Every finding on record at Clinton Healthcare LLC - SNF

Based on interview, record review and policy review the facility failed to have an Advance Directive readily available for staff usage if needed for one (1) of twenty-three (23) resident Advance Directives reviewed. Resident #83Findings include:A record review of the facility policy, Residents Rights Regarding Treatments and Advance Directive, no date, revealed, Policy: It is the resident's right to formulate an Advance Directive, and to accept to refuse or accept medical or surgical treatment. Procedure. 1. On admission, the facility will determine if the resident has formulated an Advance Directive .On 11/18/25 at 12:25 PM in an interview with License Practical Nurse #2 (LPN) who works in Medical Records confirmed that the advance directive was not in the paper chart. She stated the purpose of having it in the chart is if the resident is unable to cognitively respond it should be in the chart so staff can have access. In an interview with the Director of Nursing (DON) on 11/20/25 at 1:15 PM, stated that Advance Directives are important to have to direct the healthcare of a resident according to his or her wishes. If they are not addressed, a resident could end up receiving more aggressive care than they really want or not receiving the care that they would have wished to have when a certain situation arises and they become incapacitated.A record review of Resident #83's admission Record revealed the facility admitted Resident 83 on 10/10/25 with diagnoses including Other Pulmonary Embolism without Acute Cor Pulmonale and Essential (Primary) Hypertension. A record review of Resident #83's electronic chart revealed it does not contain Advance Directive. A record review of the paper chart revealed it does not contain the Advance Directive.On 11/18/25 at 12:18 PM in an observation of DON reviewing the chart for Advance Directive she confirmed it was not in the paper chart.A record review of Resident #83's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/17/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicates the resident is cognitively intact.

Based on interview, record review, and facility policy review, the facility failed to implement its abuse-prevention policy by not completing a written investigation when staff were made aware of suspected physical abuse for one (1) of 21 sampled residents (Resident #106).Findings include:A review of the facility's Abuse Policy Employee Responsibility dated 3/21/23, revealed, .5. The facility will identify and INVESTIGATE all suspicions or allegations of abuse.a. the facility will thoroughly INVESTIGATE all alleged violations under the direct supervision of the Administrator.7. Any alleged incident REPORTED must be investigated.A review of the facility's Abuse Investigation Process, dated 3/21/23, revealed, The investigation will include the following: a. Written report from the person reporting the incident with date of report and date and time of incident (Incident/Accident Report).d. Signed statements from all witnesses, stating time, date and shift of incident. Documentation of investigation should include: A description of resident's behavior and environment at the time of the incident, injuries present, observation of resident staff's behavior during the investigation.On 11/17/25 at 2:52 PM, during an observation and interview, Resident #106 was seated in a wheelchair with her sister present. The sister stated she had concerns related to care. She stated that on 11/10/25 at 1:48 PM, she found the resident crying and the resident said someone had pushed her and had been mean to her. She stated she contacted the Director of Nursing (DON), who questioned the resident; the resident responded yes when asked if someone had pushed her. She stated the DON and two staff conducted a body audit. She stated the DON placed an intervention requiring a nurse to be present during care.On 11/19/25 at 9:48 AM, during an interview with the DON, she stated Resident #106's sister had reported concerns on 11/10/25 that a staff member was mean and had shoved the resident. She stated the resident is difficult to interview because she will respond yes to all questions. She confirmed a full body audit was completed and there were no signs of injury, and the resident was questioned. The DON reported that she did not document the investigation and confirmed the facility's policy required a written investigation and she did not follow policy.On 11/19/25 at 10:45 AM, during an interview with the Administrator, she stated all nurses can complete an incident report. She stated she was aware of the allegation but did not instruct staff to complete a written incident report. On 11/19/25 at 3:52 PM, during a follow up interview with the Administrator, she confirmed all allegations of abuse must be addressed. She stated she had reviewed policy and regulations but also used common sense and felt no further action was necessary because the resident could not communicate clearly.A record review of the admission Record revealed the facility admitted Resident #106 on 9/17/21 with a diagnosis including Aphasia Following Cerebral Infarction.A record review of Resident #106's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/25 revealed staff assessment for mental status was modified independence - some difficulty in new situations only.

Based on interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for one (1) of twenty-three (23) residents reviewed for assessment accuracy (Resident #40). This is evidenced by the facility incorrectly coding the resident as receiving anticoagulant therapy on two consecutive MDS submissions. Findings include:A review of the MDS Assessment Policy, dated 5/2006, reveals, It is the policy of this facility to follow the RAI (Resident Assessment Instrument) process as set forth by CMS (Centers for Medicare and Medicaid Services) protocol .A record review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/11/25 and 10/9/25 reveals a yes indicating the resident is on an anticoagulant.A record review of the physician orders does not reveal Resident #40 received anticoagulant medication.At 11/18/25 at 10:39 AM, in an interview with Licensed Practical Nurse #1 (LPN) who is the MDS Nurse, confirmed that she did code the annual MDS with Assessment Reference Date (ARD) of 7/11/25 and the quarterly MDS with ARD of 10/9/25 wrong and that it was an oversite on her part. She said it is important to ensure accuracy of the coding so that everything about the resident is captured and that the facility uses that information to get paid.On 11/20/25 at 12:36 PM, in an interview with the Director of Nursing (DON), she explained that the MDS informs the facility of the needs of the resident such as the type of care, interventions, diets, fall risk and medication plans. Therefore, ensuring its accuracy is crucial since it's how the facility tailors and delivers the right care for each resident. A record review of the admission Record revealed the facility admitted Resident #40 on 7/15/24 with a diagnosis including Unspecified Congestive Heart Failure.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure oxygen-use cautionary signage was posted on or near the resident's door for one (1) of one (1) resident reviewed for respiratory care, Resident #78.Findings included:A review of the facility's policy, Oxygen Safety, revealed, .No Smoking' signs must be clearly visible in areas where oxygen is stored or in use.On 11/17/25 at 11:48 AM, during an observation, Resident #78 was lying in bed and receiving oxygen via a nasal cannula at two (2) liters per minute. There was no Oxygen in Use sign posted on or near the resident's door. On 11/17/25 at 11:50 AM, during an observation and interview, Registered Nurse (RN) #1 came to the doorway of Resident #78's room and confirmed the absence of cautionary oxygen signage. RN #1 stated that a sign had previously been present and must have fallen off. RN #1 acknowledged that clearly posted signage is necessary for safety.On 11/20/25 at 2:00 PM, during an interview with the Director of Nursing (DON), she stated that oxygen is a highly flammable gas and confirmed that signage identifying oxygen use is necessary to ensure resident and staff safety.A record review of the admission Record revealed the facility admitted Resident #78 on 7/31/25 with diagnoses including Shortness of Breath.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/7/25 revealed Resident #78 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Further review revealed he received Oxygen therapy within the last 14-day lookback period.A record review of the Order Summary Report revealed Resident #78 had a Physician's Order, dated 9/9/25 for Oxygen at two (2) liters via nasal cannula every shift.

Based on observation, staff interview, record review, and facility policy review, the facility failed to follow infection control guidelines when a Certified Nursing Assistant (CNA) provided catheter care while wearing false fingernails that interfered with glove use and effective hand hygiene for one (1) of four (4) care observations, Resident #5.Findings included:A review of the facility's Hand Hygiene policy, dated 7/1/24, revealed, .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors .A review of the facility's Dress Code (undated), revealed, .Long nails should not be worn. Nails should be no longer than the tip of the finger. Fingernails should always be kept clean.On 11/19/25 at 10:39 AM, during an observation of catheter care for Resident #5, Certified Nursing Assistant (CNA) #1 was observed wearing artificial fingernails approximately two (2) inches beyond the fingertips. She had difficulty placing gloves over the nails, requiring four glove changes during the procedure. Each time gloves were changed, she used hand sanitizer but did not clean underneath the long artificial nails.On 11/19/25 at 10:55 AM, during an interview with CNA #1, she stated that her fingernails were fake and acknowledged that they were very long, causing difficulty when putting on gloves during care. She stated the facility had instructed CNAs during monthly in-service training not to wear long or artificial nails because they can spread infection and may scratch or injure residents.On 11/19/25 at 3:35 PM, during an interview with the Director of Nursing (DON), she stated that staff nails should be kept neatly trimmed per facility policy to prevent the spread of infection caused by bacteria that can live under long or artificial fingernails.On 11/20/25 at 11:00 AM, during an interview with the Infection Preventionist (IP) Nurse, he stated that the facility policy recommends nails be kept no longer than the fingertip. He explained that long nails can harbor bacteria, are difficult to clean under, and can contribute to the spread of infection.A record review of Resident #5's admission Record revealed the facility admitted the resident on 8/11/23 with diagnoses including Encephalopathy.A record review of Resident #5's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/31/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

Based on observations, interviews, record reviews, and facility policy reviews, the facility failed to provide wound care and incontinent care in a manner to prevent the possibility of spreading infection by not wearing a gown for Enhanced Barrier Precautions (EBP) during wound care and failing to perform proper hand hygiene during incontinent care. This deficient practice was observed for two (2) of two (2) residents reviewed for infection control practices (Resident #1 and Resident #4). Findings include: A record review of the facility's Infection Prevention and Control Program policy dated 8/2017, revealed It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 4 .b. Staff shall wash their hands before and after performing resident care procedures A record review of the facility's policy Enhanced Barrier Precautions, undated, revealed it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown, and gloves use during high contact resident care activities. On 04/10/25 at 11:12 AM, during an observation of wound care for Resident #1 provided by Licensed Practical Nurse (LPN) #1 (Wound Care Nurse), assisted by Certified Nursing Assistant (CNA) #1, revealed they did not follow Enhanced Barrier Precautions. LPN #1 performed wound care without a gown, and CNA #1 assisted by turning Resident #1 without wearing a gown. On 04/10/25 at 2:18 PM, in an interview, CNA #1 stated it slipped her mind to put on a gown while assisting LPN #1 with wound care. She stated she should have applied a gown to protect the wound and acknowledged prior training on Enhanced Barrier Precautions. On 04/10/25 at 2:08 PM, during an observation of incontinent care for Resident #4 provided by CNA #2, she exited the room wearing a gown from prior wound care, removed it in the hallway, and returned to the room with supplies. She did not wash hands or don a new gown but applied gloves and began peri care. Resident #4 had feces in the brief. CNA removed soiled gloves three times but did not perform hand hygiene between glove changes. She continued to provide care, pulling wipes from the package with soiled gloves. CNA #2 finished care, removed gloves, and washed hands before exiting the room. On 04/10/25 at 2:23 PM, in an interview, LPN #1 stated she forgot to wear a gown during Resident #1's wound care. On 04/10/25 at 2:41 PM, in an interview, CNA #2 stated she should have worn a gown and washed her hands before and during care. She confirmed that she used soiled gloves to handle wipes and acknowledged the resident could get an infection from the care provided. On 04/10/25 at 4:52 PM, in an interview, Registered Nurse (RN) 1 (Infection Prevention Nurse) she confirmed that LPN #1, CNA #1 and CNA #2 should have worn gowns before starting care, placing the residents at risk of infection and potential spread to others. She also stated CNA #2 failed to follow proper hand hygiene during incontinent care. The last EBP training was conducted in January 2025. On 04/10/25 at 5:31 PM, in an interview, the Director of Nursing (DON) stated LPN #1, and the CNAs should have applied gowns prior to care, and that when residents are on EBP, extra precautions are required. She acknowledged possible infection spread due to improper gown use and hand hygiene lapses. Resident #1: Record review of the admission record revealed admitted : 06/12/24. Diagnoses: Heart Failure and Type 2 Diabetes Mellitus with Hyperglycemia. A record review of Resident #1 Order Summary Report revealed an order dated 4/8/25 Cleanse stage IV pressure injury to sacrum with Dakins Solution, pat dry. Apply collagen then hydrofera blue and secure with silicone foam dressing every other day and as needed. A record review of Resident #1 Minimum Dat Set (MDS) with Assessment Reference Date of 3/13/25 revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicates the resident had moderate cognitive impairment. Resident #4: Record review of the admission record revealed an admitted [DATE] with diagnoses of Essential Hypertension and Type 2 Diabetes Mellitus without complications. Record review of the Order Summary Report for Resident #4 revealed an order dated 4/4/25 Cleanse with Dakin's solution, pat dry. Apply Mupirocin to wound bed and cover with alginate and silicone sacral border dressing daily and prn (as needed), one time a day related to Pressure Ulcer of Sacral Region, Stage 3. Record review of the MDS with ARD: 03/5/25 revealed BIMS score 99 indicating the resident was unable to complete the interview.

Based on observations, interviews, record reviews and policy reviews, the facility failed to provide wound care in a manner to prevent the possibility of wound infection for two (2) of (2) wound care observations. Resident #1 and Resident #4 Findings Include: A record review of the facility's policy titled Wound Care dated 1/2015 revealed Policy: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Procedure: .After cleaning the wound as ordered, clean the tissue around the wound . On 4/10/25 at 11:12 AM during an observation of wound care for Resident #1 by Licensed Practical Nurse (LPN) # 1/Wound Care Nurse and assisted by Certified Nursing Assistant (CNA) #1 revealed LPN #1 cleaned the stage IV pressure injury wound bed from the outer edge toward the inner aspect in a circular motion. She dried wound site with gauze from the outer edge toward the inner wound bed in a circular motion four times and applied clean dressing. On 4/10/25 at 1:55 PM in an observation of wound care for Resident #4 completed by LPN #1 and assisted by CNA #2 revealed LPN#1 cleaned wounds from the outer edge toward the inner aspect three times each in a circular motion. She discarded gauze and used a clean gauze and dried the wound from the outer edge towards the inner area of the wound bed. On 4/10/25 at 2:23 PM in an interview with LPN #1 confirmed that she did not clean Resident #1 and Resident #4 wounds correctly. She stated she should clean the inside and move outer to prevent contaminating the wound. She stated Resident #1 and #4's wounds can get infected by the way she cleaned the wounds. On 4/10/25 at 4:52 PM in an interview with Registered Nurse #1 (RN)/ Infection Preventionist Nurse stated LPN #1 should have cleaned the wound from inner to outer to prevent possibly infecting the wounds. She stated LPN #1 contaminated the wounds. On 4/10/25 at 5:31 PM in an interview with the Director of Nursing (DON) stated LPN #1 should clean from inner to outer and dispose of gauze. She stated LPN #1 could possibly spread infection. Resident #1: Record review of the admission record revealed admitted : 06/12/24. Diagnoses: Heart Failure and Type 2 Diabetes Mellitus with Hyperglycemia. A record review of Resident #1 Order Summary Report revealed an order dated 4/8/25 Cleanse stage IV pressure injury to sacrum with Dakins Solution, pat dry. Apply collagen then hydrofera blue and secure with silicone foam dressing every other day and as needed. A record review of Resident #1 Minimum Data Set (MDS) with Assessment Reference Date of 3/13/25 revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicates the resident had moderate cognitive impairment. Resident #4: Record review of the admission record revealed an admitted [DATE] with diagnoses of Essential Hypertension and Type 2 Diabetes Mellitus without complications. Record review of the Order Summary Report for Resident #4 revealed an order dated 4/4/25 Cleanse with Dakin's solution, pat dry. Apply Mupirocin to wound bed and cover with alginate and silicone sacral border dressing daily and prn (as needed), one time a day related to Pressure Ulcer of Sacral Region, Stage 3. Record review of the MDS with ARD: 03/5/25 revealed BIMS score 99 indicating the resident was unable to complete the interview.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right to reasonable accommodation of needs regarding a call light for one (1) of 24 sampled residents. Resident #39. Findings Include: Review of the facility's booklet, A Matter of Rights: A Guide to Your Rights and Responsibilities as a Resident that is provided to residents upon admission, page four (4) revealed, Dignity and Respect . This includes the right .to expect care and a residential setting that .promotes your quality of life .reflects your individual needs and preferences . During an observation and interview, Resident #39 was observed lying on her side in bed on 6/11/24, at 9:10 AM, with the call light attached to her blanket just below her hands. The resident mentioned she frequently finds it difficult to get staff members to check on her. She admitted that she cannot operate her call light because the right and left fingers of her hands are contracted. The call light was observed to be a standard call light in which a button must be pressed for the light to activate and indicate assistance was required by the resident. On 6/12/24 at 12:28 PM, in an interview with Resident # 39, she reiterated her inability to use the call light due to her contracted hands. She shared her usual method of seeking assistance involved waiting for someone to pass by and calling out for help. She expressed her dissatisfaction with the situation and stated that she had learned to accept it as the norm. On 6/12/24 at 1:19 PM, in an interview with Certified Nursing Assistant #2 (CNA), she acknowledged the resident's inability to use her call light due to her contracted hands. CNA #2 explained rounds were completed every two hours and if the resident required immediate assistance, the resident could call out to any staff member passing by the door for help. In an interview with the Director of Nursing (DON) on 6/12/24 at 4:04 PM, she disclosed that the call light served as a means for residents to alert staff members when they required assistance. The DON explained the type of call light required for a resident was determined at the time of admission for each resident. The DON stated the facility typically offered residents a pancake light (a type of call light for residents with limited mobility) who might have problems utilizing the standard call light. She explained that if Resident #39 could not activate the call light, it could keep her from getting the care she needed. On 6/12/24 at 4:33 PM, during a follow-up interview in the resident's room with the DON, she confirmed Resident #39 had contracted hands which prevented her from using her present call light. She stated she would get the resident a more functional call light, such as a pancake light, because it would allow the resident to alert staff members by touching the light instead of pressing a button. A record review of the Admission Record revealed the facility admitted Resident #39 on 9/20/2021 with current diagnoses including Contracture of Muscle, left Upper Arm, Contracture, Left Hand, and Muscle Weakness. A record review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/11/24 revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated her cognition was moderately impaired.

Based on observation, interviews, record review, and the facility policy review, the facility failed to ensure a residents' right to privacy by posting a sign regarding resident's care in view, above the bed for one (1) of 24 sampled residents. Resident #28. Findings include: A review of the facility's policy Resident's Rights dated 4/2012 revealed, . Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . d. Privacy and confidentiality . On 06/11/24 at 10:35 AM, in an observation, Resident #28 was lying in bed and there was a sign above the bed which indicated, *Aspiration Risk* Please ensure pt (patient) is pulled up in bed and head is raised for all Meals- Speech therapy. Resident #28 reported he was not aware of the signage on the wall. On 06/12/24 at 5:00 PM, during an interview, Licensed Practical Nurse (LPN) #2 confirmed Resident #28 had a sign in view above his bed with private information regarding aspiration precautions. LPN #2 was unsure how long the sign had been on the resident's wall. On 06/13/23 at 11:05 AM, during an interview with the Speech Therapist (ST), she confirmed she placed the sign above Resident#28's bed regarding aspiration precautions. She explained she had educated the staff on how to position the resident for meals and then placed the sign. The ST reported she was informed by the Administrator the signs could not stay up due to privacy and she stated she would no longer place signs in view in resident's rooms. On 06/13/24 at 02:21 PM, during an interview with the Administrator and the Director of Nursing (DON), the Administrator reported she was made aware yesterday there was signage in view in Resident #28's room. She confirmed information posted did not honor the resident's right to privacy and both she and the DON reported they expected the facility staff to always respect the privacy and dignity of all residents. Record review of the Admission Record revealed the facility admitted Resident #28 on 04/13/23 and he had current diagnoses including Dysphagia. Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/12/24, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) summary score of 12, which indicated moderate cognitive impairment.

Based on interviews, record review, and facility policy review, the facility failed to ensure a resident was free from unnecessary medication by continuing an as needed (PRN) psychotropic medication past a 14-day duration for one (1) of six (6) residents sampled for unnecessary medications. Resident #55 Findings include: A review of the facility's policy Monitoring of Antipsychotic Medication Therapy, revised 06/2015 revealed . It is the policy of this facility to monitor the effectiveness and side effects for any resident that is taking an antipsychotic medication. Procedure .5. The Pharmacy consultant will review these meds (medications) monthly and make dose reduction recommendations as indicated per CMS (Center for Medicare and Medicaid Services) guidelines . A record review of the Order Summary Report with active orders as of 4/30/2024, revealed Resident #55 had a Physician's Order, dated 4/18/24 for Amitriptyline HCL (Brand name of Elavil and classified as a psychotropic medication) 25 milligrams (mg), one (1) tablet by mouth every 24 hours as needed for depression at bedtime. There was no stop date indicated on the Physician's Order. A record review of the May 2024 Interdisciplinary Psych Dashboard revealed Resident #55 had a medication of Elavil 25 mg PRN and included the Pharmacist Comments of PRN Psychotropic orders must have a 14 day stop order and patient must be evaluated by physician prior to continuing. The IDT (Interdisciplinary Team) responded, Current Medication Regime appears appropriate and agreeable at this time unless otherwise noted. A record review of the Admission Record revealed the facility admitted Resident #55 on 01/11/17 with diagnoses including Other Recurrent Depressive Disorders. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/20/24, Section N . Medications .High-Risk Drug Classes: . revealed Resident #55 was code as taking an antidepressant. On 06/13/24 at 11:39 AM, during a phone interview with Nurse Practitioner, she explained she was aware PRN psychotropic medications needed a new order after 14 days. On 06/13/24 at 2:26 PM, during an interview with the Administrator and Director of Nursing (DON), both reported they expected staff to follow the federal guidelines regarding a 14-day duration for PRN psychotropic medications.

Based on observation, interview, and facility policy review, the facility failed to ensure an enteral feeding pump was operated by licensed staff for two (2) of three (3) residents observed with Percutaneous Endoscopic Gastrostomy (PEG) tube feedings. (Resident #47 and Resident #93) Findings Include: Review of the facility's policy, Enteral Pump Alarm revised 1/2015, revealed It is the policy of this facility for enteral pumps to only be turned off and on by a licensed nurse. This procedure should never be delegated to assistive personnel .Procedure .Only licensed nurses will control the operations of the enteral feeding pump . Resident #47 During an observation, on 6/11/24 at 2:11 PM, Certified Nurse Aide (CNA) #1 entered Resident #47's room to provide incontinent care. CNA #1 turned off the resident's enteral feeding pump. After the incontinent care was completed, CNA #1 turned the enteral feeding pump back on. During an interview on 6/12/24 at 3:00 PM with CNA #1, she confirmed she had turned the enteral feeding pump off and back on. She explained she was nervous and was not thinking at the time. CNA #1 stated she should have asked the nurse to turn the pump off and back on and she was aware nurses were responsible for operating the feeding pumps. A record review of the Admission Record revealed the facility admitted Resident #47 on 6/18/21 with diagnoses including Dysphagia. Resident #93 During an observation on 6/12/24 at 3:15 PM, CNA #3 and CNA #4 began providing incontinent care for Resident #93. The enteral feeding for Resident #93 was on hold prior to entry into the room. During the care, the enteral feeding pump began beeping. CNA #4 instructed CNA #3 to press the hold button to stop the beeping. CNA #3 pushed the hold button on the enteral feeding pump to silence the beeping. As the CNAs continued the care, the enteral feeding pump began beeping again and CNA #3 pressed the hold button on the feeding pump again. After incontinence care was completed, CNA #3 pressed the button to restart the enteral feeding. On 06 12/24 at 4:08 PM, in an interview with CNA #3, she confirmed she had operated the enteral feeding pump several times during care by placing it on hold and turning it back on after incontinence care was completed. She stated she should not have touched the feeding pump and should have let the nurse operate it. Record review of the Admission Record revealed the facility admitted Resident #93 on 10/13/23 with current diagnoses including Dysphagia. During an interview on 06/12/24 at 4:00 PM, with the Director of Nursing (DON), she stated only licensed nurses should operate an enteral feeding pump and CNAs should not turn them off or on, nor place them on hold. She explained the CNAs had been trained that only licensed nurses were allowed to operate the feeding pumps.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff treated residents who had visual impairment with dignity and respect, as evidenced by failure to knock on doors and identify themselves prior to entry for two (2) of six (6) residents reviewed. Resident #1 and Resident #2. Findings Include: Review of the facility's policy titled, Residents' Rights, dated 1/24/2022, revealed, .Residents' rights, policies, and procedures shall insure that each resident admitted to the center: .9. Is treated with consideration, respect, and full recognition of his dignity and individuality, including privacy in treatment and in care for his personal needs . Resident #2 On 12/11/23 at 4:20 PM, during an interview with Resident #2, the resident reported that she had been diagnosed with Legal Blindness. Resident #2 revealed that staff frequently enter her room without knocking or introducing themselves. She stated that sometimes she could hear someone moving around the room, who said nothing at all unless she called out to them. She stated that the behavior of the staff made her uncomfortable. She commented that she did not appreciate anyone entering her room unannounced, as she could not see to recognize staff. Resident #2 stated that she preferred to have staff knock on the door, make their presence known, and introduce themselves and talk to her and let her know what's going on. On 12/11/23 at 4:30 PM, an observation revealed that Certified Nurse Aide (CNA) #2 entered the room of Resident #2 without knocking or introducing herself to the resident. On 12/11/23 at 5:15 PM, during an interview with CNA #2, she revealed she had not received in-service training from the facility regarding the care of residents with visual impairment. However, she confirmed that she was aware that Resident #2 was legally blind and required assistance from staff for Activities of Daily Living (ADL). She also stated that staff were always supposed to knock on the resident's door prior to entering the resident's room. She stated that she was aware that it was very important to knock and introduce oneself upon entry into the room of a resident with visual impairment, so they will know who you are, because those residents cannot visually identify individuals. On 12/11/23 at 5:30 PM, in an interview with CNA #1, she revealed that staff were supposed to knock and introduce themselves upon entering a resident's room. She stated that she was aware that it was very important to knock and introduce oneself upon entry into the room of a resident with visual impairment to prevent confusion for the resident. Record review of the Admission Record for Resident #2 revealed the facility admitted the resident on 3/04/21, with diagnoses that included Legal Blindness, Acute Kidney Failure, and Pulmonary Hypertension. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/8/23, revealed in Section B that Resident #2's vision was severely impaired - no vision or sees only light, colors or shapes. Section C revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #2 was cognitively intact. Section GG revealed Resident #2 displayed dependence on staff for toileting and required partial/moderate assistance to substantial/maximal assistance for all other ADLs, including hygiene, dressing and transfers . Resident #1 On 12/12/23 at 10:55 AM, during an interview with Resident #1, the resident reported that staff made it a habit of entering her room without knocking or introducing themselves. Resident #1 stated that she could not identify by name the staff members who failed to do so. Resident #1 revealed that it bothered her that staff were aware that she could not see and did not respect her privacy or provide verbal cues as to their identity and intentions, upon entering her room. On 12/12/23 at 1:00 PM, during an interview with the primary physician for Resident #1 and Resident #2, the physician stated that knocking on the door or residents' rooms and introducing oneself upon entry was important for all residents, because it is their home, their personal space. He stated he considered it very important that staff knock and introduce themselves upon each entry into the rooms of residents with visual impairment because those residents relied on non-visual cues to understand what was taking place. On 12/12/23 at 1:30 PM during an interview with the Director of Nurses (DON), she stated that all staff had received monthly in-service training on Resident Rights which included respect for resident's personal space and introduction of self upon entering each resident's room. She acknowledged that care for a blind resident would include knocking on the resident's door prior to entering and introducing oneself in order to maintain privacy and dignity and ensure feelings of security for the resident. Record review of the Admission Record for Resident #1 revealed that the resident was admitted by the facility on 3/22/23, with diagnoses that included Type 2 Diabetes Mellitus and Legal Blindness. Record review of the Quarterly MDS with an ARD of 9/25/23, revealed in Section B that Resident #1's vision was Severely impaired - no vision or sees only light, colors or shapes. Section C revealed a BIMS score of 15, which indicated Resident #1 was cognitively intact. Section GG revealed Resident #1 required Supervision or touching assistance or Setup or clean-up assistance for ADLs, including eating, hygiene, dressing, and transfers .

Based on observation, interview, record review, and facility review the facility failed to implement care plan interventions for a resident who had visual impairment for one (1) of six (6) residents reviewed. Resident #2 Findings Include: Record review of the facility policy titled, Following the Care Plan Policy, dated 3/21/22, revealed, Policy: It is the policy of this facility to follow a written and approved care plan for each resident. All employees will be trained upon hire and be required to follow the care plan . Procedure . 3. All employees will follow the written care plan that is developed in order to assure the residents needs are met. Record review of the Care Plan for Resident #2 revealed Focus I am legally blind, Dx (diagnosis) of Legal Blindness, Diabetes, ESRD (End Stage Renal Disease) .Date Initiated: 3/10/21 GOAL I will maintain a good quality of life and remain safe in my environment .Revision on: 5/15/23 .Interventions .Identify self when entering room or approaching resident. Explain tasks before performing them Date Initiated 3/10/21. During an interview on 12/11/23 at 4:20 PM, with Resident #2, the resident reported that she was legally blind. Resident #2 stated that staff frequently entered her room without knocking or introducing themselves. She stated that sometimes she could hear someone moving around in her room and they didn't tell her that they were in there unless she called out to them. The resident revealed that the behavior of the staff made her uncomfortable. She commented that she did not appreciate anyone entering her room unannounced, as she was unable to see and recognize staff. Resident #2 stated that she preferred to have staff knock on the door, make their presence in her room known, introduce themselves and talk to her and let her know what's going on. An observation on 12/11/23 at 4:30 PM, revealed that Certified Nurse Aide (CNA) #2 entered the room of Resident #2, without knocking or identifying herself to the resident. An interview with CNA #2 on 12/11/23 at 5:15 PM, revealed that she was aware that Resident #2 was legally blind and required assistance from staff for Activities of Daily Living (ADLs). She stated that staff were always supposed to knock when you go into a resident's room. CNA #2 also stated that she was aware that it was very important to knock and introduce oneself upon entry into the room of a resident with visual impairment, so that will know who you are. She reported that she usually received care instructions for residents verbally from nurses or other CNAs. During an interview on 12/12/23 at 1:00 PM, with Resident #2's primary physician, the physician stated that it was important for individualized care plans to be implemented for each resident to receive care in an appropriate manner to meet their individual needs. In an interview on 12/12/23 at 1:30 PM, with the Director of Nurses (DON), she stated that resident care instructions, based on each resident's individualized care plan were available to the CNAs on the facility kiosks under the Kardex. The DON stated that it was very important that all nursing staff to follow each resident's individualized care plan, in. She acknowledged that care for a blind resident would include knocking on the resident's door prior to entering and introducing oneself to maintain privacy and dignity and ensure feelings of security for the resident. During an interview with the Minimum Data Set (MDS) Nurse on 12/13/23 at 5:35 PM, she revealed that individualized care plans were developed for each resident based on a number of factors which included each residents' abilities and needs. She said that nursing staff were expected to follow each resident's individualized care plans to ensure that residents received appropriate care and that their individual needs were met. She stated that the computer software utilized by the facility pulled information and care instructions from the residents' care plans and generated care instructions for each resident which was available to all CNAs on the kiosks under the Kardex. The MDS Nurse stated that the CNAs also used the software to document care for the residents. Record review of the Admission Record for Resident #2 revealed the facility admitted the resident on 3/04/21, with diagnoses that included Legal Blindness, Acute Kidney Failure, and Pulmonary Hypertension. Record review of the Quarterly MDS with ARD 11/08/23 for Resident #2 revealed that the resident had a BIMS score of 15 which indicated no cognitive impairment and the resident's vision was Severely impaired - no vision or sees only light, colors or shapes.

Based on staff interview, facility policy review and record review the facility failed to provide to the Resident or Resident Representative (RR) written notice at the time of transfer of the duration of the Bed Hold Policy for three (3) of three (3) residents reviewed for transfers and discharges. Resident #31, Resident #68, and Resident #88 Findings included: Record review of the facility policy Bed Hold Policy and Procedure with a revision date of 12/2019 revealed Policy: At the time of transfer for hospitalization . the facility will provide to the resident and/or the resident representative written notice which specifies the bed-hold policy . Bed Hold Notice upon Transfer 1. Before a resident is transferred to the hospital . the facility will provide to the resident and/or resident representative written information the specifies: a. The state bed-hold policy, during which the resident is permitted to return . 2. In the event of emergency transfers of a resident, the facility will provide within 24 hours written notice of the facility's bed-hold policies according to the Mississippi Medicaid allowed days . The facility's Business Office Manager or Social Service Director (as assigned by the facility Administrator) will be responsible for providing written notice of bed-hold policy during normal business hours (Monday through Friday 8:00 am-5:00 pm) and follow up notification per phone for odd hour and weekend emergency transfers . Resident #31 A record review of the Admission Record revealed the facility admitted Resident #31 on 07/15/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of a Physician's Order for Resident #31, dated 09/07/2022 at 9:26 PM, revealed, May send out to (Proper Name of Local Hospital) for evaluation of SOB (Shortness of Breath), desaturation, and fluid overload . A record review of Resident #31's Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/07/2022, revealed, Section A .A0310. Type of Assessment .F. Entry/discharge reporting was coded as 11. Discharge assessment-return anticipated and A 2100 Discharge Status was coded as 03. Acute Hospital . A record review of a Physician's Order for Resident #31, dated 09/12/22 at 09:49 AM, revealed, May send to (Proper Name of Local Hospital) for further eval (evaluation) due to CHF (Congestive Heart Failure) Exacerbation, SOB, fluid overload . A record review of Resident #31's Discharge MDS with an ARD of 09/12/2022, revealed, Section A .A0310. Type of Assessment .F. Entry/discharge reporting was coded as 11. Discharge assessment-return anticipated and A 2100 Discharge Status was coded as 03. Acute Hospital . A record review of the clinical record for Resident #31 revealed there was no record of a written notification of the bed hold policy upon transfer for 09/07/2022 and 09/12/2022. Resident #68 A record review of the Admission Record revealed the facility originally admitted Resident #68 on 08/01/2022 and the recent admitted was 08/22/2022. He was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of a Physician's Order for Resident #68, dated 08/13/22 at 12:21 PM, revealed May transfer to (Proper Name of Local Hospital). A record review of Resident #68's Discharge MDS with an ARD of 08/13/2022, revealed, Section A .A0310. Type of Assessment .F. Entry/discharge reporting was coded as 11. Discharge assessment-return anticipated .A 2100 Discharge Status was coded as 03. Acute Hospital . A record review of the clinical record for Resident #68 revealed there was no record of a written notification of the bed hold policy upon transfer for 8/13/22. Resident #88 During an interview on 10/03/2022 at 12:29 PM, with the RR visiting with Resident #88, he stated that Resident #88 recently went to the hospital several times and he had never received a written notification from the facility regarding the bed hold policy when he was transferred. A record review of the Admission Record revealed the facility admitted Resident #88 on 05/11/2017 and he had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #88's Order Details with order date 07/27/2022 revealed May send to (Proper Name of Local Hospital) ER (emergency room ) for further evaluation. A record review of Resident #88's Discharge MDS with an ARD of 07/27/2022 revealed Section A . A0310. Type of Assessment . F. Entry/discharge reporting was coded as 11. Discharge assessment-return anticipated . A 2100 Discharge Status was coded as 03. Acute Hospital . A record review of Resident #88's Order Details with order date 08/07/2022 revealed May send to (Proper Name of Local Hospital) for further evaluation. A record review of Resident #88's Discharge MDS with an ARD of 08/07/2022 revealed Section A . A0310. Type of Assessment . F. Entry/discharge reporting was coded as 11. Discharge assessment-return anticipated . A 2100 Discharge Status was coded as 03. Acute Hospital . A record review of Resident #88's Order Details with order date 09/04/2022 revealed May transfer to (Proper Name of Local Hospital) . A record review of Resident #88's Discharge MDS with an ARD of 09/04/2022 revealed Section A . A0310. Type of Assessment . F. Entry/discharge reporting was coded as 11. Discharge assessment-return anticipated . A 2100 Discharge Status was coded as 03. Acute Hospital . A record review of the clinical record for Resident #88 revealed there was no record of a written notification of the bed hold policy upon transfer to an acute care hospital for the transfers that occurred on 07/27/2022, 08/04/2022, and 09/04/2022. During an interview on 10/05/22 at 11:40 AM, with the Social Services Director (SSD), she stated that she calls the families to advise them that the resident is going to the hospital and advises them of the bed-hold policy. She stated that she does not send notification of the bed hold policy to the families after each transfer because she was not aware that she was supposed to do so. During an interview with the Administrator on 10/06/22 at 12:00 PM, she explained that the SSD is responsible for mailing letters for bed-holds for residents that do not have Medicaid because if the resident has Medicaid, Medicaid pays for bed-holds. She reported the nurses will also send the bed-hold letters in a folder with the resident to the hospital. If the RR does not come in to sign the form, they will call the RR and make a note in the chart. She reported the facility has not been consistent with mailing letters and have not mailed letters with each hospital transfer regarding the bed hold policy.

Based on interviews, record review, and facility policy review, the facility failed to provide services to meet professional standards of practice regarding the administration of medications to [CONDITION(S)] residents per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #47 Findings Include: Review of the facility's policy Administration of Eye Drops or Ointments, updated 4/20/22, revealed Eye medications are administered as ordered by the physician and in accordance with professional standards of practice to lubricate the eye or treat certain eye conditions . Review of Resident # 47's Admission Record revealed admission of 01/10/2018 with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 47's current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #47's September 2022 Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During the current month of October 2022, the resident's EMAR revealed that the resident had not received the ordered [MEDICATION(S)] Suspension on October 3rd and 5th. Review of Resident # 47's Quarterly Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 8/15/22, revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicates the resident was unable to complete the interview. On 10/6/22 at 11:11 AM, in an interview, the Nurse Practitioner (NP) revealed that she and the Medical Director follow the orders as written by the eye specialist. She stated they sign off on specialist orders and expect the staff to follow them as written. The NP confirmed that she expects staff to administer the resident's eye drops three (3) times a day, on all days. On 10/6/22 at 2:13 PM, in an interview with Licensed Practical Nurse (LPN) #4/Unit Nurse Manager, she stated that Resident #47 should get her eye drops as ordered. She explained that the eye medication is for [CONDITION(S)], and it is essential that the resident receive the eye drops as ordered. On 10/6/22 at 2:39 PM, in an interview, the Director of Nursing (DON) confirmed the importance of staff administering a resident's eye drops for [CONDITION(S)] three (3) times a day as ordered. She stated the nursing staff should have used better judgment and called the practitioner and clarified the administration times to accommodate the administration of the medication on [CONDITION(S)] days.

Based on interviews, record reviews, and facility policy review, the facility failed to resolve repeated dietary concerns reported during three (3) of the six (6) Resident Council meeting minutes reviewed. Findings include: Review of the facility's policy, Resident and Family Grievances/Complaints (undated) revealed, It is the policy of this facility to support each resident's and family member's right to voice grievances, without discrimination, reprisal or fear of discrimination or reprisal . Prompt efforts to resolve, include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance . 1. Social Director has been designated as the Grievance Official and can be reached at Social Services office. 2. The Social Worker is responsible for overseeing the grievance process: receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances: issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations . 8. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or Social Worker. b. Written complaint to a staff member or Social Worker. c. Written complaint to an outside party. d. Verbal complaint during resident or family council meetings . 10 .d. The Social Worker will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. i. Steps to resolve the grievance my involve forwarding the grievance to the appropriate department manager for follow up. ii. All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the Grievance Official. Prompt efforts include acknowledgement of complaint/grievances and actively working toward a resolution of that complaint/grievance . 12. The facility will make prompt efforts to resolve efforts to resolve grievances. Reviews of the facility's policy, titled Resident Rights, dated 1/24/22 revealed, The center through its Administrator, is responsible for establishing written policies that will safeguard the rights and responsibilities of medical assistance residents. The staff of the center is trained and involved in the implementation of these policies and procedures. The Administrator is responsible of adherence of the policies and procedures and for making them known to residents, families, and sponsor. Resident rights, policies, and procedures shall insure that each resident admitted to the center . 5 may voice grievance and recommend changes in policies and service to center staff and/or outside representatives of his choice, free from restraint, interference, coercion, discrimination, or reprisal . During a Resident Council meeting on 10/4/22 at 10:00 AM, the Resident Council members told the State Agency (SA) that they have complained for several months about the food being salty, cold, and bland, but nothing has been done to make things better. The Council reported that in September, the Dietary Manager was asked to attend their meeting to discuss the food issues. The members revealed that they were told their complaints would be given to the Dietary, Director of Nursing (DON), Administrator, and Social Worker. Resident #76 commented that the Dietary Manager told him one day in the hallway that she wanted to lose weight and look like him. Resident #76 said he told her that if you want to lose weight, maybe you should eat the food in this facility. It will make you lose weight, because its cold and taste awful. The residents in Resident Council said some of their families bring them food and other stated that they eat snacks. The Council members reported that, as of this date, nothing has been done to address their complaints. Review of Resident Council minutes dated 7/21/22, 8/18/22, 9/21/2022 revealed Resident #97 complains about food being cold and salty. In an interview on 10/4/22 at 1:00 PM, with the Activity Director, she confirmed the residents have complained about the food being salty and cold. The Activity Director explained that she gave a copy of the Resident Council minutes to the Administrator, DON, Dietary, Maintenance and the Social Worker. The Activity Director said it is up to the Department Heads to resolve the grievances. During an interview on 10/4/22 at 2:00 PM, with the Dietary Manager, it was confirmed the residents have complained of cold food for six months. The Dietary Manager said the previous Administrator ordered an electric plug for the plate warmer to keep the food warm, but the plates don't fit the food warmer. The Dietary Manager said she had been waiting on approval from corporate for the purchase of new plates but had failed to follow up with the new Administrator regarding the status of the approval. In an interview with the Administrator on 10/06/22 at 03:04 PM, she said she called the previous Administrator after the Dietary Manager told her the residents complained the food was cold. The Administrator said the previous Administrator said a Performance Improvement Project (PIP) was done before he left regarding cold food but stated she could not find the PIP. The previous Administrator told her that he ordered the plate warmer and had an electrician to come in. The kitchen was rewired to adjust to the plate warmer. The previous Administrator told her the plates that the facility has is too small and the tops don't stay down on the plates and new plates should have been ordered. The Administrator confirmed that the new plates were not ordered because everything got lost during the change in administration. The Administrator confirmed that she was going to get the plates to keep the resident food warm. During an interview with the previous Administrator on 10/6/22 at 3:30 PM, he confirmed the residents complained the food was cold six months ago when he was at that facility and a PIP had been done. He also confirmed that the electrical work had been done to accommodate the plate warmer, but the plates used at that time were too small. The Previous Administrator confirmed he did not order the plates prior to leaving the facility, so the plate order fell through the cracks.

Based on interviews, record reviews, and facility policy review, the facility failed to provide a financial record or quarterly statements to the resident or his/her representative, as voiced in Resident Council for four (4) of 12 residents interviewed. Residents #16, #19, #32, and #45. Findings Include: Review of the facility's policy, Quarterly Accounting of Resident Funds (undated) reveals, Our facility provides each resident who has funds managed by the facility on his/her behalf with a quarterly accounting of such funds . 1. An individual quarterly accounting of funds managed by the facility will be provided to each resident with personal funds entrusted to the facility. Residents may also receive an accounting of such funds upon making such request known to the Business Office. 2. Separate quarterly statements will be prepared by the Business Office and each record will include: a. The resident's balance the beginning of the statement periods; b. The total of deposits and withdrawals by the resident for the quarter; c. Any interest earned; and d. The ending balance for the quarter. 3. Statements of residents who are eligible for SSI or medical assistance will also reflect the difference between the ending balance and the applicable benefits eligibility level . On 10/04/22 at 10:00 AM, four (4) Resident council members revealed that they do not receive quarterly financial statements. Resident #16 During an interview on 10/4/22 at 10:15 AM with Resident #16, she stated she has not received a statement in a long time. Resident #16 said she doesn't know how much money she has available. Review of the Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 9/26/22, revealed Resident #16 has a Brief Interview for Mental Status (BIMS) score of 15, which indicates Resident #16 is cognitively intact. In an interview on 10/4/22 at 12:30 PM, with Resident #16's Resident Representative (RR), she revealed she has not received the resident's quarterly statements. The RR said she needs to know the resident's balance, as the resident needs burial insurance. Resident #19 During an interview on 10/04/22 at 10:30 AM, with Resident #19, he revealed that he has not received a quarterly statement of his funds. Resident #19 said he has been at the facility for over a year and doesn't know his balance. Record review of the MDS with the ARD of 9/27/22, revealed Resident #19 has a BIMS score of 15, which indicates Resident #19 is cognitively intact. Resident #32 During an interview on 10/4/22 at 11:15 AM, with Resident #32, she said she has not received a quarterly statement of her funds. Record review of Resident #32's Quarterly MDS with an ARD of 7/20/22, reveals Resident #32 has a BIMS score of 15, indicting the resident is cognitively intact. An interview on 10/4/22 at 11:30 AM, with Resident #32's RR, revealed she has not been consistently receiving Resident #32's quarterly statements. She stated statements were received January through March but had to call the Business Office Manager (BOM) in July to request a statement. The RR stated at this time, she doesn't know how much money is in the resident's account. Resident #45 During an interview on 10/4/22 at 11:40 AM, with Resident #45, she stated she has not received a quarterly statement of her funds. Record review of the Quarterly MDS with an ARD of 08/12/2022, revealed Resident #45 has BIMS score of 15, which indicates Resident #45 is cognitively intact. During an interview on 10/4/22 at 2:00 PM, with the BOM, she stated she gives the cognitive residents a copy of their quarterly statements and mails the statements to the families of the residents that are not cognitively intact. The Administrator confirmed during an interview on 10/4/22 at 2:30 PM, the BOM is unable to provide documentation that the statements were mailed or that the residents received a quarterly statement.

Based on interviews, record review, and facility policy review the facility failed to provide written notification to the Resident and the Resident's Representative (RR) of an emergency transfer to the hospital for three (3) of three (3) residents reviewed for hospitalization s. (Resident #31, Resident #68, and Resident #88) Findings Include: A record review of the facility's policy Transfers and Documentation with a revised date of 11/2017, revealed . E. Documentation . The documentation for all discharges and transfers must include, as a minimum, and as they apply: 1. The reason (s) for the discharge or transfer. 2. That an appropriate notice was provided to the resident and/or resident representative. Resident #31 A record review of the Admission Record revealed the facility admitted Resident #31 on 07/15/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #31's Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/07/2022, revealed, Section A .A0310. Type of Assessment .F. Entry/discharge reporting was coded as 11. Discharge assessment-return anticipated and A 2100 Discharge Status was coded as 03. Acute Hospital . A record review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] CHF (Congestive Heart Failure) Exacerbation, SOB, fluid overload . A record review of Resident #31's Discharge MDS with an ARD of 09/12/2022, revealed, Section A .A0310. Type of Assessment .F. Entry/discharge reporting was coded as 11. Discharge assessment-return anticipated and A 2100 Discharge Status was coded as 03. Acute Hospital . A record review of the clinical record for Resident #31 revealed there was no record of a written notification of transfer to an acute care hospital for the transfers that occurred on 09/07/2022 and 09/12/2022. Resident #68 A record review of the Admission Record revealed the facility admitted Resident #68 on 08/01/2022. He was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #68's Discharge MDS with an ARD of 08/13/2022, revealed, Section A .A0310. Type of Assessment .F. Entry/discharge reporting was coded as 11. Discharge assessment-return anticipated .A 2100 Discharge Status was coded as 03. Acute Hospital . A record review of the clinical record for Resident #68 revealed there was no record of a written notification of transfer to an acute care hospital for the transfer that occurred on 8/13/22. Resident #88 On 10/03/22 at 12:29 PM, during an interview with the RR visiting with Resident #88, he explained that he is the resident's nephew. He reported that Resident #88 recently went to the hospital several times and although the facility calls him when the resident is sent to the hospital, he had never received a written notification from the facility regarding the transfer. A record review of the Admission Record revealed the facility admitted Resident #88 on 05/11/2017 and he had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #88's Order Details with order date 07/27/2022 revealed May send to (Proper Name of Local Hospital) ER (emergency room ) for further evaluation. A record review of Resident #88's Discharge MDS with an ARD of 07/27/2022 revealed Section A . A0310. Type of Assessment . F. Entry/discharge reporting was coded as 11. Discharge assessment-return anticipated . A 2100 Discharge Status was coded as 03. Acute Hospital . A record review of Resident #88's Order Details with order date 08/07/2022 revealed May send to (Proper Name of Local Hospital) for further evaluation. A record review of Resident #88's Discharge MDS with an ARD of 08/07/2022 revealed Section A . A0310. Type of Assessment . F. Entry/discharge reporting was coded as 11. Discharge assessment-return anticipated . A 2100 Discharge Status was coded as 03. Acute Hospital . A record review of Resident #88's Order Details with order date 09/04/2022 revealed May transfer to (Proper Name of Local Hospital) . A record review of Resident #88's Discharge MDS with an ARD of 09/04/2022 revealed Section A . A0310. Type of Assessment . F. Entry/discharge reporting was coded as 11. Discharge assessment-return anticipated . A 2100 Discharge Status was coded as 03. Acute Hospital . A record review of the clinical record for Resident #88 revealed there was no record of a written notification of transfer to an acute care hospital for the transfers that occurred on 07/27/2022, 08/04/2022, and 09/04/2022. On 10/05/22 at 11:40 AM, during an interview with the Social Services Director (SSD), she stated that she calls the families and lets them know the resident is going to the hospital, but she does not provide any notification in writing. She commented that she did not know she was supposed to send written notification to the RR's. On 10/06/22 at 12:00 PM, during an interview with the Administrator, she explained that the SSD is responsible for providing written notification of transfers. She reported the nurses will send transfer notifications in a folder with the resident to the hospital. If the RR does not come in to sign the form, they will call the RR and make a note in the chart. She reported the facility has not mailed written notification with each hospital transfer regarding the reason for transfer.

Based on observation, staff interviews, record reviews, and facility policy review, the facility failed to develop a comprehensive care plan for a resident who was at risk of falls for one (1) of 22 residents reviewed. Resident #304 Finding Include: Review of the facility's policy, Care Plans-Comprehensive, dated 10/2016, revealed an individualized (person-centered) comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . Record Review of Resident #304's Admission Record, reveals the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/23/22, revealed that Resident #304 has a Brief Interview for Mental Status (BIMS) score of 10, which indicates moderate cognitive impairment. A record review of the Fall Risk assessment dated [DATE], revealed that Resident #304 has a moderate risk for falls. A review of Resident #304's comprehensive care plan revealed that the resident's care plan does not identify a risk for falls. On 10/03/22 at 12:00 PM, the State Agency (SA) observed Resident #304 sitting in her wheelchair by the bed. Observation revealed a swollen area on the left side of her forehead. On 10/04/22 at 04:05 PM, the SA conducted an interview with Certified Nurse's Aide (CNA) #1 regarding the injury noted to Resident #304's forehead. The CNA stated that as far as she knows, the resident has not had a fall since being here. On 10/06/22 10:50 AM, in an interview with Licensed Practitioner Nurse (LPN) #4, she confirmed that the resident has not experienced a fall since admission but had fallen at a previous facility. On 10/06/22 at 11:20 AM, in an interview with the Minimum Data Set (MDS) Coordinator, she revealed that they normally put a risk for falls on every resident's care plan. She confirmed that Resident #304's care plan does not include a risk for fall. On 10/06/22 at 01:47 PM, during an interview with the Director of Nursing (DON), she confirmed that Resident #304 is at risk for falls and should have had a care plan developed to address that risk.

Based on interviews and facility policy review, the facility failed to provide mail delivery on Saturday to residents. This deficient practice has the potential to effect 103 of 103 residents residing at the facility. Findings include: Review of the facility's, Mail Delivery Policy dated February 2009 revealed It is the policy of this facility to deliver the Resident's mail timely. The mail will be delivered to the Resident Monday thru Friday by the Activity Director. If the Resident receives mail on Saturday, it will be delivered to the Resident's by the week-end-RN Unit Manager. During an interview on 10/04/22 at 10:00 AM, with Resident Council members revealed the residents complained they don't receive their mail on Saturdays or Sundays. The residents said the Activity Director is off on weekends. During an interview on 10/06/22 at 12:15 PM, with the Activity Director, she confirmed the mail that is received on Saturday is not delivered to the residents until Monday morning when she returns to work. She said there is no weekend staff to deliver the mail. In an interview on 10/06/22 at 03:04 PM, the Administrator confirmed the Residents are not getting their mail on Saturdays. The Administrator said until today, she thought the Manager on duty was delivering the mail on weekends. The Administrator stated that she learned today the mail was being held until Monday when the Activity Director returned to work. The Administrator stated the Manager on duty will begin delivering mail received on Saturdays to the residents.

Based on interviews, record review, facility investigation review and facility policy review, the facility failed to provide adequate staff supervision to prevent Resident #1's elopement from the facility at 7:03 PM on 6/19/22, per video surveillance. Resident #1 was last seen by facility staff at 6:40 PM. The 3 PM to 11 PM shift Licensed Practical Nurse (LPN) #1/Charge Nurse/Staff Development Nurse was notified by Resident #1's Resident Representative (RR) at 8:00 PM, that she had been telephoned by a family friend that Resident #1 was observed walking around the church parking lot and the RR had immediately gone to the church, one half mile from the facility, and picked up Resident #1 and returned him to the facility. This concern was identified for one (1) of four (4) residents reviewed for wandering behavior and risk for elopement. Facility staff were not aware that Resident #1 left the facility without staff knowledge or supervision until approximately 8:00 PM on 6/19/22. The resident had been assessed by the facility as High Risk for Elopement. During the facility investigation, staff reviewed the security surveillance video and discovered the resident walked out the front door behind a group of visitors at 7:03 PM on 6/19/22. The front door was kept locked and required the intervention of staff to open. Staff members at the 100 Hall nurses station had viewed a line of visitors in line at the front door on a video screen at the nurses station and disengaged the lock which allowed the door to open. Resident #1 was not in view of the surveillance camera at the front door because he was at the end of the line of visitors and out of camera view. Resident #1 followed the visitors out of the facility's front door. Video footage from the surveillance camera outside the facility showed the resident walked off of the facility property at 7:07 PM. Resident #1's RR received a telephone call from a family friend who told her that they observed Resident #1 in the church parking lot one-half mile from the facility. Resident #1's RR went to the church, picked up the resident and returned him to the facility at 8:00 PM. Resident #1's assigned nurse, LPN #2 performed a head-to-toe body audit immediately upon his return to the facility which revealed no injuries; he was also immediately placed on one-on-one monitoring until he was transported to another facility with a dementia unit. The resident reported to the Staffing Development Nurse that he had gone to visit his mother and niece (RR). Resident #1's most recent Minimum Data Set (MDS), dated [DATE], revealed he scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated severe cognitive impairment. Resident #1 was identified on his Wandering Elopement assessment dated [DATE] as Resident at risk for wandering/elopement, and he was independently ambulatory. The facility's failure to provide adequate supervision to prevent an elopement for Resident #1 who was at risk for elopement allowed the resident to be away from the facility, unnoticed and unsupervised until the resident's RR returned him to the facility. This placed Resident #1, and other residents at risk for elopement, in a situation likely to cause serious injury, harm, impairment or death. On 6/24/22, the SA identified an Immediate Jeopardy (IJ), and Substandard Quality of Care (SQC), which began on 6/19/22, when Resident #1 exited the facility through the front door and was located just prior to 8:00 PM one-half mile away in a church parking lot and returned to the facility at 8:00 PM. The IJ and SQC existed at: 42 CFR(s): 483.25 (d)(1)(2)-Free of Accidents, Hazards/Supervision/Devices (F 689)-Scope and Severity J. The SA notified the facility's Administrator of the IJ and SQC on 6/24/22 at 2:22 PM, and provided the IJ template. Based on the facility's implementation of corrective actions on 6/20/22, the SA determined the IJ was removed as of 6/20/22, prior to the SA's first entrance on 6/23/22. Findings include: Record review of the facility policy titled RESIDENT AT RISK FOR WANDERING BEHAVIOR dated 4/26/22 revealed, This facility ensures that residents who exhibit wandering behavior receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Further review revealed The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for unsafe wandering .Adequate supervision will be provided to help prevent accidents or elopements. Record review of the facility's investigation dated 6/19/22 confirmed the last time Resident #1 was seen was at 6:40 PM. At 8:00 PM, the RR of Resident #1 delivered him to the facility. The facility's investigation revealed staff immediately completed a count of all residents to ensure that other residents were accounted for with no concerns noted. Exit doors and windows were checked by the staff and were operating correctly. On 6/23/22 at 6:30 PM, observation revealed the resident walked approximately one hundred fifty-six (156) feet from the front door to the sidewalk, then one-half (1/2) mile to the nearby church parking lot. The facility was situated approximately 55 yards off the road, posted speed limit thirty-five (35) miles per hour, with a fifteen (15) foot sidewalk and five (5) foot strips of grass on each side of the sidewalk. There was a white, broad board fence separating the road and the side yard of the facility. The road was parallel to the east side of the facility. The front of the facility faced a cement parking lot. The grass of the lawn was short, trimmed, and well-maintained. The parking lot was cement, clear, clean, free of holes and tripping hazards. The four lane street ran north to the red light at the intersection with a bank on the right (same side of the street as the facility) on the block on the corner 0.2 miles from the facility. From the bank it was 0.3 miles to the church across the two lane street (left side of the street) with a posted speed limit of thirty-five (35) miles per hour. The church was 0.5 miles from the facility. Record review of weather conditions in [NAME], MS on 6/19/22 according to website 'localconditionscom' revealed that at the time of elopement 7:00 PM until 7:15 PM, the temperature was 89.6 degrees Fahrenheit, clear with three (3) mile an hour northerly wind. Record review of the sunrise-sunset.org website revealed that on 6/19/22 the sun set at 8:12 PM. On 6/23/22 at 7:10 PM, observation from the east facing window of the facility revealed in a one-minute timed observation, there were fifteen (15) vehicles counted total (north to south and south to north). On 6/23/22 at 7:11 PM, observation from the east facing window of the facility revealed in a one-minute timed observation, there were twenty-five (25) vehicles counted total (north to south and south to north). On 6/23/22 at 8:15 PM, observation out of the window of the living room revealed the area was well lit and there was adequate natural lighting to see without problem. On 6/23/22 at 8:35 PM, an interview with the Administrator revealed that the facility reported incident identified as Elopement was discovered on 6/19/22 at 8:39 PM, when Resident #1's Resident Representative (RR), niece, returned Resident #1 to the facility side door and LPN #1 let them in and notified the Administrator, immediately observed Resident #1 for injury and dehydration and encouraged fluids by mouth, supervised a one-hundred percent (100%) head count/room check with resident census and performed a door check on all exit doors to ensure they were closed and locked. The Administrator stated the LPN #1 notified the Director of Nurses (DON) and performed interviews of facility staff for the facility investigation. The Administrator said Resident #1's RR reported the elopement to the facility and the Administrator reported the elopement to the State Agency on 6/19/22 at 9:29 PM. The Administrator stated that she had viewed surveillance camera footage of the front door and observed that the resident exited the front door at 7:03 PM on 6/19/22 by following behind a family group which included two people in wheelchairs, which she said, made the length of the line of people leaving out of the front door longer. She confirmed the resident had been wearing a pair of pants, a short-sleeved shirt and regular shoes at the time of elopement. She explained You can't put a code in on the outside (to open any of the doors), you must wait for someone to put in a code on the inside for each door. She stated that 8 AM-5 PM, the receptionist, Business Office Manager (BOM) and Administrator have a button at their desks that will open the front door. She stated, The Administrator has a monitor, the receptionist and BOM have windows they can see out. There's a doorbell outside the front door and the 100 hall or rehab nurses station has a little screen which shows view of camera with microphone of the front door and the nurses at the nurses station can open the front door from the nurses' station on the 100 hall, down the hall from the front door. The Administrator reported that surveillance camera footage revealed Resident #1 left out of the front door at 7:03 PM and left the facility property at 7:07 PM, and staff reports Resident #1 returned at approximately 8:00 PM. Resident #1 was gone from the facility for about an hour and a half. The Administrator stated that Resident #1 did not suffer any injuries of any kind during or due to the elopement. The Administrator revealed the facility completed a Quality Assurance and Assessment (QAA)/Quality Assurance Performance Improvement (QAPI) meeting on 6/20/22 in which the appropriate members were in attendance and policies were discussed with no changes to facility policies. She stated the facility conducted in-services/training related to elopements in which staff would not be able to work until in-serviced. The Administrator reported that she audited all residents at the facility that had been previously assessed as High Risk For unsafe wandering or elopement. She stated she that her audit revealed Resident #1 was the only resident at the facility who had been confirmed as having High Risk for Elopement. She stated she audited the remaining residents and it was her conclusion that no other residents were at more than Moderate Risk for Elopement. The care plans were reviewed for all residents at Moderate Risk for Elopement. On 6/23/22 at 9:00 PM, an interview with LPN #1 revealed she said she was working the night of 6/19/22 on the 3 PM-11 PM shift. She stated the elopement was discovered when family brought him (Resident #1) back to the facility at 8:00 (PM). Resident #1 was wearing a pair of pants, a short-sleeved shirt, and regular shoes at the time of elopement. LPN #1 stated Resident #1 was gone from the facility for about an hour and a half. The LPN stated that as soon as Resident #1's RR returned him to the facility at 8:00 PM, she telephoned the Administrator, recommended and provided cold water for the resident, then she completed a check of all the facility exit doors while the nursing staff performed a full body audit of Resident #1, conducted room checks and confirmed the presence of all residents compared to the printed daily census. No injuries or signs/symptoms of dehydration were noted. LPN #1 said the RR for Resident #1 told her that a family friend observed Resident #1 in the parking lot of a nearby church and telephoned the RR who had immediately gone to the church and picked the resident up and brought him to the facility. On 6/23/22 at 9:30 PM, an interview with the Director of Nurses (DON) revealed that prior to elopement, the resident was assessed as being at risk for elopement. She confirmed she had attended the Quality Assessment Performance Improvement (QAPI) meeting on 6/20/22 and the facility elopement policy was reviewed. On 6/24/22 at 3:00 PM, a telephone interview with the Resident Representative (RR) for Resident #1 revealed that she was contacted by telephone a little before 8:00 PM on 6/19/22 by a family friend who told her they had just seen Resident #1 in the parking lot of the nearby Church. She said she immediately went and picked Resident #1 up and took him to the facility. She stated Resident #1 had no noted injuries and no signs of dehydration or heat injury at the time. She stated she had conferred with the Administrator on 6/20/22 for care planning and was informed of a sister facility a short distance away which had a 'Dementia Care Unit' and she had agreed for Resident #1 to be transferred to the sister facility upon recommendation of the Nurse Practitioner. On 6/27/22 at 3:00 PM, an interview with CNA #1 confirmed she was working North Hall on the 3 PM-11 PM on the evening of 6/19/22 and visually observed Resident #1 on the North Hall at approximately 6:40 PM. She stated that Resident #1 walked around a lot, he didn't always stay on his unit; he left his unit every day. Record review of the Admission Record for Resident #1 revealed he was admitted by the facility on 6/25/21. Record review of the Diagnosis Information for Resident #1 revealed he had diagnoses of [CONDITION(S)], Dementia and Generalized Muscle Weakness. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/22, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated severe cognitive impairment. Further review of the MDS revealed Resident #1 was independently ambulatory. Record review of the Wandering Elopement Assessment for Resident #1, dated 9/21/21, revealed the evaluation stated Resident at risk for wandering/elopement. The facility implemented the following Corrective Action Plan prior to the SA's entrance on 6/23/22: Corrective Action Plan 1. On 6/19/2022, at 7:03 PM, Resident #1 exited the facility unsupervised, through the facility's front door with visitors holding door for Resident #1, after staff had disengaged the door for visitors. This represented an Immediate Jeopardy, and the Administrator was presented with an IJ template 6/24/2022 at 2:22 PM by the State Surveying Agency (SSA). 2. On 6/19/2022, at 8:00 PM, Resident #1's niece who is the Responsible Party (RP) returned him to the facility. She was greeted by Licensed Practical Nurse (LPN) #1. She stated someone had seen him and called her and she went and got him from the church (0.5 miles from facility) and is returning him to the facility. 3. On 06/19/22 at 8:00 PM, an investigation was initiated by LPN #2 and a body audit was completed for Resident #1 and there were no injuries noted. 4. On 6/19/22, upon return to facility, 8 PM, Resident #1 was placed on 1:1 observation by facility staff until discharged . 5. On 6/19/22, at 8:10 PM, LPN #2, notified the physician on call of the incident and there were no new orders given. 6. On 6/19/22, 8:10 PM, LPN #1, completed a head count and bed checks. All other residents were accounted for. 7. On 6/19/22, at 8:30 PM, LPN #1, checked all doors for proper functioning and locking. All doors were secured, locked and functioning properly. 8. On 6/19/22, at 8:35 PM, LPN #1 notified the Administrator and the Director of Nursing (DON) via phone. 9. Resident #1's care plan was reviewed and updated on 6/19/22, at 8:40 PM by LPN #1 and LPN #2. LPN #1 obtained statements from those working for any knowledge of the incident. 10. On 6/19/22, at 9:29 PM, the Administrator notified the State Agency via Complaint Line of Resident #1 exiting the facility. On 6/19/22, at 9:38 PM LPN #1, initiated an In-service education to staff, on Door release and observation, 1:1 to continue, Policy on Elopement or Missing Resident, including what to do if employee observes resident leaving premises, procedure for locating missing resident and Procedures Post-elopement. Also included in the in-service wandering elopement assessments, Adequate supervision to help prevent accidents or elopements (The staff will observe the door, not just the remote camera, henceforth), and Abuse/Neglect. No staff will be allowed to work until in-serviced by LPN #1, Staff Development Coordinator or DON. 11. On 6/19/22, statements obtained by LPN #1 at 9:40 PM, reveal CNA #1 last saw resident at 6:40 PM on South Unit. 12. On 6/19/22 at 9:40 PM, the Administrator audited Wandering Assessments and Care plans in Electronic Health Record remotely. All residents who are at high or moderate risk for wandering were audited, by review of most recent Elopement Assessments and Brief Interview of Mental Status (BIMS) scores. No other high-risk residents were identified. All moderate risk residents were also reviewed to determine risk score and that appropriate plan of care and interventions were in place. There were no new at risk identified and no other care plans updated as a result of the audit. 13. On 6/19/21, at 10:45 PM, Employee #1, included steps of Elopement Drill (Code [NAME]), as part of the in-service training for Wandering Risk Residents/Elopement Procedures. 14. On 6/20/22 at 7:00 AM the Administrator arrived at facility for review of Video Camera footage. Camera footage confirmed at 7:03 PM, a group of visitors exited the facility through the front door, including two in a wheelchair and 4 others. The staff released the door lock for the visitors to exit. As each visitor exited the facility they held the door open for the next person, the last visitor exiting the facility held the door open for Resident #1 to exit. Resident #1 walked with the visitor group through the parking lot to their cars. Resident #1 continue to walk the perimeter of the parking lot around to the sidewalk at approx. 7:06-7:10 PM. Resident #1 was returned to facility at approx. 8:00 PM. 15. On 6/20/22 at 8:00 AM, Maintenance #1, checked all the doors and locks again to ensure/validate appropriate functioning. All door locks were secure and functioning appropriately. 16. On 6/20/22, at 8:30 AM, the Administrator notified the facility's Medical Director of the incident. 17. On 6/20/22, the Nurse Practitioner (NP) recommended Resident #1 be transferred to a dementia unit. 18. On 6/20/22 at 8:00 AM -10 AM, an AD HOC Quality Assurance Performance Improvement (QAPI) meeting held with the NP, Administrator, DON, Staff Development Coordinator/LPN#1, infection preventionist and Registered Nurse (RN) unit Managers. The NP is the Medical Director's designee for the QAPI meeting. QAPI Committee Recommendations followed: On 6/20/22 at 10:00 AM, Referral sent to local facility with a dementia unit. Continue In-service education to staff, on Door release and observation, 1:1 to continue, Policy on Elopement or Missing Resident, including what to do if employee observes resident leaving premises, procedure for locating missing resident and Procedures Post-elopement. Also included in the in-service wandering elopement assessments, Adequate supervision to help prevent accidents or elopements (The staff will observe the door, not just the remote camera, henceforth), and Abuse/Neglect. No staff will be allowed to work until in-serviced by LPN #1, Staff Development Coordinator or DON. Resident care plan reviewed and updated on 6/19/22. Continue 1:1 observation until transfer to Dementia unit complete. Reviewed 06/19/22 audits of all resident's identified at risk for elopement. No new recommendations. No other HIGH risk residents present at this time. Door Screener's hours to be increased on 6/20/22 to 7 PM, Business Office Manager (BOM) to ensure Coverage and schedule. DON reviewed Elopement Binder, on 06/20/22. Resident #1 remains only high risk for elopement and resident information (face sheet and picture are in the binders). The Administrator, DON, LPN #1 and SDC to monitor for compliance. Wandering Resident and elopement Policy and Procedure Reviewed on 6/20/22, with no revisions recommended by the QAPI committee. 19. 06/20/22 9:30 AM, the Attorney General's Office was notified via Phone by the Administrator and DON. The facility alleges all corrective action to remove the immediate jeopardy was completed as of 6/20/22. VALIDATION: On 6/27/22, the SA validated the facility's investigation of the incident and implementation of the Corrective Action through observations, facility record review and interviews. 1. SA validated through interviews with LPN #1 and the facility Administrator, record reviews of the facility investigation, 'Incident Report' dated 6/19/22 and Resident #1's 'Progress Notes' and observation of facility surveillance video that on 6/19/2022, at 7:03 PM, Resident #1 exited the facility unsupervised, through the facility's front door with visitors holding door for Resident #1, after staff had disengaged the door for visitors. This represented an Immediate Jeopardy, and the Administrator was presented with an IJ template 6/24/2022 at 2:22 PM by the State Surveying Agency (SSA). 2. SA validated through interviews with Resident #1's RP and LPN #1 and record review of the facility investigation, that on 6/19/2022, at 8:00 PM, Resident #1's niece who is the Responsible Party (RP) returned him to the facility. She was greeted by Licensed Practical Nurse (LPN) #1. She stated someone had seen him and called her and she went and got him from the church (0.5 miles from facility) and is returning him to the facility. 3. SA validated through record review of the facility investigation, 'Incident Report' dated 6/19/22, and Resident #1's Progress Notes and interview with LPN #2 that on 06/19/22 at 8:00 PM, an investigation was initiated by LPN #2 and a body audit was completed for Resident #1 and there were no injuries noted. 4. SA validated through record review of 1:1 Resident Observation Form's dated 6/19/20 through 6/22/22, the facility investigation, 'Incident Report' dated 6/19/22, and Resident #1's Progress Notes and interview with LPN #1, LPN #2 and the Administrator that on 6/19/22, upon return to facility, at 8:00 PM, Resident #1 was placed on 1:1 observation by facility staff until discharged . 5. SA validated through record review of the 'Incident Report' dated 6/19/22 that on 6/19/22, at 8:10 PM, LPN #2, notified the physician on call of the incident and there were no new orders given. 6. SA validated through record review of the facility Census dated 6/19/22 used as a checkoff and the facility investigation, and interviews with LPN #1 and the Administrator that on 6/19/22, at 8:10 PM, LPN #1 completed a head count and bed checks. All other residents were accounted for. 7. SA validated through record review of the facility investigation and interview with LPN #1 that on 6/19/22, at 8:30 PM, LPN #1 checked all doors for proper functioning and locking. All doors were secured, locked and functioning properly. 8. SA validated through record review of the facility investigation and interview with LPN #1 that on 6/19/22, at 8:35 PM, LPN #1 notified the Administrator and the Director of Nursing (DON) via phone. 9. SA validated through record review of the care plan for Resident #1 and the facility investigation that Resident #1's care plan was reviewed and updated on 6/19/22, at 8:40 PM by LPN #1 and LPN #2. LPN #1 obtained statements from those working for any knowledge of the incident. 10. SA validated through record review of the facility investigation and interview with the Administrator that on 6/19/22, at 9:29 PM, the Administrator notified the State Agency via Complaint Line of Resident #1 exiting the facility. SA validated through record review of In-Service Training forms with sign-in sheets attached and interview with LPN #1 and CNA #1 that on 6/19/22, at 9:38 PM, LPN #1 initiated an In-service education to staff, on door release and observation, 1:1 to continue, Policy on Elopement or Missing Resident, including what to do if employee observes resident leaving premises, procedure for locating missing resident and Procedures Post-elopement. Also included in the in-service wandering elopement assessments, adequate supervision to help prevent accidents or elopements (The staff will observe the door, not just the remote camera, henceforth), and Abuse/Neglect. No staff will be allowed to work until in-serviced by LPN #1, Staff Development Coordinator or DON. 11. SA validated through interview with CNA #1 and record review of the facility investigation, including the written, signed statements of staff working the 3-11 shift that on 6/19/22, statements obtained by LPN #1 at 9:40 PM, reveal CNA #1 last saw Resident #1 at 6:40 PM on South Unit. 12. SA validated through interview with the Administrator and record review of sampled resident's clinical health records (Resident #2, Resident #3 and Resident #4), and reports printed by the Administrator that on 6/19/22 at 9:40 PM, the Administrator audited Wandering Assessments and Care plans in Electronic Health Record remotely. All residents who are at high or moderate risk for wandering were audited, by review of most recent Elopement Assessments and Brief Interview for Mental Status (BIMS) scores. No other high-risk residents were identified. All moderate risk residents were also reviewed to determine risk score and that appropriate plan of care and interventions were in place. There were no new at risk identified and no other care plans updated as a result of the audit. 13. SA validated through interviews with LPN #1 and CNA #1 and record review of In-Service Training forms with sign-in sheets attached that on 6/19/21, at 10:45 PM, Employee #1, included steps of Elopement Drill (Code [NAME]), as part of the in-service training for Wandering Risk Residents/Elopement Procedures. 14. SA validated through interview with the Administrator and observation of facility surveillance video that on 6/20/22 at 7:00 AM the administrator arrived at facility for review of Video Camera footage. Camera footage confirmed at 7:03 PM, a group of visitors exited the facility through the front door, including two in a wheelchair and 4 others. The staff released the door lock for the visitors to exit. As each visitor exited the facility they held the door open for the next person, the last visitor exiting the facility held the door open for Resident #1 to exit. Resident #1 walked with the visitor group through the parking lot to their cars. Resident #1 continue to walk the perimeter of the parking lot around to the sidewalk at approximately. 7:06-7:10 PM. Resident #1 was returned to facility at approximately. 8:00 PM. 15. SA validated through interview with the Administrator and record review of the facility investigation that on 6/20/22 at 8:00 AM, Maintenance #1, checked all the doors and locks again to ensure/validate appropriate functioning. All door locks were secure and functioning appropriately. SA confirmed through observation that all door locks were secure and functioning appropriately. 16. SA validated through record review of the 'Incident Report' dated 6/19/22 that on 6/20/22, at 8:30 AM, the Administrator notified the facility's Medical Director of the incident. 17. SA validated through record review of the 'Progress Notes' for Resident #1 dated 6/20/22 that on 6/20/22, the Nurse Practitioner (NP) recommended Resident #1 be transferred to a dementia unit. 18. SA validated through record review of the QAPI meeting minutes with attached sign-in sheet that on 6/20/22, Resident #1's 'Progress Notes', 1:1 Resident Observation forms, In-Service Training sheets, Resident #1's Care Plan, facility Elopement Binders, Interview with the on duty Door Screener, Administrator, LPN #1 and DON that at 8:00 AM -10 AM, an AD HOC Quality Assurance Performance Improvement (QAPI) meeting held with the NP, Administrator, DON, Staff Development Coordinator/LPN#1, infection preventionist and Registered Nurse (RN) unit Managers. The NP is the Medical Director's designee for the QAPI meeting. QAPI Committee Recommendations followed: On 6/20/22 at 10:00 AM, Referral sent to local facility with a dementia unit. Continue In-service education to staff, on Door release and observation, 1:1 to continue, Policy on Elopement or Missing Resident, including what to do if employee observes resident leaving premises, procedure for locating missing resident and Procedures Post-elopement. Also included in the in-service wandering elopement assessments, Adequate supervision to help prevent accidents or elopements (The staff will observe the door, not just the remote camera, henceforth), and Abuse/Neglect. No staff will be allowed to work until in-serviced by LPN #1, Staff Development Coordinator or DON. Resident care plan reviewed and updated on 6/19/22. Continue 1:1 observation until transfer to Dementia unit complete. Reviewed 06/19/22 audits of all resident's identified at risk for elopement. No new recommendations. No other HIGH risk residents present at this time. Door Screener's hours to be increased on 6/20/22 to 7 PM, Business Office Manager (BOM) to ensure Coverage and schedule. DON reviewed Elopement Binder, on 06/20/22. Resident #1 remains only high risk for elopement and resident information (face sheet and picture are in the binders). The Administrator, DON, LPN #1 and SDC to monitor for compliance. Wandering Resident and elopement Policy and Procedure Reviewed on 6/20/22, with no revisions recommended by the QAPI committee. 19. SA validated through interview with the Administrator and record review of the facility investigation that on 6/20/22 at 9:30 AM, the Attorney General's Office was notified via phone by the Administrator and DON. The facility alleges all corrective action to remove the immediate jeopardy was completed as of 6/20/22. The SA validated that all corrective action to remove the immediate jeopardy was completed as of 6/20/22 and the Immediate Jeopardy was removed on 6/20/22, prior to entrance.