Every finding on record at Diversicare of Moss Point

Based on observation, staff interview, and facility policy review, the facility failed to ensure dishes were properly air-dried prior to use when dishware with visible moisture was used during meal service, including (10) plate dome covers and five (5) serving bowls for one (1) of two (2) kitchen observations. Findings include:A review of the facility's policy, Warewashing, revised 2/2023, revealed, .All dishware, service ware, and utensils will be cleaned and sanitized after each use. Procedures.4. All dishware will be air dried and properly stored.On 4/21/26 at 11:30 AM, during an interview and observation of tray preparation for the [NAME] Wing, the Dietary Manager was observed assisting the cook with preparing lunch trays. Plate dome covers were on a table behind the tray line with visible moisture and water dripping from the surfaces. (10) dome covers were observed to be wet. The Dietary Manager and District Dietary Manager were present during the observation and acknowledged the dome covers were wet but continued preparing trays and using the wet dome covers. During the same observation, a staff member brought five (5) serving bowls that were wet with water dripping from them, and the Dietary Manager used the bowls for tray preparation. At 11:55 AM, the last tray was removed for temperature testing, and water droplets were observed on the dome cover of the sample tray.On 4/22/26 at 1:30 PM, during an interview with the Dietary Manager, she confirmed that on 4/21/26 the plate dome covers and serving bowls used during tray preparation were wet, with water dripping from the items, and that staff used those items while preparing trays. She reported this practice is referred to as wet nesting and stated staff are expected to allow dishware to dry completely before stacking or use. She explained failure to properly clean and dry dishware and wet nesting could allow bacteria to grow and potentially cause foodborne illness.On 4/22/26 at 2:10 PM, during an interview with Registered Nurse (RN) #6, Infection Preventionist, she reported the facility had not experienced recent foodborne illness. When informed that dishware was observed to be wet during use, she explained this practice could allow bacterial growth and increase the risk of foodborne illness.On 4/22/26 at 4:46 PM, during an interview with the Administrator, he reported staff are expected to ensure all dishware is properly dried prior to stacking and use. He explained wet nesting can promote bacterial growth and increase the risk of foodborne illness. He further reported there is adequate space in the kitchen to allow proper drying and stated this issue had been previously identified and staff had been instructed to ensure dishware is fully dried before use.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a safe, clean, comfortable, homelike environment for residents when the facility failed to maintain resident rooms free from debris, ensure linens were clean and intact, ensure soiled items were handled in a manner that maintained a clean resident environment, and maintain clean and sanitary shower facilities, affecting three (3) of 19 sampled residents (Residents #25, #7, and #72) and all residents utilizing the North shower room.Findings include: A review of the facility's Resident Rights & Quality of Life Policy, dated 3/13/20, revealed, .It is the policy.that all patients and residents have the right to a dignified existence.Procedure A patient or resident has the right.To receive services in a center environment that is safe, clean, and comfortable. Resident #25 On 4/19/26 at 11:45 AM, during an interview and observation with Resident #25, he reported there were times the facility failed to provide clean linens. There was a bag of odorous soiled linens resting on the floor against the wall in the resident's room. He had a clean bedspread on his bed that had a football-sized hole near the head of the bed and the mattress was exposed. Resident #25 commented that it was not unusual for bags to be on the floor and for the bedding to be damaged. On 4/19/26 at 11:52 AM, during an interview with Certified Nurse Aide (CNA) #1, she confirmed a bag of soiled linens was resting on the floor in Resident #25's room. She reported soiled linens should be promptly placed in a designated linen receptacle. She further reported that staff commonly left soiled linens in bags on the floor after morning care and removed them later in the day. CNA #1 confirmed that the facility had linens available without holes in the linen cart and stated that torn bedding should not be placed on resident beds. On 4/19/26 at 12:46 PM, during a follow-up interview with Resident #25, he reported that CNA #1 changed the bedding with the hole, but she added it to the existing bag that had been on the floor and then placed it on top of his furniture where his clean clothes were hanging. On 4/19/26 at 12:52 PM, during an observation and interview with Licensed Practical Nurse (LPN) #3, she confirmed the bag of soiled linens was resting on Resident #25's furniture where the resident's clean clothing was hanging and stated the placement was not appropriate. On 4/20/26 at 12:20 PM, during an observation and interview with Resident #25, he reported he was still upset that a bag of soiled linens that was previously on the floor was placed on top of his clean clothing yesterday. There was one (1) dead roach noted under his bed near the headboard. On 4/20/26 at 3:04 PM, during a follow-up interview with CNA #1, she reported she placed the bag of soiled linens on the resident's furniture to avoid dragging it across the floor and planned to return later with a soiled linen cart. She acknowledged she did not realize his clean clothing was underneath the bag and understood why he would be upset. A record review of the admission Record revealed the facility admitted Resident #25 on 3/13/20 with diagnoses including Type 2 Diabetes Mellitus. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/26 revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact. Resident #7 On 4/19/26 at 12:05 PM, during an observation and interview with Resident #7, he reported housekeeping staff did not clean under the beds. There were three (3) large dead roaches under Resident #7's bed. On 4/20/26 at 12:27 PM, during an observation and interview with Resident #7, (3) large dead roaches continued to be observed under the bed. He reported housekeeping staff had not cleaned under his bed and stated he had not observed staff mopping or deep cleaning the room. On 4/21/26 at 10:39 AM, during an interview and observation with the Housekeeping Supervisor, he reported staff were expected to clean under beds during routine cleaning. There were five (5) dead roaches under Resident #7's bed. The Housekeeping Supervisor stated the area should not have been in that condition and required cleaning. A record review of the admission Record revealed the facility admitted Resident #7 on 3/10/25 and readmitted him on 3/31/26 with diagnoses including End Stage Renal Disease. A record review of the Comprehensive MDS with an ARD of 3/16/26 revealed Resident #7 had a BIMS score of five (5), which indicated the resident's cognition was severely impaired. Resident #72 On 4/19/26 at 12:15 PM, during an interview with Resident #72, he reported he often picked up dead roaches himself and disposed of them because staff did not remove them. There was (1) large dead roach under his bed. A record review of the admission Record revealed the facility admitted Resident #72 on 10/23/25 with diagnoses including Diffuse Traumatic Brain Injury. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/29/26 revealed Resident #72 had a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated the resident's cognition was moderately impaired. On 4/21/26 at 2:35 PM, during an interview with the Director of Nursing (DON), she reported it was her expectation that residents reside in a clean environment. She stated soiled linens should not be left in resident rooms or placed on residents' furniture and that the CNA should have immediately taken the dirty linen bag out of the room. She explained that torn or frayed sheets should immediately be removed and thrown out by housekeeping or removed and discarded by nursing staff. She stated they should never be applied to the residents' beds. North Shower Room On 4/20/26 at 3:00 PM, during an interview with thirteen (13) Resident Council members, three (3) residents had BIMS scores of eleven (11) and twelve (12), which indicated their cognition was moderately impaired, and ten (10) residents had BIMS scores ranging from thirteen (13) to fifteen (15), which indicated they were cognitively intact. Residents reported they refused to use the shower room due to cleanliness concerns. They reported observing dirty clothing, feces (bowel movement) and residue on shower chairs and floors. On 4/21/26 at 10:36 AM, during an interview with a housekeeper, she reported she cleaned the shower rooms multiple times throughout the day, however, Certified Nurse Aides (CNAs) were responsible for cleaning and sanitizing the shower room after each use. She reported observing occasions when CNAs failed to clean the shower room. On 4/22/26 at 9:30 AM, during an observation, the north shower room was observed with soiled clothing, including a soiled brief, on a shower chair. A yellow fluid-like substance was observed on the floor and shower chair, and a white powdery substance was observed on the floor. No staff were present at the time of observation. On 4/22/26 at 9:45 AM, during an interview with the Social Services Assistant, she acknowledged staff were expected to clean and sanitize the shower room after each use. On 4/22/26 at 10:00 AM, during an interview with the Director of Nursing (DON), she reported staff were expected to clean and sanitize the shower room after each use to ensure it was clean for the next resident. On 4/22/26 at 2:00 PM, during an interview with the Administrator, he confirmed staff were expected to clean and sanitize the shower room after each use and stated the shower room should not be left in an unsanitary condition.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure meals were served with an acceptable flavor, palatability, and appearance for two (2) of four (4) meal observations, with the potential to affect all residents receiving meals in the facility. (4/20/26 and 4/21/26)Findings include:A review of the facility's policy, Food: Quality and Palatability, dated 2/2023, revealed .Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperatures .On 4/20/26 at 11:30 AM, during an observation of lunch meal tray for Resident #48, the resident asked the surveyor to touch a grilled cheese sandwich because she could not eat it. The sandwich was hard and the cheese was not melted. A bowl containing a thick red substance identified as tomato soup was present. Resident #48 reported she could not eat the meal due to its condition.On 4/20/26 at 3:00 PM, during an interview with thirteen (13) Resident Council members, three (3) residents had Brief Interview for Mental Status (BIMS) scores of (11) and (12), which indicated their cognition was moderately impaired, and (10) residents had BIMS scores ranging from (13) to (15), which indicated they were cognitively intact The residents reported that the food was not palatable and explained they had voiced concerns about food quality during monthly food committee meetings. Residents reported they used their personal funds to purchase snacks instead of eating facility meals.On 4/21/26 at 12:13 PM, during an observation of a test lunch meal tray, the green beans were salty, and the meatballs lacked taste, were not formed, and appeared as loose ground meat in gravy. On 4/21/26 at 12:30 PM, during an interview with the Dietary Manager for facility meal services, the Dietary Manager reported she was not aware residents had complained about the food recently and she was not aware of concerns regarding food palatability.On 4/21/26 at 1:00 PM, during an interview with the Activity Director for facility residents, the Activity Director reported residents complained about food being not palatable and reported residents expressed concerns regarding taste, salt content, and food texture.On 4/22/26 at 9:10 AM, during an interview with the Social Services Director (SSD) for facility residents, the SSD reported she attended monthly food committee meetings and reported residents complained about food taste and temperature. The SSD reported the Dietary Manager documented the meeting minutes and confirmed the minutes did not reflect resident complaints.On 4/22/26 at 2:00 PM, during an interview with the Administrator regarding facility meal services, the Administrator reported he observed a thick tomato soup on 4/19/26 and reported he relied on the Dietary Manager to address food-related concerns and reported he would become involved in food committee meetings.

Based on observation, interview, record review, and facility policy review, the facility failed to prevent the possible spread of infection for two (2) of four (4) survey days when, on 4/21/26, staff failed to utilize appropriate Personal Protective Equipment (PPE) during high-contact resident care for a resident on Enhanced Barrier Precautions and on 4/19/26, the facility failed to ensure a nurse did not carry uncovered medications and water into one resident's room, contact the resident and the resident's environment, and then administer the same medications to another resident without performing hand hygiene.Findings include: A review of the facility's policy, Infection Control Guide, dated 2025, revealed, .Enhanced Barrier Precautions (EBP).refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (multidrug resistant organisms) to staff hands and clothing.The use of gown and gloves for high-contact resident care activities is indicated.for nursing home residents with wounds and/or indwelling medical devices. A review of the facility's policy, Policies and Practices – Infection Control, dated 11/1/2017, revealed, .This center's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Enhanced Barrier Precautions: On 4/21/26 at 11:00 AM, during an observation and interview for Resident #89, three (3) Certified Nurse Aides (CNAs) were observed in the resident's room. All CNAs used hand sanitizer and applied gloves; however, no gowns were worn while providing care. Catheter care was completed by CNA #4 with assistance from CNA #2 and CNA #3. During an interview, all three (3) CNAs confirmed Resident #89 was on Enhanced Barrier Precautions due to a wound and indwelling catheter and acknowledged gowns were not worn while providing care. The CNAs reported they had been educated on Enhanced Barrier Precautions and denied any shortage of PPE. Enhanced Barrier Precaution signage was observed on the resident's door. On 4/21/26 at 4:10 PM, during an interview with the Director of Nursing (DON), she reported she expected all staff to wear appropriate PPE when providing care to residents on Enhanced Barrier Precautions. She stated staff had received repeated education and in-services on PPE use and confirmed PPE was readily available on each unit. On 4/22/26 at 2:06 PM, during an interview with Registered Nurse (RN) #5, Infection Preventionist, she reported Enhanced Barrier Precautions are required for residents with wounds, catheters, or PEG tubes during high-contact care activities. She stated PPE is expected to be worn during care and confirmed staff had received repeated education on these requirements. A record review of the admission Record revealed the facility admitted Resident #89 on 2/2/26 with diagnoses including End Stage Renal Disease. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/9/26 revealed Resident #89 had a Brief Interview for Mental Status (BIMS) score of seven (7), which indicated the resident's cognition was severely impaired. A review of Section H revealed Resident #89 had an indwelling catheter. A record review of the Order Summary Report revealed Resident #89 had a physician's order, dated 2/4/26, for a Foley (indwelling catheter) for neurogenic bladder. Hand Hygiene: On 4/19/26 at 12:42 PM, during an observation, Licensed Practical Nurse (LPN) #6 entered an unsampled resident's room carrying an uncovered cup containing medications and an uncovered cup of water intended for another resident. While in the room, LPN #6 used her free hand to adjust the resident's nasal cannula and reposition the resident in bed. LPN #6 then exited the room carrying the same uncovered medications and water, proceeded to another resident's room, and administered the medications without performing hand hygiene. On 4/19/26 at 2:55 PM, during an interview with LPN #6, she acknowledged she should not have taken medications intended for one resident into another resident's room and confirmed she failed to perform hand hygiene. She reported she believed hand hygiene was only required after every third (3rd) resident. She acknowledged this practice could result in contamination of medications and the potential spread of germs between residents. On 4/21/26 at 12:09 PM, during an interview with the Director of Nursing Services (DNS), she confirmed medications should be taken directly to the intended resident and stated staff are expected to perform hand hygiene after contact with a resident or the resident's environment. She reported carrying uncovered medications into another resident's room created a risk of contamination and potential transmission of infection.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain an effective pest control program to prevent and control the presence of pests throughout the facility, resulting in ongoing roach activity in resident rooms and common areas for four (4) of (19) sampled residents. (Residents #25, #7, #72, and #110).Findings include:A review of the facility's policy, Pest Control, dated 9/1/2014, revealed, .It is the policy of this center to maintain an effective pest control program. Procedures.1. The center maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.Resident #25On 4/19/26 at 11:45 AM, during an observation and interview with Resident #25, two (2) gnats were observed flying in the resident's room. Resident #25 reported he observed roaches frequently in his room and stated he and his roommate continued to see roaches and flying insects despite the facility spraying for pests.On 4/20/26 at 12:20 PM, during an observation of Resident #25's room, one (1) dead roach was observed under the bed near the headboard.A record review of the admission Record revealed the facility admitted Resident #25 on 3/13/20 with diagnoses including Type 2 Diabetes Mellitus.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/26 revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of (14), which indicated the resident was cognitively intactResident #7On 4/19/26 at 12:05 PM, during an observation and interview with Resident #7, three (3) large dead roaches were observed under the resident's bed. Resident #7 reported he and his roommate observed roaches regularly in the room, particularly at night, and stated roaches had been seen crawling on the ceiling and had fallen onto him and his roommate. He reported staff had been notified; however, he had not observed staff responding to assess or treat the issue.On 4/20/26 at 12:27 PM, during an observation and interview with Resident #7, (3) large dead roaches continued to be observed under the bed. Resident #7 reported an incident in which an emergency medical technician (EMT) observed roaches crawling from under the bed and expressed concern regarding the condition.A record review of the admission Record revealed the facility admitted Resident #7 on 3/10/25 and readmitted on [DATE] with diagnoses including End Stage Renal Disease.A record review of the comprehensive MDS with an ARD of 3/16/26 revealed Resident #7 had a BIMS score of five (5), which indicated the resident's cognition was severely impaired.Resident #72On 4/19/26 at 12:15 PM, during an observation and interview with Resident #72, one (1) large dead roach was observed under the resident's bed. Resident #72 reported he had observed roaches crawling on the ceiling and under the bed and stated he often removed dead roaches himself because staff did not.A record review of the admission Record revealed the facility admitted Resident #72 on 10/23/25 with diagnoses including Diffuse Traumatic Brain Injury.A record review of the quarterly MDS with an ARD of 1/29/26 revealed Resident #72 had a BIMS score of ten (10), which indicated the resident's cognition was moderately impaired.Resident #110On 4/21/26 at 4:30 PM, during an interview with the family member of Resident #110, she reported she felt it was necessary to bring her own roach spray to the facility due to concerns about roaches in the resident's room. She stated she was told she could not keep the spray in the room and expressed concern that the roach problem needed to be addressed.A record review of the admission Record revealed the facility admitted Resident #110 on 4/3/26 with diagnoses including Metabolic Encephalopathy.A record review of the comprehensive MDS with an ARD of 4/9/26 revealed Resident #110 had a BIMS score of eight (8), which indicated the resident's cognition was moderately impaired.On 4/20/26 at 3:00 PM, during an observation and interview with thirteen (13) Resident Council members, two (2) large roaches were observed crawling across the floor. Three (3) residents had BIMS scores of eleven (11) and twelve (12), which indicated their cognition was moderately impaired, and ten (10) residents had BIMS scores ranging from thirteen (13) to fifteen (15), which indicated they were cognitively intact. The resident's reported roaches were commonly observed in resident rooms and common areas, and stated roaches were seen crawling on walls, ceilings, and floors, particularly at night.On 4/20/26 at 3:50 PM, during a phone interview with contracted pest control staff, he reported he provides pest control services monthly, focusing on different areas of the facility during each visit. He reported receiving occasional complaints of roaches but not frequently and stated he primarily treats entry points and exterior areas. He reported he had not personally observed roaches in the facility.On 4/21/26 at 10:39 AM, during an interview with the housekeeping supervisor, he reported staff are expected to notify maintenance when pests are observed so pest control services can be requested.On 4/21/26 at 2:35 PM, during an interview with the Director of Nursing (DON), she reported it was her expectation that residents reside in a sanitary environment free from pests and that staff should report pest concerns for follow-up.On 4/22/26 at 11:50 AM, during an interview with the Maintenance Director, he reported the facility utilizes a contracted pest control service monthly and as needed. He stated staff can submit maintenance requests through an electronic system for pest concerns and reported he also treats rooms when notified. He confirmed pest control services address both interior and exterior areas of the facility.

Based on interview and record review, the facility failed to ensure an ongoing program of activities designed to meet the interests and preferences of one (1) of two (2) residents reviewed for activities. Resident #70, when the facility failed to ensure weekend activities were implemented, monitored, and reflective of the resident's expressed interests.Findings include:A record review of the admission Record revealed the facility originally admitted Resident #70 on 01/09/2017 with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction affecting the left non-dominant side. He was readmitted by the facility on 7/3/2021.A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/20/25 revealed Resident #70 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. The MDS further revealed the resident reported multiple activity preferences as very important, including listening to music, participating in group activities, engaging in favorite activities, going outside, and participating in religious services.A record review of the Activity Participation Review - V3 dated 02/19/26 revealed under Attendance and Participation Summary that Resident #70 participated in Small Group and Large Group activities with frequency documented as VARIES, and under Independently, Individual activities were documented as DAILY, while participation with Family/friends and With other residents was documented as VARIES. The record further revealed under Describe resident's favorite activities, special accomplishments, new interests: that the categories Cognitive (trivia, discussion, reading, word puzzles), Entertainment (television, music, movies, visiting groups), Games (board games, bingo, cards, video games, tablets), and Spiritual (church, readings, nature, music, meditation, etc.) were selected, with Games further specified as BINGO, while Entertainment, Spiritual, and Social were documented as VARIES. A continued review revealed under Activity Plan Review that Goals were not met and have been revised. See care plan, and Interventions/approaches have not been effective in attaining goals. New approaches have been added to the care plan.A record review of the facility's activity calendar for April 2026 revealed scheduled activities throughout the week, including weekend entries such as Puzzles, Word Search, Coloring, and Watch TV in Resident Room. The calendar reflected that activities were planned for Saturdays and Sundays; however, the listed weekend activities were limited in variety and did not demonstrate individualized or structured programming specific to Resident #70's interests.On 04/19/26 at 12:50 PM, during an interview with Resident #70, he reported there were no activities for men on Saturdays and no activities on Sundays. He explained that on Saturdays there may be manicures, but nothing of interest to him. He stated he typically stayed in his room, went into the hallway, or went to the kitchen, and stated there was a need for more activities.On 04/20/26 at 12:30 PM, during an interview with the Activities Director (AD), she reported the Activities Department provided activities Monday through Friday and that activity staff did not work on Sundays. She stated that on Saturdays, activity staff may be present but are primarily assigned to transportation duties from 5:00 AM to 5:00 PM, with additional responsibilities in the dining room. She reported board games and puzzles were available in the dining room and that a movie may be left for staff to play. She stated that if a church group visited on Sunday, that would serve as an activity. The AD confirmed there was no system in place to monitor whether weekend activities occurred.On 04/20/26 at 2:00 PM, during an interview with Restorative Certified Nurse Aide (RCNA) #5, she reported the Restorative Department did not provide activity services on weekends and had not been assigned to do so. She explained her duties remained consistent seven (7) days a week and involved restorative care and dining assistance.On 04/20/26 at 3:20 PM, during an interview with Licensed Practical Nurse (LPN) #7, Director of Care Coordination, she confirmed the RCNAs were fully assigned to restorative duties and did not have time to provide activities.On 04/22/26 at 3:25 PM, during an interview with the Director of Nursing Services (DNS), she confirmed the RCNAs were not assigned to provide activities and would not have time to do so.On 04/22/26 at 5:12 PM, during an interview with the Administrator, he acknowledged that activities were not consistently provided on weekends and stated the facility planned to implement a process to ensure activities were provided.

Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies, specifically, the facility was cited for failing to follow infection control practices by not implementing Enhanced Barrier Precautions (EBP) for a resident at high risk for Multidrug Resistant Organisms (MDRO) during an annual recertification survey on 12/05/2024 and was cited again for the same deficiency during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of (12) deficiencies cited. F880. Findings Include:Review of the facility's policy, Quality Assessment and Performance Improvement (QAPI), dated March 2025, revealed, .The center develops, implements, and maintains an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care.Procedure.3. The QAPI plan will address the following elements:.c.addressing how the committee will conduct activities necessary to identify and correct quality deficiencies.i. Tracking and measuring performance. ii. Establishing goals and thresholds for performance improvements. Iii. Identifying and prioritizing quality deficiencies. iv. Systematically analyzing underlying causes of systemic quality deficiencies. v. Developing and implementing corrective action or performance improvement activities. vi. Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed.Record review of the Provider History Report revealed the facility received a citation during the annual recertification survey for F880-Infection Prevention & Control.Record review of the CMS-2567 (a record that identifies the federal regulation in violation and describes the findings of noncompliance and the facility's plan of correction), with a survey date of 12/05/2024, revealed the facility received a citation for F880, .Based on observation, staff interviews, record reviews, and facility policy reviews, the facility failed to follow infection control practices by not implementing Enhanced Barrier Precautions (EBP) for a resident at high risk for Multidrug-Resistant Organisms (MDRO) for one (1) of 21 sampled residents.During the current recertification survey, the facility failed to prevent the possible spread of infection when on 4/21/26, staff failed to utilize appropriate Personal Protective Equipment (PPE) during high-contact resident care for a resident EBP.On 04/22/2026 at 5:15 PM, during an interview with the Administrator, he stated that in response to the previous citation the QAPI team developed a plan of correction that was ongoing for (13) weeks to ensure EBP procedures and carried out correctly. The Administrator stated that the plan was implemented by all staff and was monitored by the Director of Nursing Services (DNS), Assistant Director of Nursing Services (ADNS), and the Director of Clinical Education (DCE). The Administrator stated that the QAPI committee revisited this citation monthly for three (3) months and that a spreadsheet was developed to track their monitoring and findings. The Administrator revealed that no relapses occurred during the facility's monitoring period. The Administrator stated this indicated that the monitoring should have been hard wired at that time. The Administrator revealed that ongoing processes to ensure improvements will include management walking around and monitoring staff in daily work, annual training on EBP, and monitoring for infections.

Based on observation, interview, and record review, the facility failed to ensure a Foley (indwelling catheter) securement device was in place to prevent tension and pulling on the catheter for one (1) of (1) resident reviewed for catheters. Resident #89.Findings include:A review of the facility's document, Proper Techniques for Urinary Catheter Maintenance, undated, revealed, .Maintain unobstructed urine flow. Keep the catheter and collecting tube free from kinking.On 4/20/26 at 12:15 PM, during an observation and interview, Resident #89 was observed sitting in a wheelchair in the hallway with catheter tubing visible. The resident was wearing shorts, and no catheter securement device was observed in place. During an interview, the resident reported he did not have anything to hold the catheter in place.On 4/21/26 at 11:00 AM, during an observation of catheter care with Certified Nurse Aide (CNA) #4, assisted by CNA #2 and CNA #3, no catheter securement device was observed in place for Resident #89. Following care, during an interview with all three (3) CNAs, they confirmed there was no catheter securement device in place. CNA #3 reported the nurse must apply the catheter securement devices and that they were locked in the central supply closet. CNA #4 reported the resident had not had a securement device in place all morning and that she had notified the nurse.On 4/21/26 at 11:25 AM, during an interview with Registered Nurse (RN) #4, she reported residents with indwelling catheters are required to have a securement device in place at all times to prevent tension, pulling, and complications.On 4/21/26 at 3:00 PM, during an interview and observation with Licensed Practical Nurse (LPN) #1, she reported that she had not been informed that a catheter securement device was needed for Resident #89. During an observation of the resident, there was no catheter securement device present. She explained the purpose of the device is to prevent pulling and trauma.On 4/21/25 at 4:10 PM, during an interview with the Director of Nursing (DON), she reported all residents with indwelling catheters are expected to have a securement device in place to prevent trauma or pulling. She confirmed staff are expected to notify nursing immediately if a device is not in place so it can be reapplied.A record review of the admission Record revealed the facility admitted Resident #89 on 2/2/26 with current diagnoses including Osteomyelitis of Vertebra.A record review of the Order Summary Report revealed Resident #89 had a Physician's Order, dated 2/4/26, for a foley catheter for neurogenic bladder.A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/9/26 revealed Resident #89 had a Brief Interview for Mental Status Score of seven (7) which indicated his cognition was severely impaired. A review of Section H revealed he had an indwelling catheter.

Based on observation, interview, and record review, the facility failed to ensure a resident receiving enteral nutrition via a Percutaneous Endoscopic Gastrostomy (PEG) tube received care and services to prevent complications when the tube feeding solution, water flush bag, and syringes were not labeled for one (1) of (1) residents reviewed for enteral feeding. Resident #90.Findings include:On 4/19/26 at 1:10 PM, during an observation, Resident #90 was observed lying in bed with the head of the bed elevated. A tube feeding was observed infusing at (55) milliliters (ml) per hour via a feeding pump. The feeding bag contained formula; however, the bag was not labeled with the type of feeding, date, time, or rate. A water flush bag was observed labeled with the resident's name and date of 4/19/26; however, no time or additional information was noted. Two (2) syringes were observed in the room, one (1) on the bed near the pillow and (1) on the bedside table; however, neither syringe was labeled or dated.On 4/19/26 at 3:05 PM, during an observation and interview with Certified Nurse Aide (CNA) #3, she confirmed the feeding bag contained formula and was not labeled. She reported the resident received tube feeding only and did not receive anything by mouth.On 4/19/26 at 3:16 PM, during an observation and interview with Licensed Practical Nurse (LPN) #4, she reported she had hung the tube feeding earlier that day and confirmed the feeding bag was not labeled with the type of feeding, date, time, or rate. She stated there was (1) label available, which she applied to the water flush bag. She confirmed the resident had (2) syringes used for care and acknowledged neither syringe was labeled or dated. She explained night shift typically replaces syringes daily; however, all syringes are expected to be labeled and dated.On 4/21/26 at 4:48 PM, during an interview with the Director of Nursing (DON), she confirmed all tube feeding solutions and supplies should be labeled with the resident's name, date, time, and rate. She reported the facility uses both prefilled feeding bottles and pourable feeding bags and stated she would expect any feeding bag in use to be labeled appropriately. She further confirmed syringes should be labeled and dated to prevent potential complications. She reported the facility did not have a policy specific to PEG feeding labeling and only had a competency skills checklist, which did not address labeling.A record review of the admission Record revealed the facility admitted Resident #90 on 1/20/26 with diagnoses including Unspecified Severe Protein-Calorie Malnutrition and Dysphagia, Unspecified.A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/27/26 revealed Resident #90 required staff assessment for mental status and had severely impaired cognitive skills for daily decision making. A review of Section K revealed the resident had a feeding tube.A record review of the Order Summary Report revealed Resident #90 had a Physician's Order with a start date of 1/20/26 for Nothing by mouth (NPO) status and an enteral feeding order dated 2/11/26 for Formula Jevity 1.5 at 55 (ml)per hour.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain a medication error rate of less than five percent (5%) when two (2) medications were prepared to be administered without appropriate clinical assessment during medication administration. Resident #110, resulting in two (2) errors out of (27) opportunities, with a medication error rate of 7.41%.Findings include:A review of the facility's policy, Medication Administration, dated 07/23, revealed, .All medications are administered as prescribed, in accordance with good nursing principles and practices.Personnel authorized to administer medications do so only after they have familiarized themselves with the medications.Procedure.Medications are administered in accordance with written orders of the attending physician. If a dose seems excessive considering the resident's age and condition.the physician is contacted for clarification prior to the administration of the medication.On 4/21/26 at 7:55 AM, during an observation of morning medication administration, Licensed Practical Nurse (LPN) #1 was observed preparing medications for Resident #110, including Entresto (Sacubitril-Valsartan) 24-26 milligrams (mg) and Metoprolol 100 milligrams (mg), and placing them into a medication cup with the resident's scheduled medications. During the observation, Certified Nurse Aide (CNA) #2 informed LPN #1 that Resident #110's blood pressure was low. LPN #1 reviewed the electronic record and identified the resident's blood pressure as 88/56. LPN #1 then secured the medication cart and proceeded toward the resident's room with the prepared medications. During questioning, LPN #1 confirmed she intended to administer the medications and stated she did not have parameters to hold them. She removed the Metoprolol and Entresto after being questioned regarding the affect the medications would have on the resident's blood pressure.On 4/21/26 at 9:28 AM, during an interview with LPN #1, she reported it is the nurse's responsibility to assess a resident when a low blood pressure is reported and confirmed she would have administered both medications if the concern had not been raised.On 4/21/26 at 2:33 PM, during an interview with the Director of Nursing (DON), she reported nurses are expected to assess residents and hold medications when appropriate and to notify the physician when a resident presents with low blood pressure prior to administering medications that could further lower it.On 4/21/26 at 3:10 PM, during an interview with the pharmacist, she reported nursing staff are expected to use clinical judgment and contact the physician when blood pressure is low prior to administering antihypertensive medications. She confirmed both Metoprolol and Entresto have the potential to lower blood pressure.On 4/22/26 at 3:12 PM, during a follow-up interview with the DON, she reported the Entresto order included a parameter to hold the medication if systolic blood pressure was less than 100. She confirmed the nurse did not identify this parameter and stated she understand the medication error rate standard was five percent (5%).A record review of the admission Record revealed the facility admitted Resident #110 on 4/3/26 with diagnoses including Metabolic Encephalopathy.A record review of the Order Summary Report revealed Resident #110 had a Physician's Orders, dated 4/3/26, for Metoprolol Tartrate, one (1) tablet by mouth two times daily, and Sacubitril-Valsartan (Entresto), one (1) tablet by mouth two times daily, with instructions to hold for systolic blood pressure less than 100.A record review of the Weights and Vital Summary revealed Resident #110 had a documented blood pressure of 88/56 on 4/21/26 at 7:58 AM.A record review of the Metoprolol: Package Insert/Prescribing Information, updated 6/16/25, revealed, .Metoprolol tartrate is a beta-adrenergic blocker indicated for the treatment of hypertension.Contraindications.systolic blood pressure <100.A record review of the Highlights of Prescribing Information, revised 4/2024, revealed, .Entresto.contains valsartan.Warnings and Precautions.Hypotension.Entresto lowers blood pressure and may cause symptomatic hypotension.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were administered safely, resulting in significant medication errors when staff prepared to administer antihypertensive medications to a resident with a blood pressure of 88/56 without appropriate assessment or adherence to hold parameters (Resident #110) and failed to administer ordered antibiotic therapy as prescribed (Resident #69) for two (2) of six (6) residents reviewed for medication administration.Findings include: A review of the facility's policy, Medication Administration, dated 07/23, revealed, .All medications are administered as prescribed, in accordance with good nursing principles and practices.Personnel authorized to administer medications do so only after they have familiarized themselves with the medications.Procedure.Medications are administered in accordance with written orders of the attending physician. If a dose seems excessive considering the resident's age and condition.the physician is contacted for clarification prior to the administration of the medication.If a dose of an ordered medication is needed but the nurse is unable to locate at the time of administration, the nurse should call the pharmacy for further instruction. Resident #110 During an interview and observation of medication administration on 4/21/26 at 7:55 AM, Licensed Practical Nurse (LPN) #1 prepared Resident #110's morning medications, including Entresto (Sacubitril-Valsartan) 24-26 milligrams (mg) and Metoprolol 100 milligrams (mg). LPN #1 placed the resident's medication into a cup. At that time, Certified Nurse Aide (CNA) #2 reported that Resident #110's blood pressure was low. LPN #1 reviewed the electronic record and stated the blood pressure as 88/56. LPN #1 then secured the medication cart and proceeded toward the resident's room with the prepared medications. During questioning, she confirmed she intended to administer the blood pressure medications and stated she did not have parameters to hold them. After questioning the safety of giving blood pressure medications to a resident with low pressure occurred, LPN #1 then removed Metoprolol from the medication cup and discarded it. After further questioning specifically about Entresto, which also lowers blood pressure, she acknowledged the concern and removed and discarded that medication prior to administering the remaining medications. During an interview on 4/21/26 at 9:28 AM, LPN #1 reported it is the nurse's responsibility to assess a resident when a low blood pressure is identified and confirmed she would have administered both medications if the concern had not been raised. On 4/21/26 at 10:35 AM, during an interview with CNA #2, she confirmed the resident's blood pressure readings were 87/58 and 88/56 and that she reported the readings to nursing staff. On 4/21/26 at 1:44 PM, during an interview with Nurse Practitioner (NP) #1, he reported the resident typically has low blood pressure and stated that administration of these medications could have caused the blood pressure to drop to an unsafe level. He reported the expectation that nursing staff notify the provider when abnormal vital signs are identified. During an interview on 4/21/26 at 2:33 PM, the Director of Nursing (DON), she reported nurses are expected to assess residents, hold medications when appropriate, and notify the provider when blood pressure is low prior to administering medications that may further decrease blood pressure. On 4/21/26 at 3:10 PM, during an interview with the pharmacist, she reported both Metoprolol and Entresto have the potential to lower blood pressure and confirmed staff are expected to use clinical judgment and notify the provider when blood pressure is low prior to administration. During a follow-up interview with the DON on 4/22/26 at 3:12 PM, she confirmed the Entresto order included a parameter to hold the medication if systolic blood pressure was less than 100 and stated the nurse failed to identify and follow this parameter. A record review of the admission Record revealed the facility admitted Resident #110 on 4/3/26 with diagnoses including Metabolic Encephalopathy. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/9/26 revealed Resident #110 had a Brief Interview for Mental Status (BIMS) score of eight (8), which indicated the resident's cognition was moderately impaired. A record review of the Order Summary Report with active orders as of 4/21/26, revealed Resident #110 had Physician's Orders, dated 4/3/26, for Metoprolol Tartrate, one (1) tablet by mouth two times daily, and Sacubitril-Valsartan (Entresto), one (1) tablet by mouth two times daily, with instructions to hold for systolic blood pressure less than 100. A record review of the Weights and Vital Summary revealed Resident #110 had a documented blood pressure of 88/56 on 4/21/26 at 7:58 AM. A record review of the Metoprolol: Package Insert/Prescribing Information, updated 6/16/25, revealed, .Metoprolol tartrate is a beta-adrenergic blocker indicated for the treatment of hypertension.Contraindications.systolic blood pressure <100. A record review of the Highlights of Prescribing Information, revised 4/2024, revealed, .Entresto.contains valsartan.Warnings and Precautions.Hypotension.Entresto lowers blood pressure and may cause symptomatic hypotension. Resident #69 A record review of the Order Summary Report revealed Resident #69 had a Physician's Order, dated 4/1/26, for Vancomycin HCl Oral Suspension 50 milligrams (mg) per milliliter (ml), to administer 2.5 ml by mouth every six (6) hours for Clostridium difficile (c-diff) for seven (7) days, with an end date of 4/8/26. A record review of the Medication Administration Record (MAR) for April 2026 revealed Resident #69 had two (2) doses coded with a 7, indicating Other/See Progress Notes, including the 6:00 PM dose on 4/1/26 and the 12:00 AM dose on 4/2/26. A record review of the progress notes for Resident #69 revealed entries dated 4/1/26 at 8:43 PM and 4/2/26 at 12:00 AM documenting medication on order. A record review of the facility's Packing Slip revealed the Vancomycin for Resident #69 was delivered on 4/2/26 at 1:56 AM. On 4/21/26 at 11:10 AM, during an interview with Registered Nurse (RN) #4, she confirmed the Vancomycin for Resident #69 was not administered due to unavailability and reported she documented medication on order. She acknowledged she did not notify supervisory staff of the missed doses. On 4/21/26 at 2:00 PM, during an interview with NP #1, he reported failure to complete a full course of antibiotic therapy could result in continued or recurrent infection. On 4/21/26 at 3:10 PM, during an interview with the consultant pharmacist, she reported the facility has access to emergency medication supplies and pharmacy resources and stated staff are expected to obtain medications through alternative means and not leave doses unadministered. On 4/21/26 at 5:15 PM, during a phone interview with RN #5, she confirmed she was aware the Vancomycin for Resident #69 was not available and that it was delivered after midnight; however, the scheduled dose was not administered, and supervisory staff were not notified. On 4/22/26 at 3:25 PM, during an interview with the DON, she reported staff are expected to notify appropriate personnel when medications are unavailable and confirmed she was not aware Resident #69 had missed doses until identified during the survey. A record review of the admission Record revealed the facility admitted Resident #69 on 4/1/26 with diagnoses including Enterocolitis due to Clostridium difficile, recurrent. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/7/26 revealed Resident #69 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. A review of Section N revealed the resident received antibiotic therapy.

Based on interview, record review, and facility policy review, the facility failed to ensure accurate and complete medical records when nursing staff failed to document accurately on administration records for one (1) of (19) sampled residents. Resident #14.Findings include:A review of the facility's Purpose of the Patient Record revealed, .Process: Clinical records are maintained to provide complete and accurate patient information for continuity of care. The record shall contain sufficient information to identify the patient clearly, justify the diagnosis and treatment, and document results accurately.A record review of the admission Record revealed the facility admitted Resident #14 on 3/30/22 with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/6/26 revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of two (2), which indicated the resident's cognition was severely impaired.A record review of the Order Summary Report revealed Resident #14 had a Physician's Order, dated 2/2/26, for wound care to the sacral pressure ulcer.A record review of the Treatment Administration Record (TAR) for March 2026 revealed Resident #14 had no nurse signature or documentation to indicate wound care was completed to the sacral pressure ulcer on 3/2/26, 3/4/26, 3/5/26, 3/6/26, 3/14/26, 3/15/26, 3/20/26, 3/24/26, 3/25/26, 3/26/26, and 3/30/26. A continued record review of the Treatment Administration Record (TAR) for April 2026 revealed Resident #1 had no nurse signature or documentation to indicate wound care was completed to the sacral pressure ulcer on 4/11/26 and 4/12/26.On 4/22/26 at 12:30 PM, during an interview with the Director of Nursing (DON), she acknowledged there were multiple blank entries on the TAR for Resident #14 and reported nurses were completing wound care but not documenting it. She stated documentation was expected at the time care was provided and acknowledged that if care was not documented, it could not be verified as completed.On 4/22/26 at 1:30 PM, during an interview with Registered Nurse (RN) #1, she acknowledged she did not always document wound care for Resident #14 on the TAR after completing treatments and reported she was responsible for ensuring documentation was completed.On 4/22/26 at 2:00 PM, during an interview with the Administrator, he reported staff were expected to document treatments for Resident #14 after providing care.

Based on staff interview, record review, and facility policy review, the facility failed to provide written notification of the facility's bed hold policies and information at the time of the transfer to the resident or the Resident Representative (RR) for three (3) of (3) residents reviewed for hospitalization s. (Residents #47, #65, and #69). Findings included: A review of the facility's Bed Hold Policy, revised November 1, 2016, revealed, (Proper Name of Facility) shall permit each resident to remain at the center and not transfer or discharge the resident from the center except in accordance with federal and state laws and as directed in this policy .Notice Requirements .4 .Before (Proper Name of Facility) transfers or discharges the Resident, it shall notify the Resident and the Resident's Representative of the basis for the transfer or discharge in a language and manner they understand . During an interview on 12/04/2024 at 10:30 AM, the Social Services Director explained she was told by the Regional Business Office Consultant not to mail or provide the RR's with written notification regarding the facility's bed hold policies and information. She stated she was told the company policy did not require written notification and that representatives could be contacted by phone. The Social Services Director reported she had stopped mailing bed hold notifications six (6) months ago. During an interview on 12/05/2024 at 9:00 AM, the Administrator revealed he was unaware the Social Services Director had stopped mailing bed hold notification information to RRs. He stated the facility would resume mailing bed hold notification to RR's immediately. Resident #47 A record review of the Admission Record revealed the facility initially admitted Resident #47 on 03/26/2020 and she had current diagnoses including Sepsis. A record review of Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/26/2024 revealed Resident #47 was discharged from the facility to an acute hospital. Resident #65 A record review of the Admission Record revealed the facility initially admitted Resident #65 on 05/04/2023 with diagnoses including Acute Respiratory Failure. A record review of Resident #65's Discharge MDS with an ARD of 10/09/2024 revealed Resident #65 was discharged to an acute hospital. Resident #69 A record review of the Admission Record revealed the facility admitted Resident #69 on 05/13/2024 with diagnoses including Paraplegia. A record review of the Discharge MDS with an ARD of 08/15/2024 revealed Resident #69 was discharged to an acute hospital.

Based on staff interview, record review, and facility policy review, the facility failed to provide written notification of resident transfers to the resident or the resident representative (RR) for three (3) of (3) residents reviewed for hospitalization s. (Residents #47, #65, and #69). Findings included: A review of the facility's policy titled Transfer & Discharge, revised November 1, 2016, revealed, (Proper Name of Facility) shall permit each resident to remain at the center and not transfer or discharge the resident from the center except in accordance with federal and state laws and as directed in this policy .Notice Requirements .4 .Before (Proper Name of Facility) transfers or discharges the Resident, it shall notify the Resident and the Resident's Representative of the basis for the transfer or discharge in a language and manner they understand . During an interview on 12/04/2024 at 10:30 AM, the Receptionist explained she was instructed by the Regional Business Office Consultant not to mail written notification of transfers to the RRs. She stated the company policy required calling the representatives instead. She confirmed she had stopped mailing written notification of transfer approximately six (6) months ago. During an interview on 12/05/2024 at 9:00 AM, with the Administrator, he explained he was unaware the receptionist had stopped mailing transfer letters. He acknowledged the regulation requiring written notification to representatives in a language they understand and stated the facility would resume mailing transfer notifications to representatives immediately. Resident #47 A record review of the Admission Record revealed the facility initially admitted Resident #47 on 03/26/2020 and she had current diagnoses including Sepsis. A record review of Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/26/2024 revealed Resident #47 was discharged from the facility to an acute hospital. Resident #65 A record review of the Admission Record revealed the facility initially admitted Resident #65 on 05/04/2023 with diagnoses including Acute Respiratory Failure. A record review of Resident #65's Discharge MDS with an ARD of 10/09/2024 revealed Resident #65 was discharged to an acute hospital. Resident #69 A record review of the Admission Record revealed the facility admitted Resident #69 on 05/13/2024 with diagnoses including Paraplegia. A record review of the Discharge MDS with an ARD of 08/15/2024 revealed Resident #69 was discharged to an acute hospital.

Based on staff interview, record review, and facility policy review, the facility failed to transmit a discharge Minimum Data Set (MDS) assessment in a timely manner for one (1) of twenty-one (21) MDS assessments reviewed. (Resident #86) Findings included: A review of the facility's policy MDS and Care Plan, effective August 2019, revealed, .Care plans and MDS will be developed and maintained per RAI (Resident Assessment Instrument) Guidelines. A record review of the Admission Record revealed the facility admitted Resident #86 on 7/2/24 with current diagnoses including Spastic Hemiplegia Affecting Left Non-Dominant Side. A record review of the Discharge Minimum Data Set (MDS) in the electronic medical record with an Assessment Reference Date (ARD) of 08/06/2024 revealed Resident #86 discharged home, however, it was not electronically submitted. During an interview on 12/05/2024 at 10:05 AM, Licensed Practical Nurse (LPN) #3 stated that the corporate nurse was responsible for submitting the discharge MDS. LPN #3 confirmed the corporate nurse completed the discharge MDS but failed to submit it to Centers for Medicare and Medicaid Services (CMS). During an interview on 12/05/2024 at 10:30 AM, Registered Nurse (RN) #2 confirmed she failed to submit the discharge MDS for Resident #86. RN #2 stated she did not know how she missed it. During an interview on 12/05/2024 at 10:45 AM, the Director of Nursing (DON) stated she did not know the MDS was not submitted and expected MDS assessments to be submitted timely.

Based on observation, interviews, record review, and facility policy review, the facility failed to develop care plan interventions related to triggers for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD) (Resident #27) and failed to implement care plan interventions related to enhanced barrier precautions (EBP)(Resident #203) for two (2) of (21) sampled residents. Findings included: A review of a statement provided by the facility titled MDS (Minimum Data Set) and Care Plans, effective August 2019, revealed, Policy: Care plans and MDS will be developed and maintained per RAI (Residential Assessment Instrument) Guidelines. A review of the facility's Social Services Manual, undated, revealed, .Trauma-informed care is an approach to providing care to trauma survivors .Incorporating their story into the care plan and daily care is key to successfully caring for patients and residents who have experienced trauma . Resident #27 A record review of Resident #27's Comprehensive Care Plan with a date initiated of 7/5/2017 revealed the care plan included forgetfulness, memory loss, and short-term memory impairment related to PTSD, but no triggers were identified in the interventions. During an observation and interview on 12/02/2024 at 12:11 PM, Resident #27 was lying in bed and reported he had PTSD due to his service in the Vietnam War. He explained that his triggers included gunfire and hearing people grunting or moaning as if being hurt. During an interview on 12/03/2024 at 11:55 AM, Licensed Practical Nurse (LPN) #1 stated Resident #27 had always been pleasant and cooperative with medications. She reported being unaware of the resident's PTSD triggers and noted that the care plan only mentioned a history of PTSD but did not include specific triggers. A record review of the Admission Record revealed the facility admitted Resident #27 on 07/01/2016 with current diagnoses including Post-Traumatic Stress Disorder (PTSD), chronic, with an onset date of 08/09/2016. A record review of the Order Summary Report with active orders as of 12/5/2024 revealed Resident #27 had a Physician's Order, dated 5/31/2023 for Ritalin (5) milligrams (mg) twice daily for PTSD. A record review of a Behavioral Health Progress Note, dated 6/29/2023, revealed Resident #27 had Subjective Interim History completed that indicated he had .PTSD that stemmed from serving in Vietnam war in the [NAME] Corp . Resident #203 A record review of Resident #203's Comprehensive Care Plan with a review start date of 11/26/2024, included enhanced barrier precautions related to tracheostomy status, with interventions requiring staff to wear gowns and gloves when rendering care. During an observation on 12/02/2024 at 10:55 AM, an Occupational Therapist (OT) was in Resident #203's room and was providing hand therapy and applying moisturizer to the resident's lips. The resident, who was non-verbal, had a tracheostomy in place and a feeding pump infusing. A sign on the resident's door indicated Enhanced Barrier Precautions, with a picture of the required Personal Protective Equipement (PPE) to wear during care. PPE, including gowns and gloves, was available on the hall and at other residents' doors. The OT was observed wearing gloves and a surgical mask but no gown. During an interview on 12/03/2024 at 12:15 PM, the OT confirmed providing therapy for Resident #203 on 12/02/2024, including hand exercises and oral care. She admitted she did not wear a gown while providing care. On 12/03/2024 at 3:00 PM, during an interview with LPN #3/Care Plan nurse, she confirmed that Resident #27's care plan did not identify any PTSD triggers. She was unaware of the need to list or identify triggers on the care plan. She stated that care plans are the guide for providing care and staff are expected to follow the care plan to provide the highest functional care for residents. She also confirmed Resident #203 had a care plan intervention for EBP to include wearing a gown while providing care. During an interview on 12/03/2024 at 3:20 PM, the Director of Nursing (DON) stated social services was responsible for evaluating PTSD and identifying triggers. She was unaware that Resident #27's care plan did not include PTSD triggers. She acknowledged that triggers must be identified to provide quality care and prevent re-traumatization of the resident. The DON also confirmed the OT did not implement the care plan intervention to wear a gown as EBP when providing care to Resident #203. A record review of the Admission Record revealed the facility admitted Resident #203 on 08/26/2024 with diagnoses including Gastrostomy Status and Encounter for Attention to Tracheostomy. A record review of the Order Summary Report revealed Resident #203 had a Physician's Order, dated 11/20/24 for OT and a Physician's Order dated 12/3/24 for enteral feedings.

Based on interviews, record review, and facility Social Services Manual review, the facility failed to ensure triggers and resident-specific interventions were identified and initiated for a resident with Post-Traumatic Stress Disorder (PTSD) for one (1) of 21 sampled residents, Resident #27. Findings included: A review of the facility's Social Services Manual, undated, revealed, .Trauma-informed care is an approach to providing care to trauma survivors. Trauma-informed care recognizes the experiences endured by survivors, responds to their needs, and helps them on their path . Safety .Survivors of trauma need to feel safe and have a low-stress environment . Care for the Traumatized Patient .Recognizing the many experiences of a trauma survivor is essential to their care .Incorporating their story into the care plan and daily care is key to successfully caring for patients and residents who have experienced trauma . A record review of the Admission Record revealed the facility admitted Resident #27 on 07/01/2016 with current diagnoses including Post-Traumatic Stress Disorder (PTSD), chronic, with an onset date of 08/09/2016. A record review of the Order Summary Report revealed Resident #27 had a Physician's Order, dated 5/31/2023 Ritalin 5 milligrams (mg) twice daily for PTSD. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/20/2024 revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated moderate cognitive impairment. Section I-Active Diagnoses listed PTSD as an active diagnosis. A record review of Resident #27's Certified Nurse Aide (CNA) Kardex revealed there were no triggers listed for PTSD. A record review of Resident #27's medical record revealed no documentation indicating the resident was evaluated to identify triggers and resident-specific interventions related to PTSD. A record review of a Behavioral Health Progress Note, dated 6/29/2023, revealed Resident #27 had Subjective Interim History completed that indicated he had .PTSD that stemmed from serving in Vietnam war in the [NAME] Corp . On 12/02/2024 at 12:11 PM, during an observation and interview, Resident #27 was lying in bed and reported he had PTSD due to his service in the Vietnam War. He explained that his triggers included gunfire and hearing people grunting or moaning as if being hurt. On 12/03/2024 at 11:20 AM, during an interview with CNA #1, she stated Resident #27 did not have problems receiving care and was always cooperative. She reported being unaware of any PTSD triggers for the resident and confirmed that no triggers were listed on the Kardex or care plan in his electronic medical record. At 11:55 AM on 12/03/2024, during an interview with Licensed Practical Nurse (LPN) #1, she stated Resident #27 had always been pleasant and cooperative with medications. She reported being unaware of the resident's PTSD triggers and noted that the care plan only mentioned a history of PTSD but did not include specific triggers. On 12/03/2024 at 2:45 PM, during an interview with the Social Services Director (SSD), she explained that when a resident is diagnosed with PTSD, assessments regarding PTSD are the responsibility of nursing. She stated she refers residents with PTSD for one-on-one consultations and to the psychiatrist if needed. She acknowledged the importance of identifying PTSD triggers to prevent re-traumatization. On 12/03/2024 at 3:20 PM, during an interview with the Director of Nursing (DON), she stated social services was responsible for evaluating PTSD and identifying triggers. She was unaware that Resident #27's care plan did not include PTSD triggers. She acknowledged that triggers must be identified to provide quality care and prevent re-traumatization of the resident. On 12/05/2024 at 2:00 PM, during an interview with the Administrator, he stated residents diagnosed with PTSD are expected to receive trauma-informed care to prevent re-traumatization.

Based on observation, staff interview, and facility policy review, the facility failed to store food in accordance with professional standards for food safety related to foods not labeled, food with no identified date, exposed foods, a scoop left in the flour bin, and an unclean ice machine for one (1) of two (2) kitchen observations. Findings included: A record review of the facility's policy, Refrigerated Storage, effective June 1, 2013, revealed, It is the policy of this facility to store, prepare, and serve foods in accordance with federal, state, and local sanitary codes . 7. All foods will be properly wrapped and/or stored in sealed containers and dated and labeled. A record review of the facility's policy, Dry Storage, effective August 1, 2012, revealed, .8. Scoops will not be stored in bulk containers. On 12/02/2024 at 10:22 AM, during an observation and interview of the kitchen with the Dietary Director (DD), the ice machine revealed dirt-like stains along the interior, in contact with the ice. When the DD wiped the soiled areas with a white towel, the smudge transferred onto the towel. An observation of Refrigerator #2 revealed six (6) trays containing portioned glasses of various liquids with no label or date. Freezer #1 was observed to contain one (1) opened bag of breaded chicken strips, leaving the food exposed, with no date. An observation of the pantry revealed one (1) opened bag containing six (6) hamburger buns, left exposed, and a scoop left in the flour bin, touching the flour. Additionally, one (1) opened bag of dehydrated onions was left exposed. On the spice rack, three (3) spice jars were noted with the lids open, leaving the spices exposed. A bottle of lemon juice was noted with manufacturer's instructions to refrigerate after opening, but it was left unrefrigerated. The DD confirmed the dirt-like stains inside the ice machine, undated food, exposed foods, and the scoop left in the flour bin. She stated she was responsible for monitoring food safety but admitted she had tried to clean the ice machine unsuccessfully. The DD reported she did not know the nature of the stains and had not tested the machine for bio-growth, as the Maintenance Director was responsible for such checks. On 12/02/2024 at 10:52 AM, during an interview, [NAME] #1 stated that cooks are responsible for monitoring food safety and labeling. The cook confirmed that staff are in-serviced monthly on food safety. On 12/05/2024 at 9:08 AM, during an interview, the Administrator he had been told of the issues observed in the kitchen. He stated he would ensure, through self-monitoring, that the DD maintains food quality and sanitation in the kitchen. He also stated he would implement a strong plan of correction to address unsafe food storage.

Based on observation, staff interviews, record reviews, and facility policy reviews, the facility failed to follow infection control practices by not implementing Enhanced Barrier Precautions (EBP) for a resident at high risk for Multidrug-resistant Organisms (MDRO) for one (1) of 21 sampled residents. (Resident #203) Findings included: A review of the facility's policy Transmission Based Precaution, dated 2022, revealed, .Enhanced Barrier Precautions recommendation is to consider expanding the use of PPE (Personal Protective Equipment) and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk . A record review of the Admission Record revealed the facility admitted Resident #203 on 08/26/2024 with diagnoses including Gastrostomy Status and Encounter for Attention to Tracheostomy. A record review of the Order Summary Reportwith active orders as of 12/4/24 revealed Resident #203 had a Physician's Order, dated 11/20/24 for Occupational Therapy (OT) and a Physician's Order dated 12/3/24 for enteral feedings. On 12/02/2024 at 10:55 AM, observed an Occupational Therapist in Resident #203's room. The Occupational Therapist was providing hand therapy and applying moisturizer to the resident's lips. The resident, who was non-verbal, had a tracheostomy in place and a feeding pump infusing. A sign on the resident's door indicated Enhanced Barrier Precautions, with a picture of the required PPE to wear during care. PPE, including gowns and gloves, was available on the hall and at other residents' doors. The OT was observed wearing gloves and a surgical mask but no gown. On 12/02/2024 at 2:30 PM, during an interview with Registered Nurse (RN) #1, she explained all residents with wounds, gastrostomy tubes, tracheostomies, or catheters were on EBP, which are designed to protect residents from infections brought in by staff. She confirmed all staff, including therapy staff, had been in-serviced on enhanced barrier precautions and stated the OT should have worn a gown while providing care for Resident #203. On 12/03/2024 at 12:15 PM, during an interview with the OT, she confirmed providing therapy for Resident #203 on 12/02/2024, including hand exercises and oral care. She admitted she did not wear a gown while providing care. She stated she was aware of the enhanced barrier signage and had been educated on the purpose of enhanced barrier precautions, which is to prevent residents from contracting infections from staff. She explained she only wears PPE when the PPE is located on the resident's door itself, but confirmed PPE was readily available on the hall. On 12/03/2024 at 3:20 PM, during an interview with the Director of Nursing (DON), she confirmed that staff are expected to follow proper infection precautions while providing care. She stated the OT should have worn a gown while providing therapy at the bedside for a resident with a gastrostomy tube and tracheostomy. She reported that PPE was readily available on the hall, noting that the absence of PPE hanging on the door was not a valid reason to omit proper precautions.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide adequate supervision to prevent Resident #1, who was previously identified as an exit-seeker and elopement risk, from exiting the facility unnoticed and unsupervised for one (1) of four (4) residents reviewed. Resident #1. Resident #1 exited the facility on 5/14/2023 without the knowledge of staff and was unsupervised approximately 10 minutes until a driver passing by the street entered the facility and notified the staff that a resident was outside of the facility at 6:45 AM. Resident #1 was last observed inside of the facility by staff at approximately 6:40 AM and was located at 6:50 AM approximately 100 yards from the facility walking on the sidewalk in front of a local business. The facility's failure to provide adequate supervision to prevent the elopement of Resident #1 placed this resident, and other residents at risk for wandering and elopement, in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 5/14/23 and existed at 42 CFR(s): 483.25(d)(1)(2) Free of Accidents Hazards/Supervision/Devices (F689) - Scope and Severity of J. The SA notified the facility's Administrator of the IJ and SQC on 5/18/2023 at 3:10 PM and provided the Administrator with the IJ template. The facility submitted an acceptable Removal Plan on 5/18/2023, in which they alleged all corrective actions to remove the IJ were completed and the IJ removed on 5/18/2023. The SA validated the Removal Plan on 5/19/2023 and determined the IJ was removed on 5/18/2023, prior to exit. Therefore, the scope and severity of CFR 483.25(d)(1)(2) Free of Accidents Hazard/Supervision/Devices (F689) was lowered to a Scope and Severity of D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy, Elopement, dated April 2017, revealed, .To establish a process that identifies risk and establishes interventions to mitigate the occurrence of elopements .Door Alarm Protocol .Once Doors/exit alarms are activated a resident search is completed ensuring there is no missing resident .Tools Resource List for Interventions to Address Elopement Risk .Utilize alarmed doors at time of meals to prevent wandering off units . On 5/17/23 at 5:00 PM, observations revealed the facility was located on the main street through town. There were local businesses on both sides of the street on each side of the facility. There were thirty (30) automobiles traversing the three (3) lane street (turn lane in the middle) in a five-minute period. The front door faced the street directly and was approximately sixty (60) feet from the street. There was an exit door perpendicular to the main street at the end of each of two wings which ran north and south of the front entrance. There was a four (4) foot wide, well-maintained sidewalk in front of the facility which separated the parking lot and grassy yard from the street. From the front, southern corner of the building of the facility where the East Hall exit door was located to the railroad tracks which intersect the street that the facility was located on was approximately one hundred (100) yards. The condition of the parking lot and yard was well maintained. Record review of the facility's Investigation Template, dated 5/17/23, revealed, .Description of the Allegation: At approximately 6:50 am, resident was noted to be outside of the facility. Staff were able to redirect and bring resident inside within a few minutes. A full body assessment was performed on resident, no issues or injuries noted .Center response: Resident was redirected back inside. A full body assessment was performed on resident, no issues or injuries noted. Building administration was notified, incident called into Reporting line at 5:25 pm. Abuse/Neglect & Elopement in-servicing started for all staff. The resident was dressed appropriately wearing slacks, a blouse and a light jacket, and not at risk for weather related issues Investigation Summary: At approximately 6:50 am, resident was noted to be outside of the facility. Staff were able to redirect and bring resident inside within a few minutes .Summary of interview: At 0635 (6:35 AM) I saw (Proper Name of Resident #1) on South wing talking to the nurse .a lady came to the door at 0645 (6:45 PM) and asked if we had anyone missing. She said a lady with long gray was walking down the road .The nurse got in the car with the lady and I got in my car. She was right up the street .We returned to the facility .Person interviewed: (Proper Name of Certified Nurse Aide (CNA) #1 .Summary Investigation . (Proper Name of Resident #1) was walking with another resident at 6:40a (AM) .(Proper Name of CNA #1) ran up the hallway and notified me that (Proper Name of Resident) had gotten outside the building .Body assessment was completed upon returned, no skin tears or lacerations noted. All doors were checked, side door on East wing was the only door unlocked. Staff also completed a head count of every resident in the building .Person Interviewed: (Proper Name of Licensed Practical Nurse (LPN) #1 . On 5/17/23 at 5:50 PM, in an interview with the Director of Nursing Services (DNS) and the Administrator, the DNS confirmed that Resident #1 was last observed in the facility at 6:40 AM, walking down the hall on the South Hall with another resident. At 6:45 AM, the report of a passerby alerted staff that Resident #1 was outside the facility unaccompanied approximately one hundred yards down the street from the facility. The DON stated that an investigation revealed that the exit door on the North end of the East Hall had an alarm and a magnetic locking mechanism that was not working properly. The resident was returned to the facility at 6:50 AM. On 5/17/23 at 6:00 PM, observation and an interview with Resident #1 revealed she was in her room sitting on her bed with call light in reach. She was not able to answer questions but was polite and pleasant. On 5/17/23 at 7:00 PM, during an observation, the exit door at the North end of the East Hall opened with a push by the DNS without the numeric code being entered into the wall mounted keypad beside the door. On 5/17/23 at 11:30 PM, during a telephone interview with LPN #1 revealed she was working at the facility on the morning of 5/14/23.At 6:40 AM she observed Resident #1 and Resident #2 walking together on the North Hall. She stated she was not aware that Resident #1 had exited the facility until a passerby entered the facility and notified her that she was concerned that a resident was walking down the sidewalk in front of the facility. She stated the nursing staff immediately called a Code [NAME] per facility protocol for a missing resident using the overhead announcement system and conducted a 100% headcount of all residents. Resident #1 was not accounted for. She stated she located Resident #1 down the street, on the same side of the street as the facility and assisted the resident back to her room in the facility. She stated that the nursing staff had checked all exit doors and determined that the side exit door at the end of East Hall had a locking mechanism issue and the alarm had failed. She said that the door should not have opened without a numeric code being entered into the keypad beside the door. If the door opened, an alarm should have sounded to alert the staff, but the door opened without the code and the alarm did not sound upon opening the door. On 5/18/23 at 11:34 AM, during an interview with the Maintenance Director, he said he reported to the facility on Sunday (5/14/23) after he was notified of the elopement of Resident #1. He stated that he assessed the side door at the end of the East Hall and determined that the door alarm, nor the locking mechanism operated correctly. He confirmed that on 5/14/23 the side door at the end of the East Hall opened without the numeric code being entered into the wall mounted keypad beside the door and the alarm did not sound upon opening of the door. Record review of local website weather information revealed the weather for the city on 5/14/2023 at 6:31 AM was 68 degrees Fahrenheit, foggy, with no wind. Record review of the Admission Record revealed the facility admitted Resident #1 on 10/05/21 (with an original admitted listed as 9/19/16) and she had diagnoses including Alzheimer's Disease and Dementia. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/07/23 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated she had severe cognitive impairment. MDS review also revealed that Resident #1 was ambulatory without assistance. Record review of the Clinical Health Status Evaluation .Section 11. Elopement, dated 5/9/23, indicated that Resident #1 had a history of wandering or elopement, wanders aimlessly about the facility and/or exhibits night wandering, and was determined to be at risk for elopement. Record review of the Care Plan for Resident #1 revealed she had a Focus of .Exhibits Exit seeking behavior R/T (related to) periods of confusion with a Goal of .will not attempt to leave the facility without being accompanied by staff or family member , and Interventions included .Wander Guard to left ankle, check placement each shift . The facility provided the following Removal Plan: At approximately 6:40 am, Resident #1 was noted to be outside of the facility. Staff were able to redirect and bring resident inside within a few minutes. A full body assessment was performed on resident, no issues or injuries noted. The resident was dressed appropriately wearing slacks, a blouse and a light jacket, and not at risk for weather related issues. The temp was 69 degrees according to the National Weather Association at the time the resident was out of the building. Based on interviews with the staff and timeline, the resident was out of the building for a brief 10 minutes. We were able to redirect easily. Resident #1 was last seen prior to incident at 6:40 a.m. in hallway ambulating with another resident. Upon investigation and door securement checks the East Wing North door released for Administrator and deemed the point of exit for Resident #1. F 689 The facility failed to ensure the resident's environment was free from accident hazards and that Resident #1 received adequate supervision. Resident #1, who was determined by the facility to be an elopement risk, left the faciity on [DATE] at 6:40 AM unnoticed and unsupervised through an exit door that was not functioning properly. Immediate Corrective Actions for Resident # 1: Resident #1 returned to the facility 5/14/23 @ 6:50 a.m. by Licensed Practical Nurse (LPN) #1 and placed 1:1 supervision with LPN #1. Wander guard bracelet placement and function verified immediately by Director of Nursing 5/14/23. Resident #1's bracelet in place and functioning properly. Full body audit was completed of Resident #1 on 5/14/23 @ 6:55 a.m.by LPN #1 with no injuries noted. Responsible Party (RP) notified 5/14/23 @ 7:10 a.m. by LPN #1. Medical Doctor (M.D) notified 5/14/23 @ 7:20 a.m. by LPN #1 Administrator notified by LPN #2 5/14/23 @ 6:45 a.m. Director of Nursing Services(DNS) was notified by Administrator on 5/14/23 @ 6:50 a.m. Elopement risk assessments performed on all residents 5/14/23 by Director of Nursing Services (DNS). Care plan reviewed and updated 5/14/23 by DNS with continued monitoring of resident's whereabouts. State Agency notified by Administrator 5/14/23 @ 5:25 p.m. Attorney General Compliant completed online by DNS 5/14/23 @ 4:57 p.m. Immediate Action take to Identify Others at Risk: Staff completed a room to room audit of all residents to assure all were safe and accounted for on 5/14/23 @ 6:40 - 7:00 a.m. by nursing staff. All residents with Wander guard bracelets were checked for functionality and positioning with all in place noted on 5/14/23 @ 7:10 a.m. by DNS. All Wander guard bracelets were in place and functioning properly. All residents at risk for wandering had their care plan and elopement book reviewed on 5/14/23 by DNS with pictures and current care plans in place. Administrator (ADM) began an investigation and Root Cause Analysis on 5/14/23 @ 6:45 a.m. to determine how resident went outside; East Wing North End door was not locking and employee placed at door to monitor and ensure no one enters or exits center through door. Employee remained at door through 3-11 shift 5/15/23 when parts were obtained and door demonstrated proper locking function when repeatedly check by Maintenance Supervisor. All doors were checked for proper function and operation 5/14/23 by Maintenance Director. All doors secure and functioning properly except East Wing North End door noted to not properly lock. Repair to East Wing North End door on 5/15/23 by Maintenance Director. Systemic Changes and Education Completed to Avoid Reoccurrence: DNS and Director of Clinical Education Immediately initiated an in-service with all staff regarding our elopement policy guideline (including nursing, maintenance, office personnel, dietary, housekeeping, therapy, and any volunteers) on 5/14/23 and completed on 5/15/23. Any staff member that was not educated at that time will be educated prior to working. Education for all staff on abuse, neglect, prevention of accidents and supervision of residents by DNS and Director of Clinical Education on 5/14/23 and completed on 5/15/23 Any staff member that was not educated on this date will be educated prior to starting next shift. Social Services Director (SSD) conducted an elopement drill on all three shifts beginning 5/14/23-5/16/23. Licensed Nursing Staff to check for proper function and placement of Wander guard bracelets every shift beginning 5/14/23, with documentation on the Treatment Administration Record (TAR). Door checks will be conducted on each shift for three days, then daily to assure proper function by Director of Maintenance/Assistant Director of Maintenance/Licensed Nurse or Administrator beginning 5/14/23. Door monitored by staff member 5/14/23 through 5/15/23 The Administrator, Maintenance Director or Nurse will assure that all exit doors will be checked after any power failure to assure they are in proper working order beginning on 5/17/23. On 5/17/23 when East Wing North door opened without disarming alarm, a staff member was place at the door for monitoring and to remain until repaired. QAPI: A focused/Adhoc Quality Assessment Performance Improvement (QAPI)meeting addressing the findings was initiated and completed on May 15, 2023 with participation of the Administrator, Medical Director, DNS, Assistant DNS, Unit Manager. Evaluation of process with placement of staff member at door until parts obtained and placed 5/15/23 and proper door function noted. After the door malfunctioned on 5/17/23, a 2nd QAPI meeting was held to re evaluate processes and additional corrective action to check all doors after electrical storms or power outages. The QAPI meeting was completed on May 17, 2023, with the participation of the Administrator, Medical Director, DNS, Assistant DNS, Infection Preventionist/DCE. Reevaluated process also included placing a staff member at door for monitoring to remain in place until repaired. Diversicare of Moss Point alleges all corrective actions were completed on 5/17/23 with IJ removal 5/18/23. The SA validated the facility's investigation of the incident and implementation of the Removal Plan through observations, facility record review, and interviews. SA validated that Resident #1 returned to the facility 5/14/23 at 6:50 AM, by Licensed Practical Nurse (LPN) #1 during a telephone interview with LPN #1 on 5/17/23 at 11:30 PM and record review of the Facility Investigation. SA validated that Wander Guard bracelet placement and function was validated immediately by the DNS on 5/14/23 with Resident #1's bracelet in place and functioning properly during an interview with the DNS on 5/18/23 at 11:10 AM. SA validated that a full body audit was completed for Resident #1 on 5/14/23 at 6:55 AM by LPN #1 with no injuries noted during a telephone interview with LPN #1 on 5/17/23 at 11:30 AM and record review of the Progress Notes for Resident #1 dated 5/14/23 18/23 and the Facility Investigation. SA validated that the Responsible Party (RP) for Resident #1 was notified on 5/14/23 at 7:10 AM by LPN #1 during a telephone interview with LPN #1 on 5/17/23 at 11:30 PM. SA validated that the Medical Doctor (MD) of Resident #1 was notified on 5/14/23 at 7:20 AM by LPN #1 during a telephone interview with LPN #1 on 5/17/23 at 11:30 PM. SA validated that the facility Administrator was notified on 5/14/23 at 6:45 AM by LPN #2 during a telephone interview with LPN #1 on 5/17/23 at 11:30 PM and during an interview with the Administrator on 5/18/23 at 10:55 AM. and during an interview with the DNS on 5/18/23 at 11:10 AM. SA validated that the DNS was notified by the Administrator on 5/14/23 at 6:50 AM during an interview with the Administrator on 5/18/23 at 10:55 AM and during an interview with the DNS on 5/18/23 at 11:10 AM. SA validated that elopement risk assessments were performed on all residents 5/14/23 by the DNS and during an interview with the DNS on 5/18/23 at 11:10 AM and record review of the elopement risk assessments for Resident #1, Resident #2, Resident #3 and Resident #4. SA validated that the Care Plan for Resident #1 was reviewed and updated on 5/14/23 by DNS with continued monitoring of resident's whereabouts by record review of Resident #1's Care Plan. SA validated that State Agency (SA) was notified by the Administrator on 5/14/23 at 5:25 PM during an interview with the Administrator on 5/18/23 at 10:55 AM. SA validated that an Attorney General Compliant was completed online by the DNS on 5/14/23 at 4:57 PM during an interview with the DNS on 5/18/23 at 11:10 AM. SA validated that Staff completed a room-to-room audit of all residents to assure all were safe and accounted for on 5/14/23 at 6:40 - 7:00 AM by nursing staff during an interview with the DNS on 5/18/23 at 11:10 AM and during a telephone interview with LPN #1 on 5/17/23 at 11:30 PM. SA validated that all residents with Wander Guard bracelets were checked for functionality and bracelet positioning with all in place noted on 5/14/23 at 7:10 AM by DNS and that all Wander guard bracelets were in place and functioning properly a telephone interview with LPN #1 on 5/17/23 at 11:30 PM and during an interview with the DNS on 5/18/23 at 11:10 AM. SA validated that all residents at risk for wandering had their care plan and elopement book reviewed on 5/14/23 by DNS with pictures and current care plans in place during an interview with the DNS on 5/18/23 at 11:10 AM and record review of the elopement books at the nurses stations. SA validated that the Administrator began an investigation and Root Cause Analysis on 5/14/23 at 6:45 AM to determine how resident went outside; East Wing North End door was not locking and employee placed at door to monitor and ensure no one enters or exits center through door and that an employee remained at door through 3-11 shift 5/15/23 when parts were obtained and door demonstrated proper locking function when repeatedly check by Maintenance Director during an interview with the DNS on 5/18/23 at 11:10 AM and during an interview with the Maintenance Director on 5/18/23 at 11:34 AM. SA validated through an interview with the DNS on 5/18/23 at 11:10 AM and during an interview with the Maintenance Director on 5/18/23 at 11:34 AM. that all doors were checked for proper function and operation on 5/14/23 by the Maintenance Director. All doors were secure and functioning properly except East Wing North End door noted to not properly lock and that repair to East Wing North End door was performed on 5/15/23 by the Maintenance Director. SA validated through an interview with the DNS on 5/18/23 at 11:10 AM and during an interview with the Maintenance Director on 5/18/23 at 11:34 AM. that the DNS and the Director of Clinical Education Immediately initiated an in-service with all staff regarding elopement policy guideline (including nursing, maintenance, office personnel, dietary, housekeeping, therapy, and any volunteers) on 5/14/23 and completed on 5/15/23. Any staff member that was not educated at that time to be educated prior to working. The SA also validated through staff interviews that all staff received the in-service including with Cook, on 5/19/23 at 1:27 PM, Housekeeper on 5/19/23 at 1:30 PM, LPN #2 on 5/19/23 at 1:38 PM, LPN #3 on 5/19/23 at 1:40 PM, and OT on 5/19/23 at 1:42 PM, and the Director of Clinical Education (and Infection Preventionist) on 5/19/23 at 1:48 PM. SA validated through an interview with the DNS on 5/18/23 at 11:10 AM and during an interview with the Maintenance Director on 5/18/23 at 11:34 AM. that the DNS and the Director of Clinical Education initiated an in-service with all staff regarding abuse, neglect, prevention of accidents and supervision of residents on 5/14/23 and completed on 5/15/23. Any staff member that was not educated at that time to be educated prior to working. The SA also validated through staff interviews that all staff received the in-service including with Cook, on 5/19/23 at 1:27 PM, Housekeeper on 5/19/23 at 1:30 PM, LPN #2 on 5/19/23 at 1:38 PM, LPN #3 on 5/19/23 at 1:40 PM, and OT on 5/19/23 at 1:42 PM, and the Director of Clinical Education (and Infection Preventionist) on 5/19/23 at 1:48 PM. SA validated through record review of Patient/Resident Elopement Drill Worksheets dated 5/14/23, 5/15/23 and 5/16/23 that the Social Services Director (SSD) conducted an elopement drill on all three shifts beginning 5/14/23-5/16/23. SA validated through record review of the Treatment Administration Record (TAR) that Licensed Nursing Staff were to check for proper function and placement of Wander guard bracelets every shift beginning 5/14/23, with documentation on the TAR. SA validated through record review of LOGBOOK DOCUMENTATION sheets that door checks were conducted on each shift for three days, then daily to assure proper function by Director of Maintenance/Assistant Director of Maintenance/Licensed Nurse or Administrator beginning 5/14/23. SA validated through record review of the Door Monitor schedule and during an interview with the DNS on 5/18/23 at 11:10 AM, an interview with CNA #2 on 5/18/23 at 10:00 AM and CNA #3 on 5/18/23 at 4:00 PM and during an interview with the Maintenance Director on 5/18/23 at 11:34 AM that the East Wing North door was monitored by staff member 5/14/23 through 5/15/23. SA validated through observation on 5/17/23 at 7:00 PM that after East Wing North door opened without the numeric code entered into the wall mounted keypad, a staff member was placed at the door for monitoring and to remain until repaired on 5/19/23. SA validated through observation and interview with the alarm repairman on 5/19/23 at 12:48 PM that the repairman performed maintenance on the East Wing North door and repeatedly tested the door to ensure proper functioning of the locking mechanism. SA validated through record review of the Quality Assurance and Performance Improvement (QAPI) Meeting sheet dated 5/15/23, including sign-in of committee members that a focused/Adhoc Quality Assessment Performance Improvement (QAPI)meeting addressing the findings was initiated and completed on May 15, 2023, with participation of the Administrator, Medical Director, DNS, Assistant DNS, Unit Manager. Evaluation of process with placement of staff member at door until parts obtained and placed 5/15/23 and proper door function noted. SA validated through record review of the Quality Assurance and Performance Improvement (QAPI) Meeting sheet dated 5/17/23, including sign-in of committee members that after the door malfunctioned on 5/17/23, a 2nd QAPI meeting was held to reevaluate the processes and additional corrective action to check all doors after electrical storms or power outages. The QAPI meeting was completed on May 17, 2023, with the participation of the Administrator, Medical Director, DNS, Assistant DNS, Infection Preventionist/DCE. The reevaluated process also included placing a staff member at door for monitoring to remain in place until repaired. The SA validated through observation, record reviews, policy reviews and interviews that the facility completed all corrective actions on 5/17/23 with IJ removal 5/18/23.