans was very important, and the purpose of care plans was to let staff know how to care for residents. She stated that it was very important to update care plans as needed related to changes in resident needs, including behaviors, for the protection and to ensure the needs of the residents were met. During a telephone interview with the former DON on 5/12/25 at 4:26 PM revealed that she became aware that Resident #5 had left the facility unnoticed and unsupervised on 5/01/25 at approximately 3:15 PM when CNA #9 escorted the resident back into the facility. She confirmed that the care plan for Resident #5 had not been updated for wandering or exit seeking behaviors prior to the elopement. On 5/12/25 at 5:07 PM an interview with the DON revealed she confirmed that identifying problems and needs of residents and updating their person-centered care plans was very important for the purpose of providing instructions to staff for care. She confirmed that any member of the interdisciplinary team could update any resident's care plan as needed. Removal Plan - IJ The facility was informed by state agency on 05/09/2025 at 5:30 PM of 5 immediate jeopardies. The state agency provided the facility with IJ template for F656, F600, F609, F610 and F689. On 05/01/2025, Resident #1 exited the facility unaccompanied and unnoticed and sitting in a staff member's car with no supervision until the resident was found by staff approximately 15 minutes later. The facility failed to implement a care plan with interventions when Resident #1 exhibited behavioral changes that included wandering and exit seeking and a history of altered mental status. The facility also failed to report the allegation of neglect within the required time frame and complete a thorough investigation. On May 1. 2025. at approximately 2:45-3 :00 PM, a CNA walked to his car on his break and noticed a resident sitting in his passenger seat. The CNA immediately told the resident that she has to come back inside. Calmly and without hesitation, the resident stated ''okay. The CNA walked the resident back inside the building, notified the front desk, and walked the resident to the sitting area on the unit The CNA also let Resident (Proper Name Resident #5) nurse know what happened. The front desk notified the Administrator and the DNS. The Resident was assisted to her room by the evening shift Charge Nurse. A skin assessment was completed by the DNS with no negative findings. Vital signs were obtained. Nurse Practitioner and Sister of Resident# 1 was notified. New orders received by the Nurse Practitioner to included to apply wanderguard signaling device and consult psych services. Resident was also seen by the Physician on 05/01/25 and new orders were received for UA with C&S and Novolog sliding scale change. Resident was also seen by the Psych NP on 05/02/25 and placed 1: 1. An interview with Resident (Proper Name Resident #5) on 05/01/25 who stated that she was going outside to wait on her brother, noticed a car that looked like her brother's and got in on the passenger side to wait until he signed her out. She stated that she exited the facility with other people and that her brother normally comes to take her out. Corrective Actions: The [NAME] President in-serviced the Social Services Department on 05/10/25 on ensuring that care plans and interventions are implemented for Residents with behavioral changes that verbalizing to leave the facility, exit seeking, wandering and packing belongs should be immediately assessed and elopement precautions implemented. On 05/10/25 The Executive Director notified the Mississippi Department of Health of the incident regarding Resident # 1 exiting the facility unaccompanied and unnoticed by staff. On 05/10/25 an audit was completed for all 18 Residents who were determined to be at risk for elopement risk to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses. On 05/10/25 a sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent Residents from leaving the facility without staff knowledge. The Executive Director and Director of Nurses reinterviewed Resident# 1 on 05/10/25. Resident# 1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not recall how many people she followed or give a decription. Letters were mailed to family members on 05/10/25 by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the leaving the facility. The Receptionist who vacated the front desk on 05/01/25 was in-serviced on 05/10/25 by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. In addition to all routine staff who [NAME] the receptionist area was in-serviced on 05/10/25 by the Executive Director. 100% audit of elopement binders were conducted on 05/10/25 by the Social Service Department to ensure the binders information was reflective of all Residents who are deemed as elopement risk. An Emergency Quality Assurance Committee was held on 05/10/25 with the following staff in attendance: [NAME] President, Executive Director, Regional Director of Clincial Services, Director of Nurses (2) Assistant Executive Directors, Social Service Director, (2) Social [NAME] vice Assistants and Medical Director. The IP nurse was present by phone. The facility completed all actions to remove the Immediate Jeopardies on 5/10/25 and alleges the IJ was removed on 5/11/25. On 5/12/25, SA validations were made onsite during the complaint investigation through interviews and record reviews that all corrective actions had been taken by the facility to remove the IJ and the IJ was removed on 5/11/25, prior to exit. Resident # 6: Record review of Resident #6 admission record revealed an admssion date of 8/29/2023 with documented medical conditions including obstructive uropathy (blocked urine flow) that required a left nephrostomy tube for urinary drainage. The hospital discharge summary and admission nursing assessment noted the presence of the nephrostomy tube. At the time of admission, staff initiated a baseline care plan for the resident ' s immediate needs; however, there was no inclusion of the nephrostomy tube care in the initial care planning documents. The admission orders did not explicitly state the care instructions for the nephrostomy tube (e.g., flush frequency or dressing change schedule), and the facility did not reach out to the physician or specialist for guidance on nephrostomy care upon admission. Record review of Resident #6 ' s comprehensive care plan, as of 5/08/25, revealed no care plan focus or goals addressing the nephrostomy tube or related care needs. The care plan contained sections for other issues (such as nutrition, mobility, and medications), but no entry was found for Urinary Device, Nephrostomy, or similar terms. There were no interventions listed for tasks like nephrostomy site care, flushing the tube, monitoring output, or infection prevention. This indicated that since admission (over 8 months), the facility failed to develop or update the care plan to include the resident ' s nephrostomy tube management. On 5/08/25 at 1:00 PM, an interview was conducted with the facility ' s MDS Coordinator. The MDS Coordinator confirmed that Resident #6 ' s MDS assessments identified the presence of a nephrostomy tube. She explained that when such a device is noted, it should trigger a care plan update to address that device and its care needs. Upon reviewing the file, the MDS Coordinator acknowledged that no care plan was ever created for the nephrostomy tube. She stated, This looks like an oversight - we should have completed a Care Area Assessment and developed a care plan back when [Resident #6] was admitted with the nephrostomy. The MDS Coordinator agreed that the care plan should include specifics like who will do the flushing, how often to change dressings, what to monitor, and physician involvement. 5/08/2025 - Nursing Staff Interview (LPN #5): In an interview on 5/08/25 (approximately 2:15 PM), LPN #5 was asked about care planning for Resident #6 ' s nephrostomy tube. LPN #5 indicated that she had never seen a care plan instruction for the nephrostomy tube. She stated, Usually the care plan or Kardex will tell us if we need to do special care. For [Resident #6], I didn ' t see anything about the nephrostomy. As a result, LPN #5 said she relied on general practice and common sense for the resident ' s care, such as keeping the area clean if she noticed any issue, but there was no formal guidance. She acknowledged that without a written care plan or orders, important care steps (like routine flushing) were missed, and said We should have had something in writing so everyone knows what to do. On 5/09/25 at 10:30 AM, the Director of Nursing (DON) was interviewed about the facility's care planning for Resident #6. The DON confirmed that no comprehensive care plan existed for the nephrostomy tube care. She stated that all significant medical devices or care needs must be reflected in the care plan, and a nephrostomy tube is definitely something that should be in the care plan with clear instructions. The DON explained that the care plan should have included interventions such as checking the nephrostomy site, changing dressings [at a specified frequency], flushing the tube [with specified solution and frequency], monitoring urine output and characteristics, and noting signs of infection. Additionally, the care plan should assign these tasks to nursing staff and include coordination (for example, consulting the urologist or Medical Director for orders or follow-up). The DON admitted that we missed it - the team did not create that section of the care plan upon admission or thereafter. She also acknowledged that no one contacted the physician/urology provider specifically regarding a care regimen for the nephrostomy tube, which should have been done. The DON agreed that this was a failure in the care planning process and could lead to staff confusion or neglect of critical care tasks. On 5/09/25 at 11:30 AM, the Medical Director was interviewed about Resident #6 ' s care coordination. He stated that he expects the facility to develop a care plan for any resident with specialized medical needs, such as a nephrostomy tube, and to communicate with him or the appropriate specialist to obtain necessary orders and guidance. The Medical Director said he had not been contacted about a care plan or specific orders for Resident #6 ' s nephrostomy tube since the resident ' s admission. He expressed that if he had been consulted, he would have recommended a standard protocol (e.g., weekly flushing with normal saline, weekly dressing changes, and prn as needed, with monitoring for signs of infection). The Medical Director remarked, Without a care plan in place, the staff might not know to do those things, and the resident could suffer as a result. He agreed that the lack of a nephrostomy care plan meant important preventive care was overlooked, placing Resident #6 at risk for infection or other complications.

Based on record review, policy review and interviews it was determined that the facility failed to initiate a thorough investigation of an allegation of neglect and incident of elopement for one (1) of six (6) sampled residents, Resident #5. On 5/01/25 the facility failed to initiate an investigation of resident neglect related to lack of adequate supervision resulting in the elopement of Resident #5. Resident #5 was out of the facility unsupervised in the parking lot of the facility at shift change and got into a car in front of a sidewalk that led to a busy four-lane boulevard with no barrier or crosswalk. This car belonged to a staff member who found her in his car around 3:15 PM and escorted her back into the facility. The facility's failure to conduct a thorough investigation of the elopement of Resident #5 on 5/1/25 placed this resident, and other residents at risk for wandering and elopement, in a situation that was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 5/1/25 and existed at 42 CFR S483.12(c)(2)-(4) Investigate/prevent/correct Alleged Violation (F610) S/S of J. The SA notified the facility's Administrator of the IJ and SQC on 5/09/2025 at 3:10 PM and provided the Administrator with the IJ templates. The facility submitted an acceptable Removal Plan on 5/12/2025, in which they alleged all corrective actions to remove the IJ were completed on 5/10/25 and the IJ removed on 5/11/2025. The SA validated the Removal Plan on 5/12/2025 and determined the IJ was removed on 5/11/2025, prior to exit. Therefore, the scope and severity of 42 CFR S483.12(c)(2)-(4) Investigate/prevent/correct Alleged Violation (F610) was lowered from a S/S of J to a S/S of D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Cross Reference F600, F609, F656, F689 Findings Include: Review of the facility policy titled, Investigation and Reporting of Violation of Laws dated 7/2003, revealed, .INVESTIGATION All investigations shall be conducted by the Executive Director or Director of Nursing Services .The investigation shall include interview of associates, visitors or resident who may have knowledge of the alleged incident. Factual information only should be documented, not assumptions or speculation .kept in the Executive Director's office in an administrative file .'Verification of Investigations' form shall be complete after the investigation is complete and provided to survey agencies when requested . Policy review of the facility policy titled, ABUSE PREVENTION with Revision Date 1/25 (January 2025), revealed the policy stated, INVESTIGATION: The facility will initiate at the time of any finding of potential abuse or neglect an investigation to determine case and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation. The facility shall coordinate its investigation with the Quality Assurance and Performance Improvement Committee . Policy review of the facility policy titled, MISSING RESIDENT/ELOPEMENTS with Revision Date 8/04, revealed the policy stated, The Charge Nurse will complete a resident Accident/Incident report. Record review of the accident/incidents log for 1/01/25 through 5/05/25 revealed no documentation of any elopement of any resident. The Progress Notes dated 5/01/25 at 3:15 PM (15:15) by Licensed Practical Nurse (LPN) #8 and at 3:30 PM by LPN #9 documented that the resident exited the facility unnoticed by staff and was observed by Certified Nursing Assistant (CNA) #9 sitting in his vehicle when the CNA went on break at approximately 3:00 PM and escorted the resident back into the facility. According to the 3:15 PM Progress Note the Unit Manager and Director of Nursing Services (DON) and Social Worker were notified and according to the 3:30 PM Note the Executive Director was made aware of the elopement of Resident #5. There was no incident report noted. In an interview on 5/08/25 at 2:25 PM, LPN #9 stated that Resident #5 had exited the facility unnoticed by staff and unsupervised on 5/01/25 at approximately 3:00 PM. At approximately 3:15 PM CNA #9 reported he had gone to his car during his break and found Resident #5 seated in his front passenger's seat. LPN #9 said no missing resident procedure had been initiated. LPN #9 stated that the Unit Manager and Director of Nursing (DON) were on the unit and aware of the incident upon the return of Resident #5. LPN #9 stated she entered a progress note following the incident but did not complete an incident report and had no request to participate in any investigation into the incident. She said she was not aware of any head count of residents. In an interview with CNA #9 on 5/08/25 at 3:10 PM revealed that on 5/01/25 he was working at the facility and had gone on break at approximately 3:00 PM and at approximately 3:15 PM he had gone out to his car, which was parked in the first parking spot to the right upon exit from the front door. CNA #9 stated, I looked at my car and saw someone sitting in the passenger seat and thought it wasn't my car, then I realized it was my car, and I opened the drivers' door and asked, 'Mam, you in my car?' and she opened the door and said she thought it was her brother's car. I went around and helped her out and took her inside. I told the receptionist and the Executive Director soon as we got inside. In an interview with LPN #8 on 5/08/25 at 3:34 PM revealed she worked the 3:00 PM till 11:00 PM shift on 5/01/25 and was assigned to the care of Resident #5. She confirmed that Resident #5 was escorted back into the facility by CNA #9 at approximately 3:15 PM, who reported he had found her sitting in his car in the facility parking lot. LPN #8 stated that she had entered a Progress Note but had not completed an incident report or participated in any investigation. She confirmed that no one had reported Resident #5 as a missing resident and no missing resident code was initiated. She said she was not aware of any head count of residents. In an interview with LPN #7 on 5/08/25 at 3:50 PM revealed she was the assigned Unit Manager for Resident #5 on 5/01/25 on Unit 1. She stated she was made aware by LPN #9 that Resident #5 had left the building unnoticed and unsupervised shortly after 3:15 PM on 5/01/25. She said she had not been involved in a head count of residents following the elopement of Resident #5 on 5/01/25 or any investigation into how the resident exited the facility. She said that she recalled staff supposing that Resident #1 may have exited the building with some Nursing Students that had left the facility around 3:00 PM. In an interview with the Executive Director on 5/09/25 at 11:00 AM revealed that the facility had investigated the 5/01/25 elopement of Resident #5 on 5/08/25. The Executive Director stated that the facility did not report the incident to the State Agency because it was determined that it was not an elopement because the resident told staff that her brother was coming to pick her up. He confirmed that no report had been made/sent to any agencies, including SA. In an interview with the facility Receptionist on 5/09/25 at 1:36 PM revealed she stated that the Executive Director was notified of the elopement approximately five to ten minutes after CNA #9 and Resident #5 came back into the facility. In a telephone interview with the Nursing Instructor at the local community college, on 5/09/25 at 2:45 PM revealed that no one had contacted her concerning the elopement of any resident from the facility on 5/01/25. In a telephone interview with the former DON on 5/12/25 at 4:26 PM revealed that she confirmed that she had become aware of the elopement of Resident #5 on 5/01/25 when CNA #9 escorted the resident back into the building. She said she had not participated in an investigation into the elopement. Record review of the Admission Record for Resident #5 revealed the facility admitted the resident on 5/23/23 and the resident had diagnoses of bipolar disorder, anxiety disorder, schizophrenia and major depressive disorder. Record review of the Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) 4/10/25 for Resident #5 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. No mood or behavioral issues were noted, including wandering or exit seeking behaviors, during the lookback period. The MDS documented she had no restraints or wander/elopement alarms in use and was able to walk with supervision only for one hundred fifty (150) feet and was at risk for falls. Removal Plan - IJ The facility was informed by state agency on 05/09/2025 at 5:30 PM of 5 immediate jeopardies. The state agency provided the facility with IJ template for F656, F600, F609, F610 and F689. On 05/01/2025, Resident #1 exited the facility unaccompanied and unnoticed and sitting in a staff member's car with no supervision until the resident was found by staff approximately 15 minutes later. The facility failed to implement a care plan with interventions when Resident #1 exhibited behavioral changes that included wandering and exit seeking and a history of altered mental status. The facility also failed to report the allegation of neglect within the required time frame and complete a thorough investigation. On May 1. 2025. at approximately 2:45-3 :00 PM, a CNA walked to his car on his break and noticed a resident sitting in his passenger seat. The CNA immediately told the resident that she has to come back inside. Calmly and without hesitation, the resident stated ''okay. The CNA walked the resident back inside the building, notified the front desk, and walked the resident to the sitting area on the unit The CNA also let Resident (Proper Name Resident #5) nurse know what happened. The front desk notified the Administrator and the DNS. The Resident was assisted to her room by the evening shift Charge Nurse. A skin assessment was completed by the DNS with no negative findings. Vital signs were obtained. Nurse Practitioner and Sister of Resident# 1 was notified. New orders received by the Nurse Practitioner to included to apply wanderguard signaling device and consult psych services. Resident was also seen by the Physician on 05/01/25 and new orders were received for UA with C&S and Novolog sliding scale change. Resident was also seen by the Psych NP on 05/02/25 and placed 1: 1. An interview with Resident (Proper Name Resident #5) on 05/01/25 who stated that she was going outside to wait on her brother, noticed a car that looked like her brother's and got in on the passenger side to wait until he signed her out. She stated that she exited the facility with other people and that her brother normally comes to take her out. Corrective Actions: The [NAME] President in-serviced the Social Services Department on 05/10/25 on ensuring that care plans and interventions are implemented for Residents with behavioral changes that verbalizing to leave the facility, exit seeking, wandering and packing belongs should be immediately assessed and elopement precautions implemented. On 05/10/25 The Executive Director notified the Mississippi Department of Health of the incident regarding Resident # 1 exiting the facility unaccompanied and unnoticed by staff. On 05/10/25 an audit was completed for all 18 Residents who were determined to be at risk for elopement risk to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses. On 05/10/25 a sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent Residents from leaving the facility without staff knowledge. The Executive Director and Director of Nurses reinterviewed Resident# 1 on 05/10/25. Resident# 1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not recall how many people she followed or give a decription. Letters were mailed to family members on 05/10/25 by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the leaving the facility. The Receptionist who vacated the front desk on 05/01/25 was in-serviced on 05/10/25 by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. In addition to all routine staff who [NAME] the receptionist area was in-serviced on 05/10/25 by the Executive Director. 100% audit of elopement binders were conducted on 05/10/25 by the Social Service Department to ensure the binders information was reflective of all Residents who are deemed as elopement risk. An Emergency Quality Assurance Committee was held on 05/10/25 with the following staff in attendance: [NAME] President, Executive Director, Regional Director of Clincial Services, Director of Nurses (2) Assistant Executive Directors, Social Service Director, (2) Social [NAME] vice Assistants and Medical Director. The IP nurse was present by phone. The facility completed all actions to remove the Immediate Jeopardies on 5/10/25 and alleges the IJ was removed on 5/11/25. On 5/12/25, SA validations were made onsite during the complaint investigation through interviews and record reviews that all corrective actions had been taken by the facility to remove the IJ and the IJ was removed on 5/11/25, prior to exit.

Based on record review, policy review and interviews it was determined that the facility failed to ensure that allegations of neglect and incident of elopement were reported to the appropriate agencies, including State Agency, in accordance with State law through established procedures for one (1) of six (6) sampled residents, Resident #5. On 5/01/25 the facility failed to report to the required agencies an allegation of resident neglect related to lack of adequate supervision resulting in the elopement of Resident #5. On 5/01/25 at approximately 3:00 PM, Resident #5, who had recently exhibited new exit-seeking behaviors, exited the facility unnoticed and unsupervised. The facility was unaware of Resident #5's whereabouts for approximately fifteen (15) minutes until a staff member went to his car on break and located her sitting in the passenger seat of his car with the windows up in an unshaded parking space approximately thirty-five yards from the facility entrance at approximately 3:15 PM. The parked car was in front of a sidewalk that led to a busy four-lane boulevard with no barrier or crosswalk. The facility failure to provide adequate supervision for Resident #5 to ensure she did not exit the facility unsupervised and report the incident to the proper authorities placed her and other residents with wandering/exit seeking behaviors at risk for serious injury, harm, impairment, and/or death. The State Agency (SA) identified Immediate Jeopardy and Substandard Quality of Care which began on 5/01/25 when Resident #5 exited the facility unnoticed and unsupervised. The SA notified the facility's Administrator of the IJ and SQC on 5/09/2025 at 3:10 PM and provided the Administrator with the IJ templates. The facility submitted an acceptable Removal Plan on 5/12/2025, in which they alleged all corrective actions to remove the IJ were completed on 5/10/25 and the IJ removed on 5/11/2025. The SA validated the Removal Plan on 5/12/2025 and determined the IJ was removed on 5/11/2025, prior to exit. Therefore, the scope and severity of 42 CFR S483.12(c)(1)(4) Reporting of Alleged Violations (F609), was lowered from a S/S of J to a S/S of D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Cross Reference F600, F610, F656, F689 Findings Include: Review of the facility policy titled, ABUSE PREVENTION with Revision Date 1/25 (January 2025), revealed the policy stated, The Executive Director, or designee, shall report any allegations of abuse, neglect, or misappropriation of resident property as well as report any reasonable suspicion of crime in accordance with Section 1150B of the Social Security Act to the Department of Health as required. Review of the facility polity titled, MISSING RESIDENT/ELOPEMENTS with Revision Date 8/04, revealed the policy stated, The Charge Nurse will complete a resident Accident/Incident report. The Executive director/Director of Nursing Services will notify the Department of Health per State Regulations. Review of the facility policy titled, Investigation and Reporting of Violation of laws dated 7/2003 (July 2003), revealed the policy stated, all alleged violation of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown source and misappropriation of resident property (alleged violations), are reported immediately to the Executive Director of the facility. Such violations will also be reported to the state agencies as required by state and federal law .TRAINING Upon hire each new employee shall be informed of the obligation to report alleged violations . Record review of the accident/incidents log for 1/01/25 through 5/05/25 revealed no documentation of any elopement of any resident. The Progress Notes dated 5/01/25 at 3:15 PM (15:15) by Licensed Practical Nurse (LPN) #8 and at 3:30 PM by LPN #9 documented that the resident exited the facility unnoticed by staff and was observed by CNA #9 sitting in his vehicle when the CNA went on break at approximately 3:00 PM and escorted the resident back into the facility. According to the 3:15 PM Progress Note the Unit Manager and Director of Nursing Services (DON) and Social Worker were notified and according to the 3:30 PM Note the Executive Director was made aware of the elopement of Resident #5. There was no incident report noted. An interview on 5/08/25 at 3:10 PM with CNA #9 revealed that on 5/01/25 he was working at the facility and had gone on break at approximately 3:00 PM and at approximately 3:15 PM he had gone out to his car, which was parked in the first parking spot to the right upon exit from the front door. CNA #9 stated, I looked at my car and saw someone sitting in the passenger seat and thought it wasn't my car, then I realized it was my car, and I opened the drivers' door and asked, 'Mam, you in my car?' and she opened the door and said she thought it was her brother's car. I went around and helped her out and took her inside. I told the receptionist and the Executive Director as soon as we got inside. An interview on 5/09/25 at 11:00 AM with the Executive Director revealed that the facility had investigated the 5/01/25 elopement of Resident #5 on 5/08/25. The Executive Director stated that the facility did not report the incident to the State Agency because it was determined that it was not an elopement because the resident told staff that her brother was coming to pick her up. The Executive Director confirmed that the facility procedure was for any person taking a resident out on pass was required to go to the nurses station and sign the resident out in a binder with the date and time unless other arrangements had been made and that on 5/01/25 no one had arrived to take the resident out, signed her out or made any arrangements for her to go out on pass. He stated that it was thought that the resident may have exited the building with a group of Nursing Students at the facility on 5/01/25 for clinical training that had left at approximately 3:00 PM. He confirmed that no report had been made/sent to any agencies, including SA at the time of interview. An interview on 5/09/25 at 1:36 PM with the facility Receptionist revealed she returned to her desk after a break while the reception desk was manned by another staff member, she could not recall whom and shortly thereafter (could not recall time) CNA #9 came in with Resident #5 and said he had found her sitting in his car in the parking lot. She stated that the Executive Director was notified approximately five to ten minutes after CNA #9 and Resident #5 came back into the facility. On 5/12/25 at 4:26 PM during a telephone interview with the former DON revealed that she confirmed that she had become aware of the elopement of Resident #5 on 5/01/25 when CNA #9 escorted the resident back into the building. She said she had not participated in an investigation into the elopement or reported anything related to the incident to any agencies. Record review of the Admission Record for Resident #5 revealed the facility admitted the resident on 5/23/23 and the resident had diagnoses of bipolar disorder, anxiety disorder, schizophrenia and major depressive disorder. Record review of the Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) 4/10/25 for Resident #5 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. No mood or behavioral issues were noted, including wandering or exit seeking behaviors, during the lookback period. The MDS documented she had no restraints or wander/elopement alarms in use and was able to walk with supervision only for one hundred fifty (150) feet and was at risk for falls. Removal Plan - IJ The facility was informed by state agency on 05/09/2025 at 5:30 PM of 5 immediate jeopardies. The state agency provided the facility with IJ template for F656, F600, F609, F610 and F689. On 05/01/2025, Resident #1 exited the facility unaccompanied and unnoticed and sitting in a staff member's car with no supervision until the resident was found by staff approximately 15 minutes later. The facility failed to implement a care plan with interventions when Resident #1 exhibited behavioral changes that included wandering and exit seeking and a history of altered mental status. The facility also failed to report the allegation of neglect within the required time frame and complete a thorough investigation. On May 1. 2025. at approximately 2:45-3 :00 PM, a CNA walked to his car on his break and noticed a resident sitting in his passenger seat. The CNA immediately told the resident that she has to come back inside. Calmly and without hesitation, the resident stated ''okay. The CNA walked the resident back inside the building, notified the front desk, and walked the resident to the sitting area on the unit The CNA also let Resident (Proper Name Resident #5) nurse know what happened. The front desk notified the Administrator and the DNS. The Resident was assisted to her room by the evening shift Charge Nurse. A skin assessment was completed by the DNS with no negative findings. Vital signs were obtained. Nurse Practitioner and Sister of Resident# 1 was notified. New orders received by the Nurse Practitioner to included to apply wanderguard signaling device and consult psych services. Resident was also seen by the Physician on 05/01/25 and new orders were received for UA with C&S and Novolog sliding scale change. Resident was also seen by the Psych NP on 05/02/25 and placed 1: 1. An interview with Resident (Proper Name Resident #5) on 05/01/25 who stated that she was going outside to wait on her brother, noticed a car that looked like her brother's and got in on the passenger side to wait until he signed her out. She stated that she exited the facility with other people and that her brother normally comes to take her out. Corrective Actions: The [NAME] President in-serviced the Social Services Department on 05/10/25 on ensuring that care plans and interventions are implemented for Residents with behavioral changes that verbalizing to leave the facility, exit seeking, wandering and packing belongs should be immediately assessed and elopement precautions implemented. On 05/10/25 The Executive Director notified the Mississippi Department of Health of the incident regarding Resident # 1 exiting the facility unaccompanied and unnoticed by staff. On 05/10/25 an audit was completed for all 18 Residents who were determined to be at risk for elopement risk to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses. On 05/10/25 a sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent Residents from leaving the facility without staff knowledge. The Executive Director and Director of Nurses reinterviewed Resident# 1 on 05/10/25. Resident# 1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not recall how many people she followed or give a decription. Letters were mailed to family members on 05/10/25 by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the leaving the facility. The Receptionist who vacated the front desk on 05/01/25 was in-serviced on 05/10/25 by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. In addition to all routine staff who [NAME] the receptionist area was in-serviced on 05/10/25 by the Executive Director. 100% audit of elopement binders were conducted on 05/10/25 by the Social Service Department to ensure the binders information was reflective of all Residents who are deemed as elopement risk. An Emergency Quality Assurance Committee was held on 05/10/25 with the following staff in attendance: [NAME] President, Executive Director, Regional Director of Clincial Services, Director of Nurses (2) Assistant Executive Directors, Social Service Director, (2) Social [NAME] vice Assistants and Medical Director. The IP nurse was present by phone. The facility completed all actions to remove the Immediate Jeopardies on 5/10/25 and alleges the IJ was removed on 5/11/25. On 5/12/25, SA validations were made onsite during the complaint investigation through interviews and record reviews that all corrective actions had been taken by the facility to remove the IJ and the IJ was removed on 5/11/25, prior to exit.

Based on observation, interviews, and record review the facility failed to protect the residents' right to be free from neglect by not ensuring staff implemented measures to mitigate the risk to prevent elopement for one (1) of six (6) sampled residents, Resident #5. On 5/01/25 at approximately 3:00 PM, the facility failed to prevent Resident #5, a resident who had recently exhibited new exit-seeking behaviors from exiting the facility unnoticed and unsupervised. The facility was unaware of Resident #5's whereabouts for approximately fifteen (15) minutes until a staff member went to his car on break and located her sitting in the passenger seat of his car with the windows up in an unshaded parking space approximately thirty-five yards from the facility entrance at approximately 3:15 PM. The parked car was in front of a sidewalk that led to a busy four-lane boulevard with no barrier or crosswalk. The facility failure to ensure Resident #5 was adequately supervised to ensure she did not exit the facility unsupervised placed her and other residents with wandering/exit seeking behaviors at risk for serious injury, harm, impairment, and/or death. The State Agency (SA) identified Immediate Jeopardy and Substandard Quality of Care which began on 5/01/25 when Resident #5 exited the facility unnoticed and unsupervised. The SA notified the facility's Administrator of the IJ and SQC on 5/09/2025 at 3:10 PM and provided the Administrator with the IJ templates. The facility submitted an acceptable Removal Plan on 5/12/2025, in which they alleged all corrective actions to remove the IJ were completed on 5/10/25 and the IJ removed on 5/11/2025. The SA validated the Removal Plan on 5/12/2025 and determined the IJ was removed on 5/11/2025, prior to exit. Therefore, the scope and severity of 42 CFR S483.12(a)(1)Free from Abuse and Neglect (F600), was lowered from a S/S of J to a S/S of D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Cross Reference F609, F610, F656, and F689 Record review of the facility policy titled, ABUSE PREVENTION with Revision Date 1/25 (January 2025), revealed the policy stated, The facility is committed to protecting the residents from abuse .DEFINITIONS .Neglect: A failure of the facility, its employees or service providers to provide goods and services necessary to avoid physical harm, mental anguish, emotional distress, or pain .PREVENTION .3. Identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. 4. Features of the physical environment that may make abuse and/or neglect more likely to occur, such as secluded areas of the facility. 5. Examples of steps that the facility may put in place immediately to prevent further potential abuse includes, but are not limited to, staffing changes, increased supervision . Review of the Admission Record for Resident #5 revealed the facility admitted the resident on 5/23/23 and the resident had diagnoses of bipolar disorder, anxiety disorder, schizophrenia and major depressive disorder. Record review of the Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) 4/10/25 for Resident #5 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. No mood or behavioral issues were noted, including wandering or exit seeking behaviors, during the lookback period. The MDS documented she had no restraints or wander/elopement alarms in use and was able to walk with supervision only for one hundred fifty (150) feet and was at risk for falls. Record review of the Progress Notes for Resident #5 dated 4/25/25 through 5/06/25 revealed that the resident began going to the facility front door with small bags packed with her clothes and reporting family was coming to get her on 4/25/25 after report that she sat up all night with increased confusion. According to Progress Note on 5/01/25 at 1:40 PM (13:40) by Licensed Practical Nurse (LPN) #9, Resident #5 had exit seeking behaviors that included confusion about her brother being outside to get her, constant redirection away from the front entrance and walking with a bag of her belongings and the Nurse Practitioner was notified with new order noted for urinalysis and change to insulin orders with family notified. The Progress Notes dated 5/01/25 at 3:15 PM (15:15) by LPN #8 and at 3:30 PM by LPN #9 documented that the resident exited the facility unnoticed by staff and was observed by Certified Nursing Assistant (CNA) #9 sitting in his vehicle when the CNA went on break at approximately 3:00 PM and escorted the resident back into the facility. There was no incident report noted. Progress Note dated 5/03/25 at 10:30 AM documented that Resident #5 was on 1 on 1 observation related to elopement attempts. On 5/08/25 at 1:08 PM during a telephone interview Contact #1 for Resident #5 stated that she was notified by LPN #9 on 5/01/25 at approximately 3:30 PM that Resident #5 had exited the facility and was found sitting in a staff member's car in the facility parking lot. On 5/08/25 at 2:25 PM during an interview LPN #9 stated that she was familiar with Resident #5 and her care and the resident had exit seeking behaviors which included packing her belongings in bags and going to the front door of the facility and talking about leaving for several days at least since 4/24/25. She stated that she had documented her observations in the Progress Notes but had not updated the resident's care plan and there had been no orders for application of wander management device or other supervision resulting from the behavior until after the resident's elopement on 5/01/25 at approximately 3:00 PM. LPN #9 confirmed she was assigned to the care of Resident #5 on 5/01/25 during the day shift. She stated that at approximately 3:15 PM CNA #9 arrived at the nurses station with Resident #5 who was wearing a short-sleeved shirt, long pants and a pair of shoes. She said CNA #9 reported he had gone to his car and found Resident #5 seated in his front passenger's seat. LPN #9 said she had not known the resident had exited the facility and no one had reported the resident missing. LPN #9 confirmed that the Social Services Director was notified of the incident as well as Contact #1 and the primary healthcare provider for Resident #5 who issued new orders for a wander guard. She confirmed that she did not complete an incident report and had no request to participate in any investigation into the incident. LPN #9 said that she was not aware of any head count of residents, and she had not participated in any elopement drills since the 5/01/25 incident. On 5/08/25 at 3:10 PM an interview with CNA #9 revealed that on 5/01/25 at approximately 3:15 PM he had gone out to his car, which was parked in the first parking spot to the right upon exit from the front door. CNA #9 stated, I looked at my car and saw someone sitting in the passenger seat and thought it wasn't my car, then I realized it was my car, and I opened the drivers' door and asked, 'Mam, you in my car?' and she opened the door and said she thought it was her brother's car. I went around and helped her out and took her inside. CNA #9 reported that the weather was clear, dry and moderate temperature. He said he was not aware of any head count of residents, and he had not participated in any elopement drills since the 5/01/25 incident. On 5/09/25 at 11:00 AM an interview with the Executive Director revealed that at approximately 3:30 PM on 5/01/25 he was notified by the Receptionist that Resident #5 left the facility unnoticed by staff and was outside unsupervised for approximately fifteen minutes and located in a staff members car. On 5/09/25 at 1:36 PM an interview with the facility Receptionist revealed she was familiar with Resident #5 because she had developed the behavior of packing her belongings in bags and coming to the front door prior to the 5/01/25 elopement. She stated that she had redirected Resident #5 several times, including on 5/01/25 with mixed results, explaining that sometimes the resident would return to her unit and sometimes she wasn't easily redirected and that CNAs had to come to the front and escort the resident back to her room. The Receptionist stated that on 5/01/25 around 3:00 PM she had taken a break and asked someone to fill-in for her but that she could not recall whom. She stated that she returned to her desk and shortly thereafter (could not recall time) CNA #9 came in with Resident #5 and said he had found her sitting in his car in the parking lot. She stated that the Executive Director was notified approximately five to ten minutes after CNA #9 and Resident #5 came back into the facility. On 5/09/25 at 3:00 PM observation revealed the first parking space on the right approximately fifty-five feet from the front entrance. Observation revealed one ambulance and six other vehicles traveling through the parking lot. The sidewalk which led from the facility's front porch/portico area, along the front of the parking spaces led to a busy four lane boulevard with a speed limit of thirty-five miles per hour and no cross walks; observation revealed one hundred twenty-five (125) vehicles traveling on the boulevard between 3:00 PM and 3:05 PM. Record review of the local weather history according to WWW.Wunderground, Copyright The Weather Channel, for the facility for 3:00 PM on 5/01/25 revealed the temperature was eighty-one degrees Fahrenheit, with zero precipitation, eight mile per hour winds and partly cloudy. On 5/12/25 at 4:26 PM during a telephone interview with the former DON revealed that she confirmed that she became aware that Resident #5 had exited the facility unnoticed and unsupervised on 5/01/25 at approximately 3:15 PM when CNA #9 escorted the resident back into the facility. She said there was no head count done to confirm the safety of other residents, and said she was not aware of any elopement drills or initiation of missing resident protocol. She confirmed that the care plan for Resident #5 had not been updated for wandering or exit seeking behaviors prior to the elopement. Removal Plan - IJ The facility was informed by state agency on 05/09/2025 at 5:30 PM of 5 immediate jeopardies. The state agency provided the facility with IJ template for F656, F600, F609, F610 and F689. On 05/01/2025, Resident #1 exited the facility unaccompanied and unnoticed and sitting in a staff member's car with no supervision until the resident was found by staff approximately 15 minutes later. The facility failed to implement a care plan with interventions when Resident #1 exhibited behavioral changes that included wandering and exit seeking and a history of altered mental status. The facility also failed to report the allegation of neglect within the required time frame and complete a thorough investigation. On May 1. 2025. at approximately 2:45-3 :00 PM, a CNA walked to his car on his break and noticed a resident sitting in his passenger seat. The CNA immediately told the resident that she has to come back inside. Calmly and without hesitation, the resident stated ''okay. The CNA walked the resident back inside the building, notified the front desk, and walked the resident to the sitting area on the unit The CNA also let Resident (Proper Name) nurse know what happened. The front desk notified the Administrator and the DNS. The Resident was assisted to her room by the evening shift Charge Nurse. A skin assessment was completed by the DNS with no negative findings. Vital signs were obtained. Nurse Practitioner and Sister of Resident# 1 was notified. New orders received by the Nurse Practitioner to included to apply wanderguard signaling device and consult psych services. Resident was also seen by the Physician on 05/01/25 and new orders were received for UA with C&S and Novolog sliding scale change. Resident was also seen by the Psych NP on 05/02/25 and placed 1: 1. An interview with Resident (Proper Name) on 05/01/25 who stated that she was going outside to wait on her brother, noticed a car that looked like her brother's and got in on the passenger side to wait until he signed her out. She stated that she exited the facility with other people and that her brother normally comes to take her out. Corrective Actions: The [NAME] President in-serviced the Social Services Department on 05/10/25 on ensuring that care plans and interventions are implemented for Residents with behavioral changes that verbalizing to leave the facility, exit seeking, wandering and packing belongs should be immediately assessed and elopement precautions implemented. On 05/10/25 The Executive Director notified the Mississippi Department of Health of the incident regarding Resident # 1 exiting the facility unaccompanied and unnoticed by staff. On 05/10/25 an audit was completed for all 18 Residents who were determined to be at risk for elopement risk to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses. On 05/10/25 a sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent Residents from leaving the facility without staff knowledge. The Executive Director and Director of Nurses reinterviewed Resident# 1 on 05/10/25. Resident# 1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not recall how many people she followed or give a decription. Letters were mailed to family members on 05/10/25 by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the leaving the facility. The Receptionist who vacated the front desk on 05/01/25 was in-serviced on 05/10/25 by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. In addition to all routine staff who [NAME] the receptionist area was in-serviced on 05/10/25 by the Executive Director. 100% audit of elopement binders were conducted on 05/10/25 by the Social Service Department to ensure the binders information was reflective of all Residents who are deemed as elopement risk. An Emergency Quality Assurance Committee was held on 05/10/25 with the following staff in attendance: [NAME] President, Executive Director, Regional Director of Clincial Services, Director of Nurses (2) Assistant Executive Directors, Social Service Director, (2) Social [NAME] vice Assistants and Medical Director. The IP nurse was present by phone. The facility completed all actions to remove the Immediate Jeopardies on 5/10/25 and alleges the IJ was removed on 5/11/25. On 5/12/25, SA validations were made onsite during the complaint investigation through interviews and record reviews that all corrective actions had been taken by the facility to remove the IJ and the IJ was removed on 5/11/25, prior to exit.

Based on interviews, record review and facility policy review, the facility failed to provide appropriate care and services for Resident #6's nephrostomy tube. Specifically, the facility did not perform or document any nephrostomy tube dressing changes or flushes since admission, creating a potential for infection due to improper device care. This deficient practice affected Resident #6, one (1) of two (2) nephrostomy appliances in the building. Findings include: Record review of facility policy Weekly Skin Audit Policy: A Skin audit will be documented on residents weekly. Any identified skin conditions will be documented and treatment initiated. Responsibility director of nursing, licensed nurses, medical records. Procedure: 1. Every resident will have a head-to-toe skin evaluation performed and documented on a weekly basis, the evaluation will be documented electronically or on a weekly scan audit form. 5. Treatment will be initiated per the physician's orders. Record review of the Mississippi Attorney General Nurse Review revealed a complaint received on 08/05/2024. The complainant, from (Proper Name of Local Hospital), reported that Resident # 6 was transferred from (Proper Name/Address of Facility). The allegation stated that upon presentation to the emergency room , the attending physician noted that the resident's urostomy dressing had not been changed in 14 days. No specific date of the incident was provided in the complaint. Based upon review of the documents submitted, the allegations of criminal abuse or neglect could not be substantiated. However, the review indicated concerns regarding the quality of care Resident # 6 received. It was recommended that the matter be reported to the Mississippi State Department of Health for further investigation. Record review of Resident #6 admission record revealed was admitted to the facility on [DATE] with multiple diagnoses, including a urinary obstruction that required a nephrostomy tube (a tube inserted into the kidney to drain urine). The hospital discharge records and admission notes indicated the presence of a nephrostomy tube. No physician orders for specific nephrostomy tube care (such as flushing the tube or changing the dressing) were noted upon admission, and no initial care plan addressing the nephrostomy tube was developed at that time. Record review of Resident #6's clinical record from admission through the survey date (May 2025) revealed no documentation of any nephrostomy tube dressing changes or flushes. There were no nursing notes or treatment records indicating that the nephrostomy site dressing had been changed or that the tube had been flushed to maintain patency. On 5/08/25 at approximately 11:30 AM, an interview was conducted with an RN (Registered Nurse) responsible for Resident #6's unit. The RN stated that she had not changed the nephrostomy tube dressing or flushed the tube since the resident's admission. She explained that I didn't have any specific orders or schedule for the nephrostomy tube care, and she assumed that perhaps the wound care nurse or urology provider was managing it. The RN confirmed that no documentation existed in the resident's chart for any dressing change or flush and acknowledged it should have been done; we normally would at least change the dressing weekly. She expressed concern that not performing these care routines could lead to infection or tube blockage. On 5/08/25 at 2:15 PM, Licensed Practical Nurse (LPN) #5 was interviewed. LPN #5 had frequently cared for Resident #6. She stated that she was not aware of any care plan instructions or physician orders regarding the nephrostomy tube. She confirmed that during her shifts she only monitored the site visually and would address it if it looked red or leaking, but otherwise did not perform routine maintenance. LPN #5 agreed that routine care (like dressing changes and flushes) should be in place to prevent complications and acknowledged that no such guidance or documentation was present for Resident #6. On 5/09/25 at 10:00 AM, an interview was conducted with the Director of Nursing (DON) regarding Resident #6's nephrostomy care. The DON stated that it is the facility's expectation and standard practice that any resident with an invasive device (such as a nephrostomy tube) has appropriate physician orders and nursing care routines. This includes regular dressing changes (at least weekly or more often if soiled) and periodic flushing of the tube as per physician orders or protocol, with each instance documented in the treatment record. Upon reviewing Resident #6's chart, the DON confirmed the lack of orders and documentation for nephrostomy care. She acknowledged that we should have been flushing that tube and changing the dressing on a schedule and documenting it every time. The DON described this as a failure in care and stated that staff should have contacted the physician or urology specialist upon admission to obtain orders for care if none were given. She agreed that not providing these services posed an infection control risk to the resident. On 5/09/25 at 11:00 AM, the facility's Medical Director was interviewed about Resident #6's nephrostomy tube management. He stated that a nephrostomy tube requires routine care and monitoring to prevent complications. The Medical Director expected the nursing staff to notify him or the consulting urologist if specific orders were needed for maintaining the tube. He expressed concern upon learning that no flushing or dressing changes had been done. The Medical Director said, According to standard care practices, a nephrostomy tube dressing should be changed regularly (e.g., at least weekly or when soiled) and the tube flushed as ordered to prevent blockage and infection. The absence of documentation suggested that these care tasks were not being performed or not recorded. He confirmed that the facility failed to follow professional standards of practice in this case, as nursing staff should proactively ensure all devices are cared for even if initial orders are missed.

Based on observation, interview, record review, and facility policy review, the facility failed to provide necessary care and services and respond appropriately to changes in a resident's condition for one (1) of four (4) sampled residents (Resident #1), when wounds were identified and treated by the dialysis clinic on 4/16/25 and the facility was notified, but failed to assess or initiate treatment until 4/21/25, resulting in a delay in care and placing the resident at risk for a worsening wound condition and infection. Findings include: A review of the facility's policy, Weekly Skin Audit, dated 11/17, revealed, .A skin audit will be documented on residents weekly. Any identified skin conditions will be documented and treatment initiated .Procedure: 1. Every resident will have a head-to-toe skin evaluation performed and documented on a weekly basis. The evaluation will be documented electronically or on the weekly skin audit form . A review of the facility's policy, Preventative Skin Care, dated 01/15, revealed: It is the practice of this facility to provide routine preventive skin care. This policy will serve as a guide to facilitate staff with regard to clinically acceptable techniques to be applied for skin care prevention .Procedure .4. Provide preventative skin care to all residents. The following interventions should be considered for incorporation into residents' care plans (this is not an all-inclusive list): a. Keep skin clean, dry, and cleansed at the time of soiling and at routine intervals .d. Moisturize skin with lotion to keep skin soft and pliable, giving special attention to participate in prevention . On 04/21/25 at 10:35 AM, during an interview with Registered Nurse (RN) #2 and RN #1 at the dialysis center, RN #2 explained that she was contacted by a staff nurse who had performed a routine foot check on Resident #1. She stated that the resident's sock on the right foot was visibly soiled with drainage and adhered to his great toe and second toe. Upon removal, skin was noted to be missing in two areas, the toes showed black discoloration, and the upper foot was covered with a significant amount of dry, dead skin. RN #2 stated that the pressure areas were cleaned, Betadine was applied, and a non-adhesive bandage was placed over the wounds. She reported that the nursing facility was notified, and the nurse assigned to Resident #1 was informed that the resident required follow-up from the facility's wound care team. RN #2 stated that the nurse at the facility indicated she would contact the wound care physician to evaluate the resident. RN #1 confirmed that she also received a report that wounds with necrotic tissue had been identified during the foot check and interviewed Resident #1, who reported that staff at the facility changed his socks approximately every two weeks, bathed him once per week, and changed his incontinent briefs two to three times daily. RN #1 stated that the concern was reported to the State Agency (SA) and that she and the charge nurse (CN) maintained communication with the facility. She added that after dressing the wounds, the CN placed marked gauze inside the resident's sock in order to assess whether the bandages and socks would be changed prior to the resident's next dialysis visit. On 04/21/25 at 11:00 AM, during an interview, Resident #1 stated that he typically receives bed baths once a week and that his incontinent brief is changed two to three times a day. He acknowledged that on 04/16/25, the nursing staff at the dialysis unit removed his sock and the sock had to be soaked so it could be removed. Resident #1 further acknowledged that the dialysis staff informed him of a possible wound and advised him to follow up with the wound care nurse at his facility. He reported that no one from the facility had checked the dressing on his foot, nor had a doctor evaluated it. He stated that the only dressing changes performed were by the dialysis facility. On 04/21/25 at 11:15 AM, during an observation at the dialysis facility, Resident #1 had dry scaly feet, thickened dark toenails, and a bandage across the toes dated 04/18/25. Further observation revealed a discolored area on the great toe and missing skin on the second toe. The dialysis nurse confirmed that the bandage was the same one placed on 04/18/25 by her staff. The dialysis nurse stated that although the socks had been changed, the dressing had not been replaced. On 04/21/25 at 12:23 PM, during an interview with the facility's Unit Manager, Licensed Practical Nurse (LPN) #1, she stated she had not been informed of any foot issues concerning Resident #1. A review of the 24-hour nursing reports dated 04/16/25 through 04/18/25 revealed no documentation of any communication from the dialysis center regarding foot concerns. Further review of the electronic medical record showed no evidence that a provider had been notified about the resident's foot condition, nor was there documentation of any nursing interventions implemented to address or safeguard the resident's foot health. LPN #1 stated that concerns of this nature should have been documented in the 24-hour report, communicated to the physician in real time, and appropriate medical orders obtained. On 04/22/25 at 09:30 AM, during an interview with the Licensed Practical Nurse (LPN) #2, who serves as the wound care nurse for Resident #1, it was revealed that the resident's care plan directed daily foot checks for open areas, sores, blisters, etc. LPN #2 stated she was not aware of any calls from an outside agency advising of issues regarding the resident's foot. She confirmed that she completed the body audits 04/16/25 after the resident had returned from dialysis and acknowledged that there was no mention of the wounds documented. After reviewing the dialysis center's documentation dated 4/16/25 regarding Resident #1's wounds, she stated she could neither confirm nor deny that she actually completed the skin check. On 04/22/25 at 9:56 AM, during an interview with the facility's Wound Care Physician and LPN #3, they stated they were contracted specialists responsible for providing wound care services to the facility. The Wound Care Physician reported he received a new consultation order for Resident #1 on 04/21/25 at 2:52 PM and stated he had not previously assessed or treated Resident #1 prior to that date. He explained that he first evaluated Resident #1 between 6:00 AM and 7:00 AM on 04/22/25. During the assessment, he described a macule on the resident's great toe as a dry, discolored, palpable area that was not open and had no depth. He stated he also assessed the resident's second toe, which exhibited hyperpigmentation, potentially an early sign of ischemia (lack of blood flow), and described it as dry with darkened skin. The physician emphasized the importance of weekly body audits and stated that he had received consultation requests for other residents based on findings from nursing staff during these audits. He also noted that he had telehealth capabilities available to evaluate urgent concerns remotely and that he visited the facility in person at least once per week. On 04/22/25 at 10:00 AM, during an interview with the facility's Director of Nursing (DON), she acknowledged that staff failed to ensure appropriate wound care, monitoring, and follow-up actions were taken for Resident #1. The DON stated that although the dialysis staff notified the facility of concerns regarding potential skin breakdown and wounds, facility staff did not implement necessary interventions, notify the physician, or initiate appropriate care. She further explained that weekly body audits are conducted for all residents and are expected to include a thorough head-to-toe assessment. The DON stated that if the audits had been completed properly, the dressing applied by the dialysis center should have been identified, prompting immediate documentation, further assessment, and medical intervention. On 04/22/25 at 3:00 PM, during an interview with the facility's Licensed Nursing Home Administrator (LNHA), he stated it was his expectation that nursing staff promptly report any changes in a resident's condition to the resident's physician, the Director of Nursing (DON), and to himself, as appropriate. A record review of the Admission Record revealed the facility admitted Resident #1 on 10/4/2017 with current diagnoses including End Stage Renal Disease. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/12/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated he had severe cognitive impairment. A record review of the Clinical Notes Report from the dialysis center revealed on 4/16/25 at 11:25 (AM) RN #2 documented that Noted today that (Proper Name of Resident) sock on rt (right) foot had some drainage and the sock was stuck to his great toe and the second toe. Skin was missing in two areas. Color of toes are black in areas. Dead skin filled his sock. Foot very dry. Pressure areas cleaned and betadine applied with a non adhesive bandaid. (Proper Name of Nursing Facility) called and the nurse assigned to (Proper Name of Resident) was given this report and that he will need to be seen in their wound care department. She report she would get the wound care doctor to evaluate. On 4/16/25 at 11:48 (AM), RN #3 documented, .In between RT (right) toe and Second toe area is back. Skin breakdown noted to Rt Great Toe and Second toe. Pt sock was stuck to toes .On 4/16/25 at 13:22 (1:32 PM), RN #1 documented, .Rn and CN (Charge Nurse) have communicated with facility, facility states they will get wound care for patient, CN put marked gauze in patient's sock after dressing wounds to see if dressing and/or sock are changed at next visit . A record review of the Clinical Notes Report from the dialysis center revealed on 4/18/25 at 13:22 (1:32 PM), RN #2 documented, Noted today when this RN did a recheck on patient's right foot wound: same sock on foot, same gauge and bandage we applied on foot Wednesday 4/16/25 was discovered . On 4/18/25 at 13:38 (1:38 PM), RN #1 documented, CN checked patient's foot to see if marked gauze was still in sock or wound dressing was changed. The marked gauze was still in patient's sock and dressing had not been changed. CN changed dressing again and placed new marked gauze, will recheck Monday. A record review of the facility's Weekly Skin assessments revealed there was no documentation of any wounds to the right foot on 4/16/25 at 2:34 PM, which was after Resident #1 had returned from dialysis in which he received treatments to the right foot wounds. The assessment was completed by LPN #2. A record review of the Surgical Note, dated 4/22/25, for Resident #1 revealed a Wound Location of Right great toe that measured 0.4 centimeters (cm) x 0.4 cm x 0.0 cm wound, area 16 cm^2. Another Wound Location of right second toe that measured 5.0 cm x 2.0 cm x 0.0 cm wound, area 10 cm^2.

Based on observation, interview, record review, and facility policy review, the facility failed to implement the resident's care plan interventions related to daily skin and foot assessments for one (1) of four (4) residents reviewed for care planning, Resident #1, which resulted in the facility not identifying or addressing developing wounds on the resident's foot, which remained untreated by facility staff for five (5) days after being discovered and treated at the dialysis center. Findings include: Record review of facility Comprehensive Person-Centered Care Plan policy dated 01/2025 revealed .Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences and goals that will identify how the interdisciplinary team will provide care .Procedure .6. Staff approaches are to be developed for each problem/strength/need .Assigned disciplines will be identified to carry out the intervention . A record review of the Care Plan Report for Resident #1 revealed a Focus of (Proper Name) has a dx (diagnosis) of Diabetes Mellitus with interventions including Check all of body for breaks in skin and treat promptly . and Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness, both initiated on 10/15/24. A record review of the Clinical Notes Report from the dialysis center revealed on 4/16/25 at 11:25 (AM) RN #2 documented that Noted today that (Proper Name of Resident) sock on rt (right) foot had some drainage and the sock was stuck to his great toe and the second toe. Skin was missing in two areas. Color of toes are black in areas. Dead skin filled his sock. Foot very dry. Pressure areas cleaned and betadine applied with a non adhesive bandaid. (Proper Name of Nursing Facility) called and the nurse assigned to (Proper Name of Resident) was given this report and that he will need to be seen in their wound care department. She report she would get the wound care doctor to evaluate. A record review of the facility's Weekly Skin assessments revealed there was no documentation of any wounds to the right foot on 4/16/25 at 2:34 PM, which was after Resident #1 had returned from dialysis in which he received treatments to the right foot wounds. The assessment was completed by LPN #2. During an observation at the dialysis facility on 04/21/25 at 11:15 AM, Resident #1 had dry scaly feet, thickened dark toenails, and a bandage across the toes dated 04/18/25. Further observation revealed a discolored area on the great toe and missing skin on the second toe. The dialysis nurse confirmed that the bandage was the same one placed on 04/18/25 by her staff. The dialysis nurse stated that although the socks had been changed, the dressing had not been replaced. During an interview on 04/22/25 at 09:30 AM, Licensed Practical Nurse (LPN) #2, who serves as the wound care nurse for Resident #1, it was revealed that the resident's care plan directed daily foot checks for open areas, sores, blisters, etc. LPN #2 stated she was not aware of any calls from an outside agency advising of issues regarding the resident's foot. She confirmed that she completed the body audits 04/16/25 after the resident had returned from dialysis and acknowledged that there was no mention of the wounds documented. After reviewing the dialysis center's documentation dated 4/16/25 regarding Resident #1's wounds, she stated she could neither confirm nor deny that she actually completed the skin check. During an interview on 04/22/25 at 9:56 AM, the facility's Wound Care Physician and LPN #3, they stated they were contracted specialists responsible for providing wound care services to the facility. The Wound Care Physician reported he received a new consultation order for Resident #1 on 04/21/25 at 2:52 PM and stated he had not previously assessed or treated Resident #1 prior to that date. He explained that he first evaluated Resident #1 between 6:00 AM and 7:00 AM on 04/22/25. During an interview on 04/22/25 at 10:00 AM, the facility's Director of Nursing (DON), she acknowledged that staff failed to implement interventions related to Resident #1's care plan regarding skin assessments and foot checks. The DON stated that although the dialysis staff notified the facility of concerns regarding potential skin breakdown and wounds, facility staff did not implement necessary interventions. The DON stated that if the audits had been completed properly, the dressing applied by the dialysis center should have been identified, prompting immediate documentation, further assessment, and medical intervention. During an interview on 04/22/25 at 3:00 PM, facility's Licensed Nursing Home Administrator (LNHA), he stated it was his expectation that staff implement a resident's care plan and promptly report any changes in a resident's condition to the resident's physician, the Director of Nursing (DON), and to himself. A record review of the Admission Record revealed the facility admitted Resident #1 on 10/4/2017 with current diagnoses including End Stage Renal Disease. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/12/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated he had severe cognitive impairment.

Based on observation, interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan intervention related to the removal of a pressure dressing from a dialysis access site for one (1) of four (4) sampled residents. Resident #4. Findings included: A review of the facility's policy, Comprehensive Person-Centered Care Plans, dated 1/2025 revealed, .Each resident will have a person-centered plan of care to identify problems, needs strengths, preferences, and goals that will identify how the interdisciplinary team will provide care .6 Assigned disciplines will be identified to carry out the intervention . A record review of the Care Plan Report for Resident #4 revealed Focus (Proper Name) is at risk for complications .receives hemodialysis .Interventions .Remove pressure dressing four hours post dialysis unless specified by dialysis communication sheet . The intervention was dated 10/15/24. The assigned discipline was listed as Licensed Practical Nurse/Registered Nurse (LPN/RN). On 04/01/25 at 11:41 AM, during an observation with the Unit Manager, Resident #4 was observed to have a bandage still in place on his left arm from his dialysis treatment on 03/31/25. The Unit Manager confirmed the dressing had not been removed and should have been taken off the previous night. A record review of the Order Summary Report revealed Resident #4 had a Physician's Order, dated 8/1/2024, to Remove pressure dressing 6 hours to left forearm dialysis shunt site after returning from dialysis . A record review of the Admission Record revealed the facility admitted Resident #4 on 10/04/2017 with diagnoses including Dependence on Renal Dialysis. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/12/25 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident was cognitively impaired. During an interview on 4/1/25 at 12:10 PM, the Director of Nursing (DON) confirmed the staff failed to remove the bandage. The DON also confirmed the staff failed to follow the care plan. The DON stated she expects the staff to follow the residents' plan of care. During an interview on 4/1/25 at 12:25 PM, with LPN #2 confirmed the facility failed to follow the comprehensive care plan by not removing the residents' bandage after dialysis. LPN #2 stated the care plan guides the residents plan of care. The staff are expected to follow the care plan. During an interview on 4/1/25 at 1:40 PM, with the Administrator he stated he did not know the residents' bandage was not being removed after dialysis. The Administrator stated he expects the staff to follow the physician's orders and the dialysis instructions. During a post survey phone interview with LPN #3 on 4/2/25 at 1:20 PM, she confirmed she failed to look at the care plan for Resident #4 regarding removing the pressure dressing.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure timely removal of a pressure dressing from a dialysis access site for one (1) of one (1) resident reviewed for dialysis services. Resident #4. Findings included: A review of the facility's Dialysis Information Update Transfer Policy, dated February 2019, revealed, Policy: A 'Dialysis Information Update Transfer form' is completed each time a resident receives outpatient dialysis. This ensures enhanced communication between the two facilities .Procedure .3. The bottom section of the form is completed by personnel responsible for the resident at the dialysis facility and returned to the nursing home with the resident .5. As applicable, any instructions related to the resident care received from the dialysis unit should be relayed to the appropriate facility staff .and followed up as indicated. A record review of the Order Summary Report revealed Resident #4 had a Physician's Order, dated 8/1/2024 Remove pressure dressing 6 hours to left forearm dialysis shunt site after returning from dialysis . A record review of the Dialysis Information Update Transfer Form revealed the following instructions written on the communication form to the facility: Remove pressure dressing at 1800 (6PM) dated 3/3/25, Remove compression dressings 4-6 hrs (hours) dated 3/7/25 and Remove compression dressings 4-6 hrs post tx (treatment) @ (at) 1900-2000 (7PM -8PM) dated 3/28/25. On 04/01/25 at 10:00 AM, during an interview with the dialysis nurse, she explained the facility fails to remove the residents' pressure dressings within four (4) to six (6) hours after returning from dialysis. She stated that she had educated the facility staff, Director of Nursing (DON), and Administrator about the importance of timely bandage removal to prevent complications such as clotting or stenosis, which could lead to unnecessary surgical procedures. She referred to the access site as the resident's lifeline. On 04/01/25 at 11:41 AM, during an observation with the Unit Manager, Resident #4 was observed to have a bandage still in place on his left arm from his dialysis treatment on 03/31/25. The Unit Manager confirmed the dressing had not been removed and should have been taken off the previous night. On 04/01/25 at 11:55 AM, during an interview, Resident #4 stated that he told the nurse to remove the bandage, but it was not removed. He explained that he could not remove the dressing himself due to being visually impaired. On 04/01/25 at 12:10 PM, during an interview, the Director of Nursing (DON) confirmed that the staff failed to remove the bandage. She stated she had only been at the facility for three (3) weeks and had not been aware this was a recurring issue. She explained she expected staff to follow both physician orders and instructions provided by the dialysis unit. On 04/01/25 at 1:40 PM, during an interview, the Administrator stated he was not aware that the bandages were not being removed after dialysis. He reported that he expected staff to follow all physician orders and dialysis instructions. A record review of the Admission Record revealed the facility admitted Resident #4 on 10/04/2017 with diagnoses including Dependence on Renal Dialysis. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/12/25 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident was cognitively impaired.

Based on observation, interview, record review, and facility policy review, the facility failed to meet current professional standards of care as evidenced by no physician order written for a resident who had an indwelling foley catheter for one (1) of eight (8) residents reviewed. Resident #5. Findings Included: Policy review of the facility policy titled PHYSICIAN ORDERS dated 1/25 (January 2025) revealed Orders received from a physician must be written on a hard script and signed by a physician. RESPONSIBILITY: All Licensed Nursing Personnel . During an observation on 3/04/25 at 5:50 PM, in the Unit 2 Dining Room revealed Resident #5 was seated in a wheelchair with a urine collection bag beneath the wheelchair, uncovered, with approximately eighty (80) milliliters of golden yellow urine visible in the collection bag. During an observation and interview on 3/06/25 at 11:20 AM, the Administrator confirmed the resident did not have a privacy/dignity cover on his urine collection bag for his urinary catheter. During an interview on 3/06/25 at 11:35 AM, Licensed Practical Nurse (LPN) #4 confirmed that Resident #5 did not have a cover on his urine collection bag to ensure the resident's dignity. She stated that she was not aware of catheter care or monitoring prior to 3/06/25. During an interview and observation on 3/06/25 at 2:35 PM, the Minimum Data Set (MDS) Nurse revealed she was not sure if Resident #5 had a catheter. Observation of the resident in the Unit 2 Dining Room with the MDS Nurse confirmed that Resident #5 had an indwelling catheter. She confirmed that there were no physician orders for a catheter for Resident #5. During an interview on 3/06/25 at 3:08 PM, Registered Nurse (RN) #1 who is the Unit 2 Unit Manager, stated that Resident #5 had the indwelling urinary catheter upon arrival at the facility on 1/15/25 and had the catheter in place since arrival. Record review of the Order Summary Report with active orders of 3/6/25 revealed the resident had no physician's order for a urinary catheter. Resident #5's orders included an order for Foley catheter care every shift with an order date and start date of 3/04/25. There were no other orders for the catheter noted. During an interview on 3/06/25 at 4:45 PM, the Director of Nurses (DON) stated that it was important for staff to identify the residents' needs and abilities at the time of admission and on an ongoing basis. She explained that the nurses used the Physician Orders, Care Plans, and Treatment Administration Record as a guide for providing resident care. She stated that the RN's, Unit Managers, and she supervised the care of residents and that she expected care to be provided in accordance with the residents' physician orders. She confirmed that Resident #5 had an indwelling catheter with no physician's order in his medical record for the catheter. During an interview on 3/06/25 at 5:30 PM, the Administrator confirmed that he expected each resident to be assessed upon admission with reconciliation of the visual assessment, physician orders, and diagnoses. The Administrator confirmed that meeting these expectations was necessary for care to be provided according to current standards of practice. Record review of the Admission Record for Resident #5 revealed the facility admitted the resident on 1/15/25. The resident had diagnoses of Chronic kidney disease, Neuromuscular dysfunction of the bladder and Prostatic hyperplasia. Record review of the 5-Day Minimum Data Set (MDS) for Resident #5 with an Assessment Reference Date (ARD) of 2/17/25 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment.

Based on observation, interview, record review, and policy review, the facility failed to develop and implement care plans for two (2) of eight (8) residents reviewed, Resident #5 and Resident #6. Findings Included: Policy review of the facility policy titled COMPREHENSIVE PERSON-CENTERED CARE PLANS dated 8/11 (August 2011) revealed POLICY: Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care . Resident #5 Record review of the comprehensive care plan revealed there was not a care plan developed related to catheter care for Resident #5. Record review of the comprehensive care plan revealed I am at risk for UTI's (urinary tract infections) and skin breakdown r/t (related to) bladder incontinence. Date Initiated 1/24/25 revealed there were no interventions that addressed the presence of an indwelling urinary catheter. Record review of comprehensive care plan included a new care plan initiated on 3/06/25 for The resident has Foley Catheter related to dx (diagnosis) of BPH (benign prostatic hypertrophy), with no mention of a collection bag cover. Observation on 3/04/25 at 5:50 PM, in the Unit 2 Dining Room revealed Resident #5 was seated in a wheelchair with a urine collection bag beneath the wheelchair, uncovered, with approximately eighty (80) milliliters of golden yellow urine visible in the collection bag. Observation and interview on 3/06/25 at 11:20 AM, with the Administrator in Resident #5's room the Administrator confirmed the resident did not have a privacy/dignity cover on his urine collection bag for his urinary catheter. On 3/06/25 at 11:35 AM, Licensed Practical Nurse (LPN) #4 confirmed that Resident #5 did not have a cover on his urine collection bag to ensure the resident's dignity. She stated that she was not aware of catheter care or monitoring prior to 3/06/25 because she was new to the facility. On 3/06/25 at 2:35 PM, an interview and observation with the Minimum Data Set (MDS) Nurse said she was not sure if Resident #5 had a catheter. Observation of the resident in the Unit 2 Dining Room with the MDS Nurse confirmed that Resident #5 had an indwelling catheter. The MDS Nurse confirmed that she had not noted an indwelling catheter at the time of the admission assessment on or around 1/15/25. She confirmed that Resident #5 needed a care plan to address his indwelling urinary catheter and that the care plan should include the provision of a collection bag cover to ensure the privacy and dignity of the resident. On 3/06/25 at 3:08 PM, during an interview, Registered Nurse (RN) #1 who is the Unit 2 Manager, stated that Resident #5 had the indwelling urinary catheter upon arrival at the facility on 1/15/25 and had the catheter in place since arrival. Resident #6 Record review of the care plan for Resident #6 revealed Focus: I have ADL (activities of daily living) self-care performance deficit r/t (related to) Dementia with behaviors .requires extensive to total dependence with ADL's .Interventions .Assist with ADL's as needed or as requested .Provide showers three (3) x weekly . On 3/05/25 at 12:00 PM, during an interview, Resident #6 reported that he needed a shower. He said he was not provided with a shower on 3/04/25 or 3/05/25 and could not recall the last time he was taken to the shower room. He stated, I need a shower, I don't want to just lay here and rot. He said he did not feel he should have to request to go to the shower because the staff had told him he was scheduled to go to the shower three times each week, so he felt they should already know. On 3/05/25 at 12:05 PM, during an interview, Certified Nurse Aide (CNA) #5 revealed Resident #6 was supposed to be assisted with a shower three times each week and upon request. She stated that she was assigned to the care of Resident #6 and had not taken Resident #6 to the shower on Thursday, 3/05/25, because his showers were scheduled for Monday, Wednesday, and Friday on the Weekly Shower List. She stated that she was not assigned to the daily care of Resident #6 on Wednesday, 3/04/25. She was unable to determine the last time Resident #6 was taken to the shower. She stated that the resident was dependent on staff for bath/shower activities and able to transfer with a mechanical lift into a shower chair. She stated that she was not aware of Resident #6 refusing care. On 3/06/25 at 2:35 PM, an interview and observation with the MDS Nurse revealed that she and the other MDS nurses developed care plans for the residents and that any nurse could update the care plans as needed based on changes to the resident's condition. She stated the purpose of care plans was to provide instructions for taking care of residents and that the development and implementation of care plans were very important. She explained that care plans were entered into the computer software and selected care instructions were pulled over into the Kardex, which all CNAs had access to via facility computers available to them. She confirmed that on 3/06/25, she had removed the specific days from the care plan for Resident #6 and left the care plan intervention as Provide Showers three (3) times weekly. On 3/06/25 at 4:45 PM, during an interview, the Director of Nurses (DON) confirmed that Resident #5 had an indwelling catheter and no care plan for catheter care. She confirmed that a discrepancy between the resident's care plan and the Weekly Shower List may have caused Resident #6 to miss scheduled showers. On 3/06/25 at 5:30 PM, during an interview, the Administrator confirmed the expectation that each resident be assessed upon admission, with reconciliation of the visual assessment, physician orders, and diagnoses. He confirmed that he expected individual care plans for each resident to be developed and implemented based on resident needs and abilities.

Based on observation, record review, facility policy review, and interviews, the facility failed to provide necessary care for hygiene, bathing, and grooming for two (2) of eight (8) sampled residents, Resident #4 and Resident #6. Findings Included: Record review of the facility policy titled SHAVING-MALE AND FEMALE dated 8/11 (August 2011) revealed the policy stated, POLICY: Residents will be free of facial hairs - both male and female. If the resident is alert and oriented and requests not to be shaved, this will be noted in the Care Plan. RESPONSIBILITY: All Nursing Assistants monitored by Charge Nurse. Record review of the facility policy titled BATH/SHOWER-DEPENDENT dated 8/11 (August 2011) revealed, POLICY: A bath (shower/tub) for cleanliness and comfort is scheduled at least weekly for each resident. RESPONSIBILITY: Nursing Assistants or Licensed Nurses monitored by Charge Nurse . Resident #4 On 3/04/25 at 3:10 PM, observation revealed Resident #4 was seated in the Unit 1 Dining/Activity Room across from the nurses' station with a long white mustache and beard. The resident was pulling his mustache into his mouth with his tongue. His mustache hair was long enough to curl over his top lip into his mouth. He reported that the long mustache hairs were too long and were bothering him. He said they interfered with his eating. He said that he wished someone would trim them for him. On 3/04/25 at 3:20 PM, an interview with Certified Nurse Aide (CNA) #1, CNA #2, CNA #3, and CNA #4 revealed all reported that grooming was traditionally done during AM and PM care, with shaving/unwanted hair removal done during showers, but that Activities of Daily Living (ADL) and grooming care could be provided at any time. On 3/04/25 at 3:35 PM, an interview with Licensed Practical Nurse (LPN) #2 and LPN #3 revealed nurses and Unit Managers supervise the care of residents to ensure care is provided according to the resident needs and abilities. Resident #6 During an interview on 3/04/25 at 4:30 PM, Resident #6 revealed the resident reported that he needed a shower. He stated that he was scheduled to have a shower three (3) times each week and had not been taken to the shower for at least two (2) weeks. During an interview on 3/05/25 at 12:00 PM, Resident #6 reported that he needed a shower. He said he was not provided with a shower on 3/04/25 or 3/05/25 and could not recall the last time he was taken to the shower room. He stated that the nursing staff had told him that he was not going to the shower because the facility no longer had a shower bed. He stated, I need a shower, I don't want to just lay here and rot. He said he did not feel he should have to request to go to the shower because the staff had told him he was scheduled to go to the shower three times each week, so he felt they should already know. During an observation and interview on 3/05/25 at 12:05 PM, CNA #5 revealed that Resident #6 was supposed to be assisted with a shower three times each week and upon request. She explained that the CNAs also used the printed Weekly Shower List located at the nurses' station as a guide for which residents were provided with showers each day. She stated that she was assigned to the care of Resident #6 and had not taken Resident #6 to the shower on Thursday, 3/05/25, because his showers were scheduled for Monday, Wednesday, and Friday on the Weekly Shower List. She stated that she was not assigned to the daily care of Resident #6 on Wednesday, 3/04/25. She was unable to determine the last time Resident #6 was taken to the shower. She stated that the resident was dependent on staff for bath/shower activities and able to transfer with a mechanical lift into a shower chair. During an observation and an interview on 3/06/25 at 4:30 PM, with the Administrator and LPN #1 revealed there was one (1) black and white shower bed labeled by the manufacturer with a five hundred (500) pound weight limit and one (1) shower chair in the Unit 1 shower room, which were available for all staff/resident use. LPN #1 stated that Resident #6 could use either the shower bed or shower chair. She confirmed the resident was to receive a shower every Tuesday, Thursday, and Saturday, and the printed Weekly Shower List at the nurses' station stated that the resident was to receive a shower every Monday, Wednesday, and Friday, but that regardless, the resident was to be provided with a shower three (3) times weekly and as requested. The Administrator stated the shower bed was stored in the Unit 1 shower room because there were more residents who required it, but that it was available for all units' use. During an interview on 3/06/25 at 4:45 PM, the Director of Nurses (DON) stated that it was important for staff to identify the residents' needs and abilities at the time of admission and on an ongoing basis and that she expected care to be provided. During an interview on 3/06/25 at 5:30 PM, the Administrator confirmed that he expected each resident to be assessed upon admission with reconciliation of the visual assessment, physician orders, and diagnoses. He confirmed that he expected care to be provided.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents were treated in a dignified manner when Resident #5's urinary catheter bag was left uncovered with urine visible in a public common area for one (1) of eight (8) residents reviewed. Resident #5 Findings Included: Policy review of the facility-provided Resident [NAME] of Rights with Review Date 1/15 (January 2015) revealed the document stated, It is the objective of the Facility to herein forth the rights of Residents so as to assure the protection and preservation of dignity . Facility Residents shall have the right to: 1. Privacy in treatment and personal care .26. Treated with consideration, respect, and full recognition of his/her dignity and individuality. Observation on 3/04/25 at 5:50 PM, in the Unit 2 Dining Room revealed Resident #5 was seated in a wheelchair with a urine collection bag beneath the wheelchair, uncovered, with approximately eighty (80) milliliters of golden yellow urine visible in the collection bag. Observation and interview on 3/06/25 at 11:20 AM, with the Administrator in Resident #5's room, the Administrator confirmed the resident did not have a privacy/dignity cover on his urine collection bag for his urinary catheter. Observation and interview on 3/06/25 at 11:35 AM, Licensed Practical Nurse (LPN) #4 confirmed that Resident #5 did not have a cover on his urine collection bag to ensure the resident's dignity. She stated that she was not aware of catheter care or monitoring prior to 3/06/25 because she was new to the facility. Observation and interview on 3/06/25 at 2:35 PM, with the Minimum Data Set (MDS) Nurse revealed she was not sure if Resident #5 had a catheter. Observation of the resident in the Unit 2 Dining Room with the MDS Nurse confirmed that Resident #5 had an indwelling catheter. The MDS Nurse confirmed there should be a collection bag cover to ensure the privacy and dignity of the resident. In an interview on 3/06/25 at 3:08 PM, Registered Nurse (RN) #1, who is the Unit 2 Manager, stated that Resident #5 had the indwelling urinary catheter upon arrival at the facility on 1/15/25 and had the catheter in place since arrival. Record review of the Admission Record for Resident #5 revealed the facility admitted the resident on 1/15/25. The resident had diagnoses of Chronic kidney disease, Neuromuscular dysfunction of the bladder and Prostatic hyperplasia. Record review of the 5-Day MDS with an Assessment Reference Date (ARD) of 2/17/25 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment.

Amendment 3/24/2022 Upon secondary review with CMS (Centers for Medicare and Medicaid Services) Regional Office staff and State Quality Assurance, the State Survey Agency (SSA) determined the scope and severity of the Immediate Jeopardy to be K, Past Non-Compliance which began on 1/20/2022 and was removed on 1/22/2022, prior to SSA entry on 1/26/2022. Based on observation, interview, record review and facility policy and procedure review the facility failed to provide Resident #1 (Res #1) with the supervision that he required to prevent accidents, hazards of a facility fire, which caused Res #1 severe [CONDITION(S)] and hospitalization , with numerous surgeries of skin grafts. Resident #1 received more than minimal harm from the facility's lack of supervision. Res #1 was severely burned over his upper body when he used a cigarette lighter while in his bed wearing oxygen. Res #1 set himself on fire along with his bed linens, mattress, oxygen tubing, mask, oxygen concentrator, and the privacy curtain. There were 213 residents living in the facility at the time of the fire. This fire affected one (1) of four (4) units in the facility, Unit 4. Resident #1 was the only one (1) of 213 Residents to suffer serious harm from the fire on 1/20/2022. On 01/27/2022 at 10:30 A.M. the facility notified of an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was provided the IJ Template for F689=J, Past Non-Compliance, for failure to prevent Accidents Hazards and lack of Supervision, which caused more than minimal harm to Res #1 when he started a fire in his bed while wearing oxygen. Res #1 had [CONDITION(S)] over his body and was placed in the hospital, where he remains to date. Based on the facility's implementation of a Corrective Action Plan as of 01/20/2022 and 01/21/2022, prior to the State Agency (SA) entering the facility on 01/26/2022, the SA determined that the IJ and the Substandard Quality of Care (SQC) was Past Non-Compliance (PNC) and the IJ was removed as of 01/22/2022. Findings include: Review of the facility policy and procedure entitled Smoking, dated 11/17 revealed, .Procedure: 1 Residents that are evaluated as independent with smoking: (and/or without history of smoking incidents; needing no interventions) will be permitted to keep and maintain their own smoking materials (i.e. cigarettes, e-cigarettes), and may smoke in designated areas without limitations . Review of the Smoking Policy Amendment revealed, Effective 01/21/2022, Residents will not be allowed to possess lighters or matches. Wall mounted cigarette lighters are present in the designated smoking area (courtyard) Independent Residents will continue to be allowed to keep their cigarettes. Nursing staff will monitor all Residents' rooms every shift to ensure no lighters are present. Review of the facility policy and procedure dated 7/18 entitled: Accident and Incidents Hazard Reports revealed: Employees shall be aware of potential hazards and all accidents or unsafe practices shall be reported. Employees shall understand how to accomplish their job(s) safely. New employees are to be assisted in developing safe practices. Interview on 1/26/22 at 8:50 AM, with the Facility Administrator (ADM) revealed that Res. #1 set his bed and his bed linen on fire as a result of playing with a cigarette lighter. 911 was called to the facility and upon the arrival of the Fire Department the staff of the facility had the fire put out and had begun assessing all residents on the unit and had begun assessing Res #1. The ADM stated that she was contacted immediately of the fire by the facility staff. The ADM arrived at the facility at approximately 10:00 P.M. The ADM stated that the EMT's (Emergency Medical Technologists) took over the assessment of Res #1 and transported Resident #1 to the local ER (emergency room ) located across the street from the facility. The ER transferred Res. #1 to a burn unit for specialized care to the [CONDITION(S)] to his upper body. She stated that she self-reported the facility fire and the [CONDITION(S)] to Res #1 to the State Agency (SA) and to the Attorney General (AG) office on 1/20/22 at 10:15 P.M. The ADM stated that the Responsible Party (RP) of Res #1 was also contacted and given a report as to what had happened. The ADM stated that when she talked to the RP, he apologized to her and told her that Res #1 had been involved in another episode of fire from a cigarette lighter and oxygen several years ago. The RP said to ADM I am so sorry he did this. The ADM stated that the burned bed and linens have been disposed of and are no longer at the facility for viewing. She stated that the room that contained the fire has been cleaned and has been closed off and no other residents were placed in that room since the fire of 1/20/22. Interview and observation on 1/26/22 at 9:30 AM, with the Regional Vice President (VP) revealed that she had been notified of the fire in the facility, caused by Res #1 playing with a cigarette lighter. The VP stated that she arrived at the facility at approximately 10:00 P.M. and began investigating the fire and in-servicing the staff and residents. She stated that the Quality Assurance Team (QA) met on 1/21/22 and immediately changed the facility smoking policy and re-educated all staff and all residents on the new policy changes. The QA team changed the policy to read that no resident may have possession of lighters and/or matches. The VP stated that all resident smokers were re-assessed on 1/21/22 and care plans updated. The VP stated that the QA team went room to room and did complete room checks and confiscated any and all lighters and matches that were found. The QA team and all working staff will conduct daily surveillance of all areas and resident rooms each morning. When lighters and matches are found they will be taken and given to the Social Worker and/or the unit supervisor to keep for the resident. The VP stated that since the fire in the facility on 1/20/22, letters were sent out to all RP's concerning the changes in the smoking policy and that no resident no matter what their cognitive status, will be allowed to possess lighters and/or matches. The VP had pictures on her cell phone, that she showed to surveyor, of the bed that Res #1 set on fire. The bed and bed linen were very badly burned. In the pictures, that the VP shared, it appeared that the top portion of the bed had a circle of black ashes approximately 16-20 inches in diameter and possibly 1-2 inches deep. The mattress stuffing and the bed linens were black with fire markings and ashes. The VP stated that Res #1 had suffered [CONDITION(S)] to the upper portion of his body, on his chest, left arm, face, and back. The VP stated that Res #1 remained calm and talking to staff during the assessing process after the fire on the night of 1/20/22. She stated that all staff and all residents had been re-inserviced and re-educated on the changes to the Smoking Policy and all corrective actions had been completed prior to the surveyors entering the facility on 1/26/22. Record review of the facility's Nursing Notes dated 1/21/2022 revealed, At 2139, I (name of LPN#4) received a call from (name of LPN) that resident (Res #1) was on fire. I had been on break for 10 minutes when I received the phone call. I rushed back to the facility and made it back within 5 minutes. At that time, resident (Res #1) was up in W/C (wheelchair) and sitting at the door towards the back of the facility with the fire department at resident's side. (Name of LPN) was also at resident's side monitoring his 02 (oxygen) SATS (Saturation) and his oxygen. Resident was receiving 2L (2 liters) via face mask and his SATS were stable at 93%. Resident's back had been severely burned, upper back looked yellow in color. His left arm was black all around his elbow, above and below it. When resident was asked what happened he said he flicked a lighter and then flames sparked and then he was on fire. Resident wears 02 at 2L (2 liters) via nasal cannula at all times when in his room. Resident's RP, (name of brother) was notified around 2200. (Name of RP) response was I'm so sorry that he did that. I'm glad that all of y'all are okay. He's had this happen before when he lived at home. Thank you so much for calling me. Resident was sent out at 2235 via (name of ambulance company) to the hospital. Interview and observation on 1/26/22 at 10:10 AM, with the Director of Maintenance (DM) revealed that the fire was caused by Res #1 playing with a cigarette lighter as he laid in bed on 1/20/22 at approximately 9:00-9:30 PM. The DM confirmed that the smoke detectors picked up the scent of smoke and automatically sounded the fire alarms and summoned the local Fire Department. The DM stated that the sprinkler system did not deploy because they are heat activated and the heat did not become severe enough to set off the water sprinklers. There was a good amount of smoke from the burning bed and linens and the smoke alarms were deployed/activated. The local Fire Department arrived on the unit within five (5) to ten (10) minutes after the smoke alarms were activated. When the Fire Department arrived the staff on the unit had extinguished the fire safely and had begun administering care to Residents. The DM stated that he arrived on the unit approximately five (5) minutes after the local Fire Department had arrived and the Fire Department had placed fans in the hallways to draw out the smoke that had accumulated in the halls and inside of Res #1's room. DM stated that he stayed at the facility that night until after midnight securing Res #1's room and clearing the air as well as assisting the staff with safety measures. The observation on 1/26/22 at 10:10 AM, of Res #1's room was made with the DM and with the State Fire and Safety surveyor. The DM had to use an electric screwdriver to unbolt the door to Resident #1's room in order to let the surveyors inside the room for observation. The room door had been bolted/screwed shut in order to keep people from entering the room where the fire had taken place. Upon entering the room was empty. There was no furniture, no window dressings, no privacy curtains, and no beds in the room. The room contained a white powered residue scattered about on the floor, and on an oxygen concentrator that was in the room. The oxygen concentrator had some small black soot marks located on the outside of the concentrator. The DM stated that he had disposed of the burned bed and linens of Res #1. He stated that the bed and the bed linen of Res #1 had been burned with what looked like approximately an area of 14-16 inches in diameter. The DM stated that he had no pictures of the burned bed and bed linens. He stated that when he arrived at the facility on 1/20/22 at approximately 9:30 P.M. the Fire Department and staff had removed the resident from the room and were administering treatment to Res #1. He stated that most of the smoke had been removed when he arrived by the fans that were placed in the hallways by the Fire Department. The DM pointed to the ceiling above where Res #1's bed was positioned to a sprinkler. The DM stated that the heat from the burning bed did not reach the water sprinkler and thus it was not activated. He stated that he in-serviced the facility staff monthly on Fire Prevention and taught all employees how to locate and use fire extinguishers. The DM confirmed that since the fire on 1/20/22 he had conducted Fire Prevention in-services and in-services on how to locate and use Fire Extinguishers. DM stated that all the staff and residents at the facility have been re-inserviced and educated again since the fire of 1/20/22. Interview on 1/26/22 at 11:30 AM, via telephone with the Clinical Director, (MD) revealed he was contacted by the facility unit nurse that Res #1 had been burned from a fire that had been set in his room. The MD went to the facility and arrived at approximately 9:45 -10:00 P.M. and he stayed at the facility until approximately 2:00 A.M. The MD stated that when he arrived the EMT's were loading Res. #1 into the ambulance for transport to the ER. The MD said he talked to Res #1 and he had [CONDITION(S)] on his left arm, chest and back. Res #1's breathing was normal, but he was not able to physically assess the [CONDITION(S)] because Res #1 was on his way in the ambulance. The MD went to the unit and saw the smoke in the hallway of the 400 hall. MD stated that he talked to the physician (MD) that was assigned to the roommate of Res #1 and they felt that Res. #7, should be sent to the ER for a more thorough assessment, and to be on the safe side, since Res #7 was in the room asleep in his bed when the fire occurred. The MD stated that the ER assessed Res #7 and released him back to the facility with no injuries or damages. The MD stated that Res #1 was burned over his upper trunk and was transferred to the burn unit for further treatment. He assisted the facility to survey the unit and to assist with the residents after the local Fire Department left the facility. He met with the facility QA team, and they changed their facility resident Smoking Policy to not allow any resident to possess lighters and/or matches. The MD stated that to his knowledge Res #1 did not reveal where or how he obtained the lighter. Interview on 1/26/22 at 1:00 PM, with Res.#7, roommate of Res #1 on the night of the fire, revealed that on the night of the fire he did not know where Res #1 got the cigarette lighter. He wasn't supposed to have no lighter Res #7 stated. Res #7 stated that he was in his bed in his room, and he saw Res #1 with a cigarette lighter in his hand and he was playing with it he wasn't smoking. Res #1 lit his privacy curtain on fire first and then the fire got big and caught Res #1's bed on fire and set his clothes on fire. Res #7 stated that he turned on the call light and started calling out for help. Res #7 stated that he was not injured and was not scared. Res #7 stated that he felt safe at the facility. Res #7 stated that the staff came fast and put the fire out and then soon the fire department got there. Res #7 stated that he went to the ER for an assessment but was released back to the facility quickly. Res #7 stated that the residents were all told that none of them were allowed to have a lighter or any matches. Interview on 1/26/22 at 1:22 P.M., with CNA#2 revealed that she was working the unit four the night of the fire on 1/20/22 and had been assigned to work with Res #1. CNA#2 stated that she never saw Res #1 with a lighter or matches. Res #1 had his call light on and then yelled help and the two CNA's, NA #1 and CNA#2 saw Res#1 on fire. CNA#2 stated that she and NA#1 went into Res #1's room and grabbed pitchers of water and ice and poured on Res #1. CNA#2 stated that Res #1 had on a short sleeve shirt and a pair of sweat pants, and his shirt was in flames and his chest and left arm was on fire. NA#1 immediately poured a bedside pitcher of water on Res #1. The water put out Res #1's body flames, but the privacy curtain and his oxygen tubing and bed were still on fire. LPN#1 came with the fire extinguisher and sprayed it on the fire and oxygen tubing and concentrator. CNA#2 stated that Res #7 was in the bed next to Res #1, and he never moved or said a word. CNA#2 stated that she and NA#1 rolled Res #1 out of his room in his bed and got him to the nursing station for assessments. CNA#2 stated that Res #1 was burned on his left arm, face, chest, and back. CNA#2 stated that when they asked Res #1 what happened and how did the fire start, he opened his hand and had a cigarette lighter in his hand. Res #1 told the staff that he was not smoking in his room, but he was playing with the lighter. Interview by telephone on 1/26/22 at 2:11 PM, with Res #1, and his brother, Responsible Party (RP) revealed that he was at the hospital with Res #1. He put the phone on speaker and the surveyor interviewed both RP and Res #1. Res #1 stated that he was not doing too good and that he had surgery for skin grafts. When surveyor asked Res #1 how the fire started and how did he get the lighter, he stated that he did not want to talk about it. RP stated that he felt like another resident had given the lighter to Res #1. RP stated that Res #1 was totally dependent upon others for all his needs. RP stated that he would have thought that Res #1 would have not used a lighter while wearing oxygen because several years prior he had experienced a younger brother to have gotten burned while wearing oxygen and smoking. RP stated that the doctors at the burn unit where Res #1 is confined, told them that Res #1 may need to have several more surgeries. RP stated that the facility contacted him the night of the fire and gave him a report of the fire and the hospital where Res #1 was taken. Interview on 1/26/22 at 3:20 PM, with CNA#3 revealed that she was walking up the hall from unit three when she saw black smoke coming from Res #1's room and the black smoke quickly filled the hallways and the visibility down the hall was poor because there was so much smoke in the hallway in front of Res #1's room. She stated that the Unit Supervisor, LPN#6 announced over the intercom that there was a fire and for staff to report to help. She stated that it was hard to see in the hallways because there was thick smoke everywhere. The fire department got there quick and when they got to the facility the fire was out and smoke was everywhere. The fire department placed three (3) fans in the halls to blow the smoke out. CNA#3 stated that even though the staff had been trained numerous times of how to use the fire extinguishers and how to react in an emergency, it was much different when the real thing happened. We were all in shock and it was kind of a panic when the smoke got so thick, and the fire was burning the resident in his bed. We all just kicked into survival mode and started running around shutting resident's doors and checking on everyone. It all happened so fast, and the fire department got there in a few minutes, and they took over telling everybody what to do and they got Res #1 and began assessing him and treating him and LPN#1. LPN#1 came with the fire extinguisher and put the fire out in the resident's room, and he inhaled smoke and the white stuff from the fire extinguisher. LPN#1 had to go to the ER and be treated too along with Res #1. Interview on 1/26/22 at 3:45 PM, with NA #1 revealed that she was assisting another resident the night of the fire when she was asked by the LPN to go to Res #1's room where the call light was on. NA #1 stated that she was on her way when she heard Res #1 yell out Help. She stated that the tone of his voice was different than usual, and she knew something was bad wrong. When she got to the door of the room smoke was coming out into the hallway fast. She stated that she just reacted without thinking and poured water on Res #1 who was on fire in his bed. NA #1 stated that CNA #2 and CNA #3 brought more pitchers of water and she poured them on Res #1 to put him out. But the flames were so much, and the smoke was so dark and thick that the LPN#1 was hardly able to see to aim the fire extinguisher, but he sprayed the room everywhere and got the bed linens and mattress and the oxygen tubing and concentrator fire put out. The NA stated that she had put resident's body fire out prior to LPN#1 entering the room. NA #1 stated that the staff were all in shock and things happened so fast. NA #1 stated that the night of the fire they closed all the residents' doors to keep out the smoke and the fire department put out fans to draw out the smoke. Interview on 1/26/22 at 4:30 PM, with CNA #4, stated that she assisted NA #1 and CNA #2 with getting Res #1 and Res #7 out of the room after the fire was put out. CNA#4 stated that they took both residents to the nursing station for assessments and then the fire department arrived, and they took over. CNA #4 stated that Res #1 was badly burning on his back and chest and left arm. CNA #4 stated that Res #1's arm was burned black and was sizzling and that his back was yellow and burned. CNA #4 stated that the mattress on Res #1's bed had a large hole burned in it and the privacy curtain was burned. CNA #4 stated that Res #1 told the staff that he had not been smoking in his room he opened his hand and handed over a lighter. Res #1 said I was not smoking I was playing with the lighter. Interview on 1/26/22 at 5:05 PM, with LPN#4, who was the Charge Nurse for hall 400 on 1/20/22. LPN#4 stated that she had given Res #1 his requested [MEDICATION(S)] earlier in the shift and after giving all her medications to the resident on the 400 hall she left the unit at approximately 9:30 PM to go get some supper. While out of the facility the other nurse called her on her personal cell phone and told her that one of the residents that she had been assigned to on hall 400 had set himself on fire with a lighter and the fire department was there. LPN#4 stated that she quickly returned to the unit and upon arriving she saw the fans in the hall and the fire department and EMT's. Interview on 1/26/22 at 5:30 PM, with LPN#1 revealed that he was the LPN on unit 300 on 1/20/22 when he saw dark thick smoke in the hallway of the 400 hall. The nurse announced over the intercom that there was a fire and please to report to unit 400. LPN#1 grabbed the fire extinguisher from the 300 hall and went running toward the 400 hall. He stated that it was hard to see because the smoke was so dark and thick. He went up the hall where the staff was guiding him to Res. #1's room and he went into the room that looked like it had flames coming up from the bed. He stated that he sprayed the fire extinguisher all over. He stated that the oxygen concentrator and the tubing were flaming with fire, so he sprayed them to put out the flames. LPN#1 stated that he had on his N95 mask and that was probably why he did not get more smoke in his lungs. LPN#1 stated that he inhaled smoke and his mask was covered with black residue. The staff assisted him as did the fire department and they placed him on oxygen because his oxygen level was low. LPN#1 was transported to the ER for evaluation and was kept overnight for observation. LPN#1 stated that Res #1 was burned on his chest and arm and that his back was burned a yellow color. LPN#1 stated that the fire produced heavy dark smoke and it was hard to see in the hall and in the room. LPN #1 stated that the staff all acted quickly, and NA #1 had put Res #1 out with water pitchers prior to his arrival with the fire extinguisher. Interview on 1/27/22 at 8:55 AM, with LPN #2 revealed that she serves as the Infection Control and Prevention Nurse and Staff Development Nurse. LPN#2 stated that she serves on the QA Committee/Team and that she began re-inservicing and re-educating all staff immediately after the fire of 1/20/22. LPN#2 confirmed that a QA Committee meeting was held first thing on 1/21/22 and the Smoking Policy was discussed and revised to read that no resident may possess a lighter and/or matches. Interview on 1/27/22 at 10:15 AM, with Director of Maintenance (DM) revealed that he had conducted in-services on Accidents Hazards; Fire Prevention; and Fire Extinguishers Usage. The DM confirmed that all staff were required to attend the in-services. The DM stated that he began the re-education of staff on 1/20/2022. The DM stated that the staff were taught to use Code Red to announce a fire in the facility. DM stated that all staff had been re-trained and re-educated. Interview on 1/27/2022 at 12:50 PM with Resident (Res) #6, Resident Council President, revealed that she had been made aware of the fire caused by a cigarette lighter and the [CONDITION(S)] that a resident had received as a result of playing with a lighter while wearing oxygen. Res #6 stated that they hold resident council meetings on a monthly basis and they do discuss the Smoking Policy. Interview on 1:10 P.M. with the Licensed Master Social Worker (LMSW), stated that the facility had a meeting on 1/21/2022 with all of the smokers in the building (33 smokers names were documented on the smokers list) and informed all that they were never to be in possession of a cigarette lighter and or matches. The LMSW also stated that all the smokers had been reassessed for smoking ability. The LMSW stated that all the smokers care plans had been revised on 1/20/22 and 1/21/22. Record review of the Resident Incident Report dated 1/20/22 at 9:35 PM revealed .Narrative of incident and description of injuries: Nurse heard CNA calling out that resident was on fire. Nurse went to room with fire extinguisher and put out fire on bed where resident was lying. Nurses assisted resident from bed to wheelchair. EMT's and fire department personnel at resident's side. [CONDITION(S)] were noted to resident's upper and mid back, and back of left arm, above, on, and below his elbow. When asking resident what happened, resident stated I flicked the liter and then it sparked and I was on fire. [CONDITION(S)] on upper and mid back, left arm and around his elbow, above and below, hair on resident's left side of head had been singed in some areas . Record review of Res #1's Face Sheet revealed that Res #1 had an admission to the facility date of 6/26 2017, with diagnoses that were not limited to [CONDITION(S)] ([CONDITION(S)]); [CONDITION(S)] disorder; Epilepsy; Nicotine Dependence, other tobacco product, with other disorders; among other various diagnoses. Record review on the Minimum Data Set (MDS) for Res #1 dated 1/24/22 revealed that Res #1 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated that Res #1 had moderate cognitive impairment. Record review of the Care Plan dated 6/26/ read: Res #1 Is a Smoker and is at risk for complications associated with smoking i.e., SOB or possible [CONDITION(S)]. Inform res#1 of New Smoking Policy, lighter free facility. Remind Res #1 that smoking is only allowed in designed areas outside of facility Res #1 is independent with smoking. Monitor Res #1 for possession of lighters and/or matches. This care plan was updated to include the actual complication on 1/20/2022 and will re-evaluated upon re-admission. Record review of Res #1's emergency room (ER) progress note dated 01/21/22 revealed: Summary: (Res #1) was admitted to the ER with [CONDITION(S)]; Hypertension; [CONDITION(S)] Disorder; and [CONDITION(S)], Left leg amputation, complete left middle finger amputation; and who was admitted secondary for [CONDITION(S)] sustained while igniting nasal cannula oxygen. The patient states that he was in bed while using a lighter and his clothing and linens caught fire. Approximately 13% total body surface area [CONDITION(S)] were sustained to face left arm and left chest area. He was seen in the ER where he was admitted for further evaluation and workup of medical condition prior to going to surgery. The record review of the Progress Note Report (local hospital) dated 01/26/22 for Res #1 revealed the patient is non-ambulatory with amputation of the lower extremity. He had full-thickness [CONDITION(S)] to the left upper extremity and to the anterior and posterior trunk. Patient was admitted to the ICU, seen by intensivist for medical management of multiple co-morbidities. He was taken to surgery on 01/23/2022 for excision and debridement with application of skin substitute to the trunk and left upper extremity for a total of 14 percent total body surface area burn injury. Hospitalist consulted for medical management continue silver [MEDICATION(S)] soaks every 8 hours. Patient is scheduled to go to the OR (operating room) on January 31, 2022, for excision of wound, removal of skin substitute, application to skin substitute, in preparation for ReCell application surgery and all other indicated procedures. The patient is also scheduled to go to the OR on February 2, 2022, for surgical prep application of split thickness skin graft and application of ReCell and all other indicated procedures. Record review of the daily Quality Improvement Rounds were reviewed for all residents. Documentation was reviewed and the QI Daily Rounds sheets contained checking rooms for lighters and matches. The facility implemented the following Immediate Jeopardy (IJ) Corrective Action Plan, prior to the State Agency (SA) entering the facility on 01/26/2022. In response to the IJ and SQC cited on 01/27/2022 at 10:30 A.M., the facility submitted the following IJ Removal Plan that was accepted by the SA as Past Non-Compliance (PNC) on 01/27/2022 at 5:30 P.M. Removal Plan-IJ--Residents supervision for environment to be free from hazards - Corrective actions: 1. Resident #1 was removed from the room by 3 PM - 11 PM Registered Nurse Supervisor with his vital signs and oxygen saturation taken. 911 was called. Resident #1 was evaluated by the Emergency Medical Technicians upon arrival to the facility and transferred to hospital with admission on 1/20/22. Resident #7 was sent to the emergency roiagnom on [DATE] for evaluation and returned to the facility with no injury. One staff member was sent to the emergency room for evaluation on 1/20/22 with discharged from hospital early A.M. with no injuries. 2. 100% Audit of all smoking residents have been evaluated, reassessed, and reviewed by Clinical Operations nurse and Registered Nurse Supervisor on each smoking resident's individualized plan of care with the Smoking Safety Evaluation forms completed on 1/20/2022. The Mississippi State Department of Health Licensure and Certification and Mississippi Attorney General 's Office were notified 1/20/22 at 10:15 P.M. 3. All staff inservices were initiated on 1/20/22 by the Executive Director, Registered Nurse Supervisor, and Staff Development Coordinator regarding facility smoking policy, fire drills, utilizing fire extinguishers, and when to evacuate residents. Staff will not be allowed to work until they have been in-serviced. 4. On 1/20/22 Fire watch was not warranted by the Maintenance Supervisor after consulting with the [NAME] Fire Department who were present in facility. Maintenance Supervisor presented to facility to ensure smoking system was reset and facility was secured. 5. On 1/20/22 100% Room to room searches were completed by facility nurses and certified nursing assistants on all residents to retrieve all lighters and/or matches. All residents were checked for physical and emotional well being by Registered Nurse Supervisor with no injuries found. 6. An Emergency Resident's Smokers meeting was held on 1/21/222 with all smokers at 2:00 P.M. by Executive Director and the Director of Nursing regarding the smoking policy and amendment to the smoking policy for all residents not to have possession of lighters and or matches. 7. On 1/21/22 the Quality Assurance (QA) committee met to include Executive Director, Director of Nurses, Regional Clinical Operations nurse, Vice President of Operations, and Medical Director in regard to the fire and supervision for Resident #1. Residents environment was free from hazards when Resident #1 set fire to bed linens, bed mattress, oxygen concentrator, and privacy curtain with a cigarette lighter. The hazard jeopardized Resident #1 and all other residents and staff safety, health, and well being. One policy was reviewed -Smoking Policy. Smoking policy was revised to add Residents will not be all to possess lighters and/or matches. 8. Facility alleges relieving the immediacy of this Immediate Jeopardy (IJ) on 1/22/22. The SA validations of the facility's Corrective Action Plans were completed by interviews, record reviews and observations on 1/28/2022 from 8:45 AM - 12:30 PM, with all staff in the building and via telephone interviews with staff that were scheduled to work first, second, and third shifts. Validations were conducted with interviews of 16 Licensed Practical Nurses (LPN's); Five (5) Registered Nurses (RN's); 1 Registered Dietitian (RD); six (6) dietary staff; four (4) business office staff; two (2) social workers; one Activities Director (AD); three (3) maintenance workers; 15 Certified Nursing Assistants (CNA's); four (4) Housekeeping staff; three (3) Laundry staff; one (1) Occupational Therapist; and three (3) Physic [TRUNCATED]